UNHCR Working With Refugees – by Dr. Natasa Diakoumopoulou
UNHCR – Relocation Scheme Project
My name is Natasa.
I am a Psychiatrist.
I have been working with Refugees since August 2016.
I work in a program funded by UNHCR, which is called Relocation Scheme Project.
And, I will start by saying, who is a Refugee?
A Refugee, is someone who has been forced to flee his or her country because of persecution, war or violence.
A Refugee has a well-founded fear of persecution for reasons of race, religion, nationality, political opinion or membership in a particular social group.
Most likely they cannot return home or are afraid to do so. War and ethnic, tribal and religious violence are leading causes of Refugees fleeing their countries.
Some statistics:
From UNHCR 2015,
About 65.3 million people have been forced from home around the world.
Among them are nearly 21.3 million Refugees, over half of whom are under the age of 18.
There are also 10 million stateless people who have been denied a nationality and access to basic rights such as education, health care, employment and freedom of movement.
Nearly 34,000 people are forcibly displaced every day as a result of conflict or persecution.
In Europe now, 49,000, almost 50,000 people have risked their lives to reach Europe by sea.
So far in 2017, and 1344 feared drowned so far in 2017.
The numbers are huge.
So about my job, what we are doing in Athens
We are two medical teams. There’s a pediatrician, internist, gynecologist, a psychiatrist and psychologist.
Both the teams work for this program and it has been renamed.
It began as relocation and now it is an accommodation program because many of the Refugees, have will stay here will stay in Greece.
The first team where I belong is located at the medical center of Patisia in Athens.
We receive referrals from our program We have almost 1600 people, adults and children, located in apartments in Athens, as well as from other, NGOs and organizations such as Arsi Solidarity Now and Doctors Without Borders.
People who we treat live either in apartments or in camps.
For example, the referrals from the Doctors Without Borders come mostly from camps.
All of them are adults and, there is no significant number difference between men and women as, as far as the, psychological support and psychiatric disorders are concerned,
Populations come mostly from Syria Afghanistan, Iraq, Iran, and much fewer from Africa and Palestinians as well.
The most violent narrations come from Iraq.
There is war in Syria. But, the the conditions in Iraq, there are no words to describe what we hear.
Mass executions, systematic rape and, horrendous acts of violence are widespread in Iraq.
Human rights and rule of law are under constant attack.
So what are the challenges when we work with Refugee populations?
Challenges and difficulties at the same time:
So first of all, we have the Refugee barriers.
Okay.
They have difficulties to seek out services. There’s stigma, around mental health. They tell me, quite often, they used to tell me that in their countries, only the crazy go to the psychiatrist.
Then there is a distrust of authority and systems of care because they they are they’re suspicious because they have they had to deal with so many difficulties during their journey.
So they do not trust easily the system.
The families recognize that there are many problems psychological, but they have to deal with other resettlement stressors like housing, employment.
And so they believe that, these issues are much more important than go to the psychiatrist.
They are, not very well informed of services. And the truth is that the referral networks are limited.
The language is, a huge problem.
Parents and children not proficient in English, of course.
And the role of interpreter is vital. We will talk about this, a little later.
Then there are difficulties around me at expressing feelings. And, they need psychoeducation.
As far as, recognizing and expressing emotions, and they are unfamiliar with psychiatric disorders, of course.
There are also many cultural barriers, for example, during the month of Ramadan, which starts in a few days, I think tomorrow.
No, on Saturday, they don’t want to visit the doctors because, they don’t want to talk.
Then they have, then that, then there are other things such as, stereotypes.
They, they often not, tell me that, you know, back to my country, the drug users get in prison, so they, they, they have difficulty to, open this.
Excuse me, to open the issue of, drug or alcohol abuse, and alcohol use, for example, is forbidden by the religion.
It is that it is forbidden, but quite often there is misuse of alcohol.
Cultural practices such as violence against women is accepted, by Muslims. So societies by so domestic violence is difficult to be revealed.
The difference between a psychologist, what the psychologist does, and what the psychiatrist does is totally unclear.
And now the difficulties:
Difficulties, the barriers, as far as the assessment is concerned, first of all, the cultural validity, how closely concepts in a question are, for example, much local concepts?
Most of the times, Western concepts may not apply locally unknown local concepts.
They might be very important, but I’m not aware of them.
So how can I include, questions?
I don’t know, I should be, I should be asking or how to include the question
[ Thank you. ]
Or how to include the question. in a not insulting way.
For example, the, the alcohol use, it is it is a very important, question when, we examine, sometimes the interpreter for example, has difficulties to ask because it is thought that if somebody is Muslim, that means he or she never drinks, especially towards women,
Then this question is quite difficult, especially towards women.
