“Mental health”
Health on the move,
migrants and displaced populations’
health care
15 Jan 2011
D. Ploumpidis ()
Greece for more than hundred years has been a country of emigration, in large scale, throughout the world.
Since twenty years Greece has to face a new problem for the Greek social structure, the problem of immigration, temporary or permanent, concerning single persons or families coming from different countries of Europe, Asia or Africa.
The problem of mental health of immigrants or refugees is, anyway, a complex one. I am a psychiatrist but I think that some immediate problems have to be faced before an eventual psychiatric care. That is to say the problems of food, of shelter (where to live decently), of hygiene and of general health care. If there is no solution for these problems, then we can have to face states of stress, of anxiety, of depression, sometimes of delusions, whose efficacious care is much more a social problem to resolve and less a problem of mental health.
Sometimes we focus on these problems of stress , of anxiety or depression in order to demonstrate the need of public interest and concrete measures for migrants or refugees.
Another reason to focus on problems of general health care is the fact, pointed it out in many studies, that in many cultures (mainly agricultural) psychic pain and stress can be expressed only through the pain or disturbed functions of the body ( It is a medical nonsense to say to these people “your body is very well you will visit a psychiatrist”. This is a process in contradiction with their culture).
What a psychiatrist or a psychologist can do, if he has an adequate training : he can evaluate if symptoms or somatic pain or general anxiety are the expression of a somatic disease, of the process of the migration or there is a more serious problem of mental health.
Medecins du Monde, Medecins sans Frontieres, Babel (see on Internet) have a large experience of these problems to evaluate in first contact with migrants.
How we can approach mental health problems :
1. Is the cultural context of a migrant proximal or distal ?
Our experience in the Transcultural Psychiatry Unit of our Department shows that we can establish, quite easily, a contact with migrants of proximal cultures
2. Migrants of distal culture can use mental health services, only if the mental health professionals can understand the complexity of the problem. ( Ex. the anxiety or somatic complains can be the expression of their overall insecurity and not of a mental health problem)
Drugs can ameliorate a problem of anxiety but it is difficult to appreciate a problem of delusions out of the cultural context of a migrant.
In Athens (especially in Kypseli) many traditional healers propose their services to African immigrants, People with a great anxiety for an uncertain future. In contrary to an individual approach of a mental health professional they propose an overall approach of the human being , in contact with a world of spirits.
II. How we can approach mental health problems
The services of cultural mediators are precious.
In Greece : Training of cultural mediators
- Babel / Βαβέλ (Intrrnet)
- Έθνική Σχολή Δημόσιας Διοίκησης και «Διάσταση»
(Ε. Ιωαννίδη Καπόλου. «Η εμπειρία από την τοποθέτηση πολιτισμικών διαμεσολαβητών στα νοσοκομεία» . ΝΕΑ ΥΓΕΙΑ (Internet), τευχ. 74 (2011), σ.9)
The problem of migrants, mainly of proximal culture, becomes more and more frequent in mental health services.
The problem of migrants of distal culture (in few cases) becomes dramatically present in public psychiatric hospitals
Acculturation
“The progressive adoption of elements of a foreign culture, ideas, words, values, norms, behaviors and institutions by persons, groups or classes of a given culture” (Sam, 2006)
A considerable amount of stress can arise as a result of immigrants continuous and sometimes unsuccessful effort of integration and acceptance by the mainstream culture (Berry, 2006)
IAS: Immigrants Acculturation Scale (Produced and standardized In Greece)
Madianos MG, Gonidakis F, Ploubidis D, Papadopoulou E, Rogakou E. “Measuring acculturation and symptoms of depression of foreign immigrants in the Athens area”. Int J Soc Psychiatry, 2008 Jul;54(4):338-49.
Table 1: Immigrant Acculturation Scale (IAS): factor analysis results (varimax rotation)
Items / Factor 1: Everyday life / Factor 2:Wishful orientations / Factor 3:
Identity
I am reading newspapers/journals in …
I am speaking/writing in …
I am watching TV/Video in …
The language I am usually speaking is …
I would prefer to go on vacations in …
I am getting my provisions etc. from stores of …
I am cooking my food …
In my work I contact only …
I prefer the music of … / 0.74
0.63
0.59
0.51
0.50
0.45
0.45
0.43
0.41
I would prefer my children to get married with …
I would prefer my doctor to be …
One day I want to go back …
The best place for an immigrant to live is… / 0.74
0.64
0.47
0.43
I am participating in associations of …
I see myself as an …
My close friends are …
I am in continuous contact with my homeland / 0.68
0.62
0.48
0.46
Percentage of variance: total scale 43.8 / 19.0 / 10.4 / 8.7
IAS: KΛΙΜΑΚΑ ΕΠΙΠΟΛΙΤΙΣΜΟΥ : 17 ερωτήσεις
Α. Καθημερινή ζωή (Everyday life ) (9 items)
1.Μιλώ, γράφω, διαβάζω.
