Healing the traumatized minds of refugees

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    Host countries need to deal with the raised levels of mental-health disorders in migrants if they expect them to integrate well, and that could mean benefits for psychological care in rich countries too.

    “Wir schaffen das!” proclaimed Germany’s chancellor Angela Merkel at the peak of the refugee crisis in August last year. “We will cope.”

    Her promise met with widespread acclaim and the German public in turn proffered a Willkommenskultur or ‘culture of welcome’. But within months, as hundreds of thousands more refugees entered the country, the phrase began to hang heavy around Merkel’s neck — and could yet sink her. And the Willkommenskultur must confront a growing shockwave of xenophobia, pushed ahead of the waves of displaced people.

    Merkel’s phrase had of course been referring to the German population, who have to cope with finding accommodation, education and jobs for the refugees, as well as providing health services. This costly range of social adjustments will be more challenging even than the 1990 reunification. (Germany is the most popular destination in Europe for refugees.)

    The refugees have to cope too. Yet in the highly charged public debate about the refugee crisis, the mental state of these vulnerable people rarely features — aside from vague and nakedly political warnings that some could be dangerous.

    Refugees must cope with having been driven from their homes by violence and fear, and arriving in a foreign country with nothing. They need clear heads to make good decisions about their immediate and longer-term futures. They need flexibility of mind to adapt to their new, often disappointing, environments. They need to learn new things quickly, not least the language of their host countries, to meet the expectations that they will integrate quickly. But the existential stresses faced by the refugees at home and on their dangerous journeys has taken a disastrous toll on the minds of many of them.

    Therapy development

    In a News Feature this week (of which Monday was World Mental Health Day), Nature examines some of the issues. The headline figure is deeply concerning. Psychologists in Germany estimate that more than half of those who have recently arrived there could be affected by post-traumatic stress disorder, depression, anxiety or another mental disorder. This is not a good basis for coping — for decision-making, adapting and learning. Such mental-health conditions reduce cognitive capacities and suck energy and motivation.

    Medics and others who have worked with traumatized populations in far-flung war zones, such as Cambodia, Vietnam, sub-Saharan Africa, the Balkans and the Middle East, are familiar with this. The World Health Organization and the United Nations High Commissioner for Refugees published new guidelines last year that stress the importance of noticing and addressing mental-health issues. Yet host countries tend not to realize the extent of the problem, or to argue that mental-health problems can be tackled after the refugees are settled. But the right moment for support is during the volatile times. That makes sense for practical as well as humanitarian reasons — to ensure the smoothest passage to integration for those who have no prospect of a return home.

    Some German cities are rolling out some modest pilot programmes for psychiatric help, and Sweden will do so soon. But, considering the numbers affected, a very large investment is required across the continent. The European Union registered 1.4 million people seeking asylum in the 18 months up to June this year, and hundreds of thousands more may have entered without registering, according to German estimates.

    Access to mental-health provision is already difficult for many citizens. Prioritizing work with new arrivals is a tough sell. So it is important to consider the payback for the wider society.

    “ Refugees must cope with having been driven from their homes by violence and fear. ”

    Huge numbers of traumatized refugees in the Middle East and Africa are camped in countries with few psychiatrists, or are caught in areas too dangerous for aid workers to access. Their fate has accelerated efforts to develop simple and cheap therapies, some Internet- or app-based, as alternatives (or supplements) to conventional contact-heavy therapies. To broaden delivery, these can often be administered by trained lay people.

    Clinical psychologists and psychiatrists now want to properly test these new therapies, which are based on the most up-to-date understanding of the brain and cognition, among refugees in Europe. Apart from the immediate relief they could bring, and the consequent chance of faster integration, there are two main reasons to encourage this.

    These efforts will help to refine the therapies for application in all refugee centres, wherever and whenever war breaks out. And they will also help to break down barriers to modern approaches to clinical psychology in Europe, where the discipline has become conservative and complacent. Too many psychologists are reluctant to consider how mobile-device and Internet-based approaches could supplement standard therapies, and are too resistant to the concept that anyone who is not a qualified psychologist could help. The experience with refugees might also inspire improvements in local access to mental-health provision by generating, through necessity, a system that works faster and has fewer barriers.

    Much could also be learnt from an ‘employment buddy system’ in Germany called Wir zusammen’ or ‘We together’. The strongest signal of successful integration is entry into the work force, but this can be fraught with diverse and unpredictable problems. Wir zusammen is a movement of chief executives who create jobs or training positions for refugees that come with on-staff mentors — volunteers who oversee and champion their charges and who can accompany them to official appointments. . This practical support could reduce the gnawing stresses that undermine mental health.

    ‘We together’ and ‘We will cope’ are feel-good phrases, but they should not be dismissed as platitudes. When it comes to mental health, they are fundamental.

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    Healing the traumatized minds of refugees. Nature 538, 139 (2016) doi:10.1038/538139a

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