And of course the translation problems
Who translates.
So the interpreter’s role is, vital is very important.
I have written here an example which I find it really interesting, during examination with a drug addicted person, the interpreter told me that he could not he could not ask the person if he has, suicidal thoughts because he couldn’t bear the question and they would cry. The interpreter would cry.
The interpreter often replies instead of the person who is examined. The Refugee builds a personal relationship with the interpreter.
Quite often he / she ask for interpreter’s trust. Trust by saying, look, I’ll tell you something, I’ll tell you a secret, but do not tell it to the doctor. Please.
The interpreters are not always well trained, especially for mental health issues.
There are many difficulties.
For instance, the word “support” cannot be sufficiently translated in Arabic, so they have to describe it.
I would also like to, to add here that, many things we believe as doctors as psychiatrists that are clear are totally unclear for, for Refugees, for example, the simple question, how do you sleep?
How is your sleep?
It can be, quite complicated because they do not understand this.
You have to explain.
When I asked you, how do you sleep? I mean, do you sleep the whole day? The whole night? Do you wake up early in the morning and do you feel tired?
You have to do many questions because they will, simply tell you “tamam”, It’s okay.
Everything is fine with my sleep, but they do not sleep well.
So, most of them, when they, they reach a psychiatrist, ask for a pill to forget or sleep.
They do not understand the importance of adherence.
They feel better. They stop taking the medication. This is a rule.
Others believe that medication is addictive or will make them sleep.
And now practical issues that, such as medication is not easily affordable and we have to look for, whatever we can, at social pharmacies.
Follow ups.
One appointment is enough.
Difficulty at keeping, stability at follow ups. They believe it’s okay. I’ve seen the psychiatrist once. I feel better. That’s enough.
It takes much more time to establish a therapeutic, relation, but it continues to be very important.
So, As far as the, the disorders, the psychiatric disorders and the symptoms the stress from the instability, in addition to the trauma they already experience, means that Refugees are particularly vulnerable to mental disorders.
The most common are depression, depression, PTSD, anxiety disorders, sleep disorders, psychosis, personality disorders, alcohol abuse, and of course, suicidal attempts.
So, this is, a case.
It’s not something, something we don’t see in Greece or in Europe. But it’s interesting as far as the, the cultural thinking is concerned.
Amira suffers from schizophrenia, diagnosed at the age of 15 years old. There might be also a kind of developmental disability as well. Undiagnosed though, the girl was a bad pupil, she used to have a lot of outbursts, and was negative to any medication.
Amira is a young woman around 30 years old, from Syria, she lives in Athens with her mother, one younger sister, who is married with two little children. But her husband has taken the children away from her to punish her. And the niece, they’re in Athens for a few months, I think 5 or 6 months. And they’re going to leave Athens to leave Greece for Germany. The father of the family has passed away a long time ago. The rest of brothers and sisters live in Germany. The three women and the niece have been accepted to Germany, and their daily journey will take place soon.
Her mother. That’s the interesting thing.
Her mother has told me that at the beginning of the disorder, and as it is common practice in Syria, she consulted a local healer who tied Amira up with chains and beat her, as is it is the ritual.
The mother eventually asked for professional help, and the girl received some kind of treatment when they first came to me she has been suspicious and not cooperative.
She didn’t want to take any medication. She was even hostile. After several appointments and follow ups, we managed to establish a good relationship. She now takes Olanzapine. Okay, 20 milligram. She asks for her pill and remains stable.
This is quite characteristic that, in some psychiatry psychiatric disorders like schizophrenia are still thought to be, are still treated, in a way that we only read in books.
So as conclusions,
Mental health support in the Refugees is often neglected.
In the current Refugee crisis, with tens of thousands of desperate and exhausted Refugees attempting to reach safe havens in Europe, mental health and psycho-social well-being is somewhat overlooked.
Amid all the needs that are crying for attention, says Peter Fenton Fogel, who is a senior mental health officer at UN Refugee agency.
I think this is quite important that these people, Refugees, are not psychologically weak.
Most of them, we meet, have traveled for one year or more before landing in Greece.
So one year of danger and dangerous situations.
The stressful wait during the months after arrival is often when drama takes shape.
The past comes back, the present is difficult. The future is uncertain.
People sometimes arrive in good, good mental health and become increasingly depressed as the months wear on.
Perhaps the most important thing to do is to treat Refugees with respect and dignity, preserving and strengthening their autonomy and self efficacy.
And, to and one more.
One last thing.