1.Μιλώ,γράφω,διαβάζω μόνο στην γλώσσα μου.
2.Μιλώ,διαβάζω μέτρια, δεν γράφω ελληνικά.
3.Μιλώ καλά, αλλά διαβάζω και γράφω μέτρια ελληνικά.
4.Μιλώ, γράφω, διαβάζω ελληνικά καλά
2.Διαβάζω εφημερίδες/περιοδικά.
1..Μόνο δικές μου εφημερίδες ή περιοδικά.
2.Ελληνικές και της πατρίδας μου εφημερίδες ή
περιοδικά.
3.Ελληνικές και δικές μου εφημερίδες ή περιοδικά.
4.Μόνο ελληνικές εφημερίδες ή περιοδικά.
0.Δεν διαβάζω/δεν αφορά.
3.Βλέπω προγράμματα στην τηλεόραση ή ταινίες video στη γλώσσα μου.
1.Συχνά στην γλώσσα μου.
2.Πιο συχνά στην γλώσσα μου παρά στα ελληνικά.
3.Πιο συχνά ελληνικά παρά στην γλώσσα μου.
4.Πάντα ελληνικά.
0.Δεν αφορά.
4.Μου αρέσει η...... μουσική.
1.Ελληνική.
2.Της πατρίδας μου και ελληνική.
3.Της πατρίδας μου μόνο.
0.Δεν αφορά.
5.Γλώσσα που μιλώ με τους άλλους συμπατριώτες ή στο σπίτι μου.
1.Μόνο την δική μου γλώσσα.
2.Ελληνικά και την δική μου γλώσσα.
3.Ελληνικά πάντα.
6.Το καλύτερο για ένα ξένο/μετανάστη στην Ελλάδα είναι.
1.Να ζει σε γειτονιά μόνο με έλληνες.
2.Να ζει σε γειτονιά με έλληνες και συμπατριώτες του.
3.Να ζει σε γειτονιά μόνο με συμπατριώτες του.
4.Να ζει σε γειτονιά με ανθρώπους άλλης εθνικής ομάδας.
0.Δεν ξέρω/δεν αφορά.
7.Οι πιο στενοί μου φίλοι είναι:
1.Συμπατριώτες μου μόνο.
2.Συμπατριώτες και άλλες εθνικές ομάδες
3.Συμπατριώτες μου και έλληνες.
4.Έλληνες μόνο.
0.Δεν αφορά.
8.Επικοινωνώ με γράμματα/τηλέφωνο με τους δικούς μου.
1Κάθε μήνα ή συχνότερα.
2.Μερικές φορές τον χρόνο.
3.Λιγότερο από (1) φορά το χρόνο.
4.Ποτέ
0.Δεν αφορά.
9.Θα επιθυμούσα μία μέρα να γυρίσω στη χώρα μου, εάν πρόκειται για χώρες με πολιτική ή οικονομική αστάθεια εάν υπάρχουν οι κατάλληλες συνθήκες.
1.Συμφωνώ απόλυτα.
2.Μάλλον συμφωνώ.
3.Μάλλον δεν συμφωνώ.
4.Δεν συμφωνώ.
0.Δεν ξέρω.
Β. Επιθυμίες (Wishful orientations ) (4 items)
10.Μετά από...... καιρό στην Ελλάδα, θεωρώ τον εαυτό μου:
1......
2...... και έλληνα.
3.Έλληνα.
0.Δεν ξέρω.
11.Συμμετέχω ενεργά σε...... σωματείο/σύλλογο.
1.Της δικής μου χώρας/καταγωγής.
2.Της δικής μου χώρας/καταγωγής και ελληνικό.
3.Ελληνικό
4.Δεν ανήκω πουθενά /δεν αφορά.
12.Το καθημερινό φαγητό θέλω να είναι μαγειρεμένο:
1.Με τον δικό μου τρόπο μόνο.
2.Με τον δικό μου και τον ελληνικό τρόπο.
3Με τον ελληνικό τρόπο.
0.Δεν αφορά.
