Zonal Similarities and Challenges in Europe: WPA Athens 2005

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Zonal Similarities and Challenges in EuropeWPA
Athens 2005

• Marianne Kastrup
• Centre for Transcultural Psychiatry
• Rigshospitalet Copenhagen
• Denmark

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Overview Presentation

• Globalization
• European challenges
• WHO Mental Health Action
• Topics of concern in the zone

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Globalization We are living in a world of rapid
change with the

most rapid
transformation in developing countries


forcing billions to face a future so
different from life when they grew up that few of
their skills are able to assist them with new
challenges. Gro Harlem Brundtland 2001
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Globalization

• Change may result in insecurity,
  un-predictability most people cope with it with
  difficulty
• Certain populations run particular risk during
  this transformation
• Gro Harlem Brundtland 2001

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Facing Challenges

• Voices of the Poor seeking
• Good health
• Sense of community and safety
• Sense of well being
• Need among rich
• Political will and decency
• Fair share to the excluded part of the world
• World Bank

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Zonal Challenges

• Delicate balance between the individualistic
  approach to services, the increasing demand for
  services, and the societal need to limit health
  care resources
• H. Nakajima
  1996

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Zonal Challenges

• The moral need for equality is made all the more
  unattainable if priority is given to progress
  over fairness, more over enough, and indefinite
  goals over limited, achievable goals
• Callaghan 1996
  

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Facing Challenges

• All persons have free and equitable access to
  health services irrespective of sex, age, social
  status, and the problem from which they suffer.
• A. Rolighed, former Danish Minister of Health
• 2001 WHO Assembly

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Zonal Similarities

• Value systems
• Moral and ethical principles guiding a profession
  
• Social values of an organisation
• Dynamic values of society

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Zonal Similarities

• Prevalent values that the European region can
  adhere to
• Fairness
• Equality
• Solidarity

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WHO Mental Health Action Plan for Europe

• Priorities
• foster awareness of importance of mental
  wellbeing
• empower mentally ill and their families to tackle
  stigma and discrimination
• design and implement comprehensive integreated
  services covering promotion, prevention, care and
  recovery
• address need for competent workforce

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WHO Mental Health Action Plan for Europe

• Promote mental wellbeing for all
• Demonstrate awareness of the centrality of mental
  health
• Empower people to counter stigma
• Activities sensitive to life stages
• Prevent mental health problems and suicide
• Ensure access to good primary care

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WHO Mental Health Action Plan for Europe

• Offer effective community bassed services to
  persons with severe mentally problems
• Establish partnership across sectors
• Create sufficient and competent workforce
• Establish good mental health information systems
• Provide fair and adequate funding
• Evaluate effectiveness and generate new evidence

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Issues of Zonal Concern

• Migration
• Stigma
• Reintegration into the workforce
• Recruitment of Psychiatrists

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Collective Violence

• Wars, terrorism, violent political conflicts
• State-perpetrated violence e.g. torture,
  repression, disappearances
• Organized violence e.g. banditry, gang warfare
• WHO Violence and Health2002

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Refugee Mental Health

• Issues of concern
• How do psychiatrists raise awareness of factors
  of importance for refugee mental health?
• How is the available knowledge implemented in the
  current immigration legislation?
• Do professionals have a responsibility in
  ensuring this?

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Immigrant Adaptation Process

• Multivariate model taking into consideration
• Pre-migratory conditions
• Characteristics of the individual
• Post-migratory factors in new country
• Goldlust Richmond 1974

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Migration and Mental Health

• Existence of PTSD associated with post-migratory
  stressors e.g.
• Delays in refugee application processing
• Experiencing conflicts with immigration officials
• Not having a work permit
• Unemployment
• Racial discrimination
• Loneliness and boredom
• Silove et al 1997

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Migration and Mental Health

• Post-migratory conditions 4 stages of settlement
• First Arrival learning about exile, period of
  mixed feelings
• Honeymoon Stage real issues have not been faced
  
• The Crash realities sink in, depressive
  feelings
• Stage 4 a. participation, sense of contributing
  again
• seeing a way ahead
• b. being parked, not achieving goals, getting
  depressed
• need help to set realistic goals
• Australian Refugee Council 2002

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Migration and Mental Health

• Post-migratory conditions Emotional needs
• Safety
• Trust
• Control over environment
• Ability to plan for the future
• Restoration of sense of dignity
• Regaining sense of self worth
• Sense of belonging
• Australian Refugee Council 2002

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Migration and Mental Health

• Post-migratory conditions
• Initial information
• Accomodation
• Material assistance
• Language
• Education
• Income support
• Employment
• Health care
• Australian Refugee Council 2002

