It’s been just over a year since Canada welcomed the first wave of Syrian refugees. Since then, nearly 34,000 private and government-sponsored refugees have come to this country.
A Senate report released last week looked at how well the Syrian refugees are doing so far. It highlighted the need for better, culturally appropriate mental health services. Based on what we know about refugees from other places, like Rwanda, Congo and Vietnam, it says, about 10 percent to 20 percent of the refugees will have significant mental health needs.
For many of those people, mental health issues might only surface now because there’s a honeymoon period when people arrive in the country. Some mental health issues are kept at bay with the euphoria of arriving and the distraction of getting settled for the first six months to a year.
“People have gotten away from war, and they’re interested in other things: getting a job, getting their kids into school, learning a language. So mental illness rates are deceptively low, and they increase over time,” says Kwame McKenzie, co-leader of the Centre for Addiction and Mental Health’s (CAMH) refugee mental health project, which offers training and information about many refugee mental health issues to health-care providers.
It’s a worry shared in the Senate report as well.
“The Committee is not convinced that Canada is fully prepared to help refugees whose mental health issues will surface in the coming months and years,” it reads. “Witnesses identified a shortage of psychiatrists and mental health resources, language barriers and cultural norms as being factors that delay or impede access to mental health resources.”
And now that many Syrian refugees are entering what’s colloquially called “the 13th month,” they’re also losing the financial and social supports that came with public or private sponsorships. Those who don’t find work will turn to regular social benefit programs like Ontario Works.
“After a year the supports start decreasing, and we expect that will have an impact [on mental health],” says McKenzie. “We’re really interested in starting to think through what needs to be done to make sure that people aren’t suffering in silence.”
Myths about mental health issues and post-traumatic stress disorder
One common mental illness in refugees is post-traumatic stress disorder (PTSD). It’s caused by a traumatizing event – which could involve being injured, having someone else be injured, or the threat of injury or death. Common symptoms are nightmares, flashbacks and being overly vigilant, all of which can have a significant impact on people’s relationships and ability to work.
Many people mistakenly believe that everyone who experiences trauma will develop post-traumatic stress disorder. But it’s not that simple. “Being a refugee does not equal PTSD,” says Lisa Andermann, a psychiatrist at Mount Sinai Hospital who specializes in trauma and the co-author of Refuge and Resilience: Promoting Resilience and Mental Health Among Refugees and Forced Migrants.
Most people who experience trauma will develop PTSD-like symptoms immediately afterwards, but they will resolve themselves naturally without treatment, and only a minority will develop true PTSD.
Rates are about twice as high in refugees as they are in the general population, with 10 percent to 15 percent of adult Syrian refugees having it. Children are also more vulnerable, with up to half of kids having it.
Those rates are greatly affected by how easy it is to settle into a new country. “The Canadian people mobilizing to receive the Syrians with open arms is a very important role in the rehabilitation process. The image of the Canadian prime minster going to the airport and welcoming them has a significant impact on their mental health,” says Mulugeta Abai, executive director of the Canadian Centre for Victims of Torture.
How well supported people are – if they find work, get adequate language training, schooling for their children and safe, affordable housing – makes a big difference in how many will develop PTSD. For example, If refugees don’t find work, says McKenzie, the rates of PTSD can double.
“Most refugees need settlement support,” says Andermann. “I’m more concerned about wait times for ESL than I am [about wait times] for psychiatry.”
Of course, refugees aren’t the only ones who develop PTSD. First responders, Armed Forces’ veterans, victims of sexual and physical abuse and First Nations’ members also develop PTSD. Even a car crash or traumatic birth can result in the syndrome.
Typical treatments are done one on one or in group sessions, with psychiatrists, psychologists or social workers who have received specific training in working with PTSD. They normally include a three-phase process, says Alexandra Heber, chief psychiatrist at Veterans Affairs Canada. The first, called stabilization, helps people control their fear and anger responses.