13.Ψωνίζω τα τρόφιμά μου σε μαγαζιά.
1.Μόνο δικά μου.
2. Δικά μου συνήθως και ελληνικά μερικές φορές.
3.Δικά μου και ελληνικά
4.Ελληνικά συνήθως.
0.Δν ξέρω /δεν αφορά.
Γ. Ταυτότητα (identity) (4 items)
14.Πηγαίνω διακοπές (χειμώνα ή καλοκαίρι)
1.Στην χώρα μου μόνο.
2.Στην χώρα μου και αλλού.
3.Στην Ελλάδα.
0.Δεν πηγαίνω διακοπές/δεν αφορά.
15.Αν δεχθούμε ότι οι γιατροί είναι εξίσου καλοί θα προτιμούσα γιατρό:
1.Δικό μου οπωσδήποτε.
2.Δικό μου γιατί δεν μιλώ καλά ελληνικά.
3Έλληνα.
0.Δεν ξέρω.
16.Τα παιδιά μου προτιμώ να παντρευτούν :
1.Δικής μου καταγωγής άτομο μόνο.
2.Ίσως ελληνα(ίδα),ίσως δικό μου.
3.Eλληνα (ίδα).
0.Δεν ξέρω.
17.Όταν εργάζομαι έρχομαι σε επαφή.
1.Με ξένους μόνο.
2.Με έλληνες και ξένους.
3.Με έλληνες.
0.Δεν αφορά.
In order to summarize my presentation I have used a review article published in WORLD PSYCHIATRY (free on internet), journal of World Psychiatric Association:
D.Bhugra, S. Gupta, K.Deep Bhui, T. Craig, N.Dogra, J. David Ingleby, J. Kirkbridge, D.Moussaoui, J.Nazroo, A. Quershi, T.Stompe, and R. Tribe. WPA guidance on mental health and mental health care in migrants. World Psychiatry. 2011 February; 10(1): 2–10
Items permitting a global approach of evaluation of mental health problems of migrants
History taking : in order to evaluate problems of mental health we have to take into consideration :
Factors before migration
- Reasons (e.g., student, economic, political)
- Preparation of the departure ( elaborated or unexpected)
- Group or singly
- Degree of control over the process of migration
- Migration (traumatic or not traumatic feelings)
- How long ago
- Age on arrival
- Possible return or permanent
- Asylum status
- Previous experiences (ex. history of violences, familial context etc),
Factors after migration
- Aspiration/achievement (what a migrant has expected and what he has achieved
- Acculturation and adjustment
- Attitudes towards new culture
- Attitudes of the new culture
- Being aware of strengths of one’s own culture and its weaknesses ( fully adopting the new culture , rejecting his culture of origin , being aware of the strong points of his culture)
(how the culture of origin and the culture of the new country interact)
- Support networks available/accessible Interviewer
- Own values, prejudices (related also to the structure of character and not only theculture)
What we expect from Policy makers
- To develop clear policies taking into account human rights of migrants, refugees and asylum seekers.
- Adequate resources should be made available according to the needs.
- Adequate resources for training, including cultural competency training, should be available.
- Different parts of the government (e.g., health, education, justice, home, external affairs) should be involved.
- Changes in admission criteria should be discussed with stakeholders, rather than being imposed arbitrarily.
- Public education and public mental health messages for refugees, asylum seekers and migrants should be carried out.
What we expect from Service providers
- Separate or joined up services should be made available, but it is essential that there are no barriers to help seeking.
- Services should be culturally sensitive, geographically accessible and emotionally appropriate.
- Cultural competence training must be provided and mandatory measures to achieve this should be considered.
(BABEL in Greece: cultural mediators)
- Other models, such as culture broker or cultural liaison, should
be employed where indicated.
- Regular research into epidemiological factors, along with
qualitative approaches, should be carried out in order to
assess and monitor pathology.
- Regular audits into treatment accessibility, acceptability and
usage must be conducted.
Clinicians
- Clinicians must have access to resources informing them of specific cultural issues.
- Cultural awareness and competence training must be mandated and regular updates must form a part of this.
- Clinicians must provide culturally appropriate services related to language and other needs of migrants, refugees and asylum seekers. Children, the elderly and other special groups must have their needs met.
- Clinicians may wish to discuss and develop specific services, either condition based (e.g., trauma) or gender based.
- Wherever possible, mental health issues of migrants, refugees and asylum seekers should be part of the curriculum and training of clinicians.
- Cultural training is everyone’s business and must be a
part of training other health professionals, including
primary care professionals.
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