• Practical needs
• Torture-trauma counselling
• Legal aid
• Community development
• Religious expressioin
• Leisure
• Becoming part of community
• Support to special groups

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Consequences of Mental Disorders

• Mental disorders have impact on individuals,
  families, social network
• Burden of illness due to e.g. stigma,
  discrimination, lack of work, economic
  difficulties, stress on families

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Marginalized Populations

• Impact on daily life of children
• Behaviour as small adult
• Responsibilities with care taking of siblings,
  parents, etc.
• Complicity of silence of what goes on in the
  family
• Lack of positive family experiences
• Difficulty in adjusting at school
• Development of behavioural problems

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Marginalized Populations

• Impact on family functioning
• Parents unable to participate in any activities
  related to school, institution, etc.
• Environment marked by unpredictability
• Parents fear consequences if revealing problems
• Taboos related to mental illness result in family
  secrets
• Schools and other institutions seen as threats
  instead of possible means of support
• Children feeling isolated from peer group with
  little social contact with peers
• Inability to speak language of host country adds
  to isolation
• Difficulty in establishing sustainable alliance
  between parent and authorities

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Marginalized Populations

• Summarising
• Mental problems of marginalized groups have
  severe social consequences
• Far-reaching as some may have impact on second
  generation

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Obstacles to Treatment

• Recognition of
• A. Special attention to reach equity of services
• B.Resources necessary due to
• Complexity of problems presented
• Involvement of many agencies
• Necessity of interpreters
• Basic training of professionals
• Supervision required
• Extra time required

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Marginalized Populations

• Transformation from traumatized to empowered
  survivors may take place
• National level
• Community level
• Individual level

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Marginalized Populations

• Empowerment
• At national level we may
• Encourage public authorities to prepare national
  strategies for integration of refugees
• In country of origin encourage strategies for
  community restoration as well as individual
  rehabilitation and provide expertise to
  colleagues in such areas
• Ensuring refugees equal access to health care
  incl. mental health care,
• Strengthen development of migrant friendly
  institutions
• Ensure that mental condition is taken into
  consideration in integrative programs

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Marginalized Populations

• Empowerment
• At community level we may work for
• Dissemination of information
• Support to local activities,incl.migrant friendly
  CMHC
• Establishment of psychoeducational programs
• Formation of self-help groups, mentor networks,
  etc

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Marginalized Populations

• EmpowermentAt individual level we may
• Facilitate individual healing and counseling
• Strengthen coping abilities of traumatized
  refugees and their immediate families

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Implication for Psychiatrists

• The majority of psychiatrists are employed in
  public services
• This implies that all psychiatrists are likely in
  their daily clinical practice to encounter
  patients of another ethnic background and
  responsible for setting up a treatment plan
• Little systematic training of psychiatrists on
  cultural issues

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Improving Cultural Competence

• Recognize that culture goes beyond skin color-
  others may identify with religion, gender, etc
• Find out each patients cultural background
• Determine your cultural effectiveness - analyse
  treatment, etc. among cultural groups
• Make patients feel at home
• Conduct culturally sensitive evaluations - avoid
  misdiagnosis
• Elicit patient expectations and preferences
• Understand your own cultural identity
• Steven Moffic (2003)

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Conclusion

• Training should focus on providing psychiatrists
• awareness of own cultural identity and prejudices
• skills of communication across cultures
• ability to question own stereotypes
• ability to show empathy across cultures
• comprehension of complexity of situation
• basic knowledge on culture dependent perceptions
  of disease

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Recommendations

• The psychiatric profession should be encouraged
• to participate in the public debate
• to express concern via public means about health
  issues among refugees
• to further collect and disseminate scientific
  literature on the various kinds of mental health
  problems in refugee groups and the relation to
  their current life situation
• to produce educational materials and guidelines
  for minimum standards for mental health care
• to establish work shops, symposia etc. for
  psychiatrists
• to further strengthen and develop professional
  networks

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Equity as a Right

• Withholding care as ethical breach
• Obligations for psychiatrists to participate in
  public debate
• Certain diagnostic groups without strong lobby
• Equitable allocation of resources

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Equity as a Right

• In the WHO manifest, Health for All - Year 2000
  it is emphasized that health including mental
  health implies a principle of equity.

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Equity as a Right

• The first target states that by the year 2000 the
  actual differences in health status between
  countries and between groups within countries
  should be reduced by at least 25 by improving
  the level of health of disadvantaged nations and
  groups.
• A central issue is thus to ensure an equity in
  mental health and mental health facilities within
  as well as between nations.

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Equity as a Right

• The second target states that by the year 2000,
  people should have the basic opportunity to
  develop and use their health potential to live
  socially and economically full filling lives.
• The implication of this positive health concept
  is that we add life to years by letting people
  utilize their resources in all aspects of life.

