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 Among the hundreds of thousands of people fleeing Syria, Afghanistan
and other war-torn areas, significant numbers are likely to have
severe psychiatric illnesses, including complex Post-Traumatic
Stress Disorder (PTSD), according to studies in peer-reviewed
scientific journals.
PTSD plagues sufferers with flashbacks and panic attacks, and can
render them sleepless, emotionally volatile and less likely to be
able to settle into a new home.
Deploying mainstream therapies designed for victims of single-event
trauma in stable, well-funded settings - such as returning soldiers
or car crash survivors - will not tackle this migrant mental health
crisis effectively, specialists say.
So therapists in Europe are honing their skills in relatively new,
refugee-focused psychological techniques such as Narrative Exposure
Therapy and Intercultural Psychotherapy.
Italian psychotherapist Aurelia Barbieri is one of a handful of
volunteer mental health experts on Europe's front line.
Working with charity Medecins Sans Frontieres (MSF) in makeshift
arrival camps in Sicily, she gives what she calls "psychological
first aid" to migrants arriving after months or years making their
escape through the desert, through Libya, across the sea.
"They often say they have been imprisoned, beaten all day long, shot
at, or scalded with boiling water. They've been treated like
beasts," she said in a telephone interview.
TERRIFYING FLASHBACKS
Almost half of 23 refugees assessed by doctors in Dresden, Germany
met the diagnosis for PTSD, according to research published in the
Nature journal Molecular Psychiatry in November.
In Sicily's Ragusa province, MSF says screening showed almost 40
percent of those suffering mental health effects had PTSD. "They
have terrifying flashbacks. They think they're going mad," said
Barbieri. "What I hope to do is first of all is listen. When they
can feel they're in a protected place, they can start talking about
their trauma."
Some refugees lose the ability to trust or form positive
relationships, according to experts at the Helen Bamber Foundation,
a British charity that supports survivors of human rights
violations.
This makes treatment more difficult, but also more critical if
refugees are to have a chance of a new life and their host countries
are to successfully integrate them, says Mina Fazel, a refugee
mental health specialist at Oxford University.
A review published in The Lancet in 2005 of 20 studies looking at
mental illness among 7,000 refugees resettled in Western countries,
found they were about 10 times more likely than the general
population to have PTSD. It concluded: "Tens of thousands of
refugees and former refugees resettled in western countries probably
have post-traumatic stress disorder."
While refugees are not a new phenomenon, it is only in about the
past decade that psychologists have refined approaches specifically
for them, partly because the international response has focused on
such needs as food, clothing and shelter.
NARRATIVE EXPOSURE
Studies of a specifically refugee-relevant psychological therapy
called Narrative Exposure Therapy (NET) show it can produce swift
and meaningful results.
Since time matters when treating refugees, who often do not stay in
one place for very long, NET - first devised by German researchers
Frank Neuner, Maggie Schauer and Thomas Elbert 10 years ago - was
developed specifically for victims of multiple trauma and designed
to be delivered in refugee camp settings.
The treatment, typically administered in six sessions of about an
hour each, focuses on clearly documenting the atrocities endured.
One clinical trial in 43 Sudanese refugees, designed to examine the
effectiveness of NET, compared results in of those who had four
sessions of NET versus others who had four supportive counseling
sessions, versus others who had one session of another established
form of psychological therapy called psychoeducation.
A year later, only 29 percent of the NET patients still met the
diagnosis for PTSD, compared with 79 of the counseling patients and
80 percent of the psychoeducation group.
Patients are encouraged to relate what has happened to them, ideally
in a chronological framework.
By emotionally exposing themselves to traumatic memories in a
coherent historical narrative, NET helps refugees "anchor in time
and context" the trauma they experienced and overcome flashbacks,
said Katy Robjant, head of therapy services at the Helen Bamber
Foundation, which uses the technique.
"You learn that you don't have to be afraid of your memories," she
told Reuters.
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Robjant says that in the past year, around 30 to 35 patients at the
foundation had been treated using NET. Her foundation is one of five
specialist trauma services in London, and all use NET for many of
their multiple trauma PTSD patients.
None of the organizations mentioned in this story would allow
Reuters access to refugees undergoing therapy, citing concerns about
patient confidentiality and welfare.
It is also difficult to gauge the costs of the treatments described,
since they are often administered by therapists working for
charities on a voluntary basis.
ALIENATION, ANXIETY
Other specialists prefer a different approach, using their own
experiences as refugees now settled and working in a new country to
help others deal with their trauma.
In an old piano factory that has become the Refugee Therapy Centre
in north London, a 44-year-old Syrian man wrings his hands, his
desperate eyes darting and restless as he tells of being imprisoned
and torture. His wife says he wakes up crying in the night, can't
work, and can become angry and unpredictable when people make
comments in the street.
He doesn't want to give his name, or details of what his jailers did
to him, but he hopes staff at the center can help.
The therapists here work in 14 languages - including Arabic, Farsi,
French, Spanish and Turkish - to help patients like the Syrian
refugee deal with issues of cultural alienation, social isolation,
anxiety and depression.
The center's clinical director, Aida Alayarian, doesn't use NET,
saying she prefers to avoid exposing her patients to painful
memories and instead wants to focus on overcoming present fears and
anxieties. She says she sees better results with a technique known
as Intercultural Psychotherapy.
With its roots in the development of cross-cultural psychiatry of
the 1970s, the treatment was refined in the past decade to focus on
refugees. It aims to rebuild psychological resilience and, Alayarian
says, is relevant for migrants currently coming to Europe,
particularly the young.
"It's really important for us to bring in young refugees who have
suffered psychologically but don't have the willingness to seek
psychological help," she said.
Over the last year, the center - funded in part by charitable
donations and in part by local government grant - has been seeing
about 50 patients a week. She says around 90 percent of her patients
meet the diagnostic criteria for PTSD.
There is no defined duration for the treatment. Therapists use
psychoanalytic techniques to work through past experiences, but the
emphasis is on providing cultural support, including advice about
schools, housing and employment, to help migrants adjust, tackle
current difficulties and rebuild confidence and self-esteem, rather
than documenting past trauma.
'TIP OF THE ICEBERG'
Whatever the preferred approach, there is little doubt demand is
high.
The United Nations refugee agency UNHCR says nearly 59.5 million
people worldwide were displaced at the end of 2014, up from 51.2
million in 2013. The U.N. sees no easing of the flow into Europe and
says the current 8,000 daily arrivals may turn out to be only "the
tip of the iceberg".
Some health experts argue that while psychological first aid may be
desirable, refugees often have more pressing needs such as food,
clothing, shelter, safety and access to justice.
Robjant agrees basic emergency needs come first, but said: "We're
talking here about people who have very serious mental health
problems, and those kinds of people will find it much more difficult
anyway to meet their own basic needs.
"Also, for those who are suicidal, addressing their mental health
could be as much a life and death situation as addressing their need
for food and shelter."
(Editing by Pravin Char)
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