The second, exposure therapy, is where people call up their memories and process them. “By doing that, the traumatic memories actually lose some of their power. They become more like normal memories, rather than these memories that come upon people when they least expect it,” she explains. In the third phase, reintegration, people address things like going back to work or repairing intimate relationships.
Various types of therapy are effective in this process. The most common is cognitive behavioural therapy (CBT) that has been tailored to trauma. It focuses on changing harmful thought patterns, like the belief that the world is unsafe or that victims are responsible for what happened to them. Exposure therapy, which encourages people to gradually recall their traumatic memories, has also been shown to be helpful. A variation of that is called eye-movement desensitization and reprocessing, which encourages people to recall traumatic events while making eye movements or moving their hands as directed, has also been proven effective.
Medication is also commonly used. Antidepressants can work well by helping reduce depression, anger and hyperarousal, as well as helping people sleep. But it’s difficult to tell which antidepressant will work best for each person without trying i out. Medication works less well on flashbacks and feeling numb.
While depression and anxiety can often successfully be treated by primary care doctors, PTSD is generally treated with psychiatrists who specialize in trauma. Access to specialists in trauma treatment is challenging, and there can be long wait lists for these services.
“There is a shortage of psychiatrists, and not all psychiatrists know about trauma informed care,” says Abai. “For Canadians, the wait lists are very high, never mind for newcomers.”
Government-sponsored refugees are covered for up to 10 individual therapy sessions in their first year. But refugees also need care that’s culturally sensitive and includes an interpreter. Those sorts of programs are offered through the Canadian Centre for the Victims of Torture, the New Beginnings clinic at Centre for Addiction and Mental Health and the Mosaic Refugee Health Clinic in Calgary, among others.
Regular screening, which used to be done in primary care, is no longer recommended, because of the risk of over diagnosis. “We need to be very careful not to overmedicalize normal reactions,” says Abai. The Senate report pointed out that we aren’t tracking the mental health needs and treatments of refugees, and suggested that we should be. It also recommended that a comprehensive mental health plan be created for Syrian refugees.
In Toronto, a pilot project, called Lending a Hand to our Future, also provides a unique program. It borrows from a German model called Narrative Exposure Therapy. It’s an eight-session group program that encourages refugees to re-tell their stories, with great specificity, to try and give them a feeling of power over what happened, and to let them gain some emotional distance. A 2013 meta analysis found that it was effective – even with refugees themselves as counselors, which offers a promising low-cost approach. The Toronto program is run by volunteers, most of whom are nurses or doctors.
The CAMH New Beginnings clinic opened in response to the needs of Syrian Refugees, but it’s used by all refugees. It’s not yet at capacity, says Branka Agic, manager of health equity at CAMH. That might be because services also need to overcome the fact that psychiatric services were not widely available or commonly used in Syria. “Formal mental health services are often seen as the last resort by refugees. The first line of support tends to be family, friends, the ethnic community, then religious leaders, and then primary care,” she explains.
The Canadian Centre for the Victims of Torture tries to take a more holistic approach to care to overcome some of those hesitations. It has a two-week wait list for most services, and it hasn’t received any extra funding from the government to help it with the more than 400 Syrian refugees that have come through its doors. “I have only one Arabic-speaking counselor for 450 clients, and I’m telling you honestly, that counselor is going to collapse,” says Abai.
They run group therapy sessions that include an Arabic speaking mental health counselor and a psychiatrist but allow the refugees themselves to shape the programs. “We want them to be the agents of their own recovery,” says Abai. “They take ownership, and then we slowly incorporate some of the things that we want them to know.”
Last summer, they also ran a day camp for children, called Summer Quest, that incorporated mental-health components along with social activities. Forty eight kids applied for 18 spots in the program – along with 65 parents who wanted to supervise their kids. They expanded the program, and also developed programs for the parents. “We incorporate things like a soccer match, and in between, we bring in some treatment,” says Abai. “We try to combine the way that they are used to back home, and then, slowly, incorporate some attributes of the Canadian mental health system.”