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Equity as a Right

• The third target states that by the year 2000
  disabled people should have the physical, social
  and economic opportunities that allow for
  socially and economically fulfilling and mentally
  creative life.
• Disabled patients whether they are
  institutionalized or not should be guaranteed all
  basic human rights.

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Cultural Influence

• Ethnic minorities represent other set of problems
• How has the Danish health services adapted to
  these group during the approx.30 years these
  patients have used the services
• In practice it is more frequently the patients
  that adapt to the health services regarding
  routines, etc.
• Nielsen 2002

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Cultural Influence

• Does our system implicitly presume an ideal
  culture in relation to which other cultures are
  evaluated?
• Health professionals who signal a particular set
  of values exert a cultural influence towards the
  culture represented by the patient from another
  etnic background
• Should a health professional engage actively in
  this cultural influence by trying to adapt
  patients to the culture of our system even though
  it may go against that of the ethnic grooup?
• Gullestrup 2003

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State-perpetrated Violence

• Individual Characteristics
• defense and coping mechanisms, e.g. humour,
  sublimation
• subjective meaning, making sense
• dissociation, daydreaming
• social networking, supportive family

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State-perpetrated Violence

• A. Immediate Consequences
• depending upon form of torture
• B. Long-term Consequences
• physical
• primarily musculo-skeletal
• psychological
• flashbacks, irritability, concentration problems,
  depressive spt, hyperarousal, aggressiveness,
  lack of energy, nightmares, sexual dysfunction

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Refugee Experiences

• Pre-Migratory experiences
• Torture
• Rape
• Ethnic cleansing
• Detention
• Persecution
• Disappearances

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Refugee Mental Health

• Pre-migratory conditions
• approx. 30 subjected to severe traumata incl.
  torture large variation in reported findings
• consequently exhibition of a high prevalence of
  psychiatric disorders incl. PTSD, depression,
  anxiety

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Refugee Experiences

• Post-Migratory
• Severe losses, e.g. family, country, status
• Racism
• Language barriers
• Work/housing problems
• Health
• Safety
• Discrimination

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Refugee Mental Health

• Pre migratory traumatic factors e.g. torture and
  post-migratory stressors e.g. passivity of
  existence and unemployment in exile constitute
  independent risk factors for refugee mental
  health
• Lavik et al, 1996

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Refugee Mental Health

• Individual characteristics including
• defense and coping mechanisms, e.g. humor,
  sublimation
• subjective meaning, making sense
• dissociation, daydreaming
• social networking, supportive family
• age
• gender

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Marginalized Populations

• Summarising
• A number of factors, e.g. migration, pre- and
  post-migratory adversities, racism, consequences
  of globalization may be associated wtih
  development of mental and behavioural disorders

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Marginalized Populations

• Trans-generational problems
• Some draw a pessimistic picture of second
  generation children
• Some report child adjustment within normal limits
• Some report the migrant status of parents as
  decisive for functioning of children

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Marginalized Populations

• Treatment issues
• cultural issues in focus in refugee work
• supportive element prevail
• support traditional religious beliefs to provide
  meaning
• some are alien to psychological treatment
• tendency to focus on physical complaints
• survival, resettlement and social needs dominate
• take functioning of entire family into
  consideration

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Recommendations

• Therapeutic aspects
• Recognition of complexity of problems
• Sharp distinction between general psychiatry and
  trauma treatment is not useful
• Multidisciplinary approach
• Community based approach with coordination of the
  various interventions
• Need for closer collaboration with ethnic groups

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Cultural Competence

• Clinical based definition
• Cultural competence is a set of behaviours,
  attitudes, and policies that come together in a
  system, agency, or among professionals that
  enable them to work effectively in cross-cultural
  situations
• Cross et al (1989)

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Cultural Competence

• Need based definition
• Cultural competence is the acceptance and
  attention to the dynamics of difference, the
  ongoing development of cultural knowledge, and
  the resources and flexibility within service
  models to meet the needs of minority populations
• Cross et al (1989)

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Cultural Competence

• Market based definition
• Cultural competence is the integration and
  transformation of knowledge, information, and
  data about individuals and groups of people into
  specific clinical standards, skills, service
  approaches, techniques, and marketing programs
  that match the individuals culture and increase
  the quality and appropriateness of health care
  and outcomes and lower costs
• King Davis (1997)

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Migration and Mental Health

• Post-migratory mental health
• Post-traumatic symptom level associated with a
  variety of factors in the current life situation
• Unemployment and low socio-economic status
• Poor social support
• No family/social network
• Passivity
• These factors are interrelated
• e.g. risk of passivity interacts with
• Unemployment
• Inability to visit native country
• Dependence on social welfare
• Limited social network