“No health care system that excludes entire groups of people from mental health services or care serves its purpose.”Kaisa Korhonen
I recommend listening to God Help the Outcasts by Heidi Mollenhauer.
Mental health refers to a state of being in which a person is aware of their own possibilities and abilities, and if they are able to cope with the normal stressors and challenges of life. In addition, a person is able to work and participate in the activities of their own community. Mental health disorder is a complex phenomenon that mainly affects the areas of human emotional life, thought and behavior. Mental disorders occur in different ways for different people and have in common that they are often every day, weighty, and threaten mental well-being. Mental disorders are often caused by untreated and difficult emotional states that, when prolonged, predispose a person to different types of disorders.
An individual’s mental health depends on individual factors and the world of experience, the social support and interaction received, social structures and resources, and the values determined by culture. Positive mental health refers to the cornerstone on which a person can build his or her life and face the challenges posed by everyday life. Positive mental health is essentially associated with the experience of well-being. An optimistic attitude to life and the experience of being able to influence one’s own affairs is associated with positive mental health. Mental health is not a permanent state of being, but as the life situation changes, the individual has to redefine his or her own mental health. For example, changes in the values of the surrounding society, as well as uncertainty in the economic situation, are factors that can pose challenges to maintaining positive mental health.
Now… how is it with asylum seekers?
According to THL’s Health and Welfare Survey of Asylum Seekers, up to 40% of adults seeking asylum in Finland have significant symptoms of depression and anxiety. Most of them have reported at least one potentially traumatic experience. In the study, 49% of women reported long-term health problems and one-tenth of the women were pregnant when they came to Finland, and about one in ten of all women reported having undergone genital mutilation. Men had fewer long-term health problems – however, 55% of men had injuries caused by accidents and violence.
For many, social contacts are severed when relatives remain in the country of origin. In their new country, on the other hand, language difficulties and cultural differences make it difficult to form social contacts and seek help. Cultural differences can also be a reason why an asylum seeker or refugee does not dare to seek treatment, as mental health problems are perceived as shameful in many cultures. For refugees and asylum seekers with mental health problems, acquiring language skills and adapting to culture is even more challenging and affect, for example, employment opportunities.
And even if an individual does not yet have mental health problems, the prejudices of the surrounding society may hinder employment and lead to financial difficulties. For example, as a result of these factors, asylum seekers and refugees are at increased risk of developing mental disorders.
In Finland, mental health work has long been part of the mainstream culture, and I do not think that every nurse has been able to treat different cultures accordingly – “when in Rome …” – but the number of foreigners coming to Finland has increased considerably because of the refugee crisis. This poses its own challenges for considering nursing practices.
Many asylum seekers suffer from depressive symptoms and/or traumatic stress disorder at some point in their lives, as stated by a recent analysis of data from 26 international studies. According to researchers, mental health services for asylum seekers should be strengthened.
Adult asylum seekers have the right to necessary health-care services such as mental health and oral health activities. The analysis states that access to mental health services was best for children and young people who are entitled to Children’s Rights. For adults, one in five reception centers reported a low level of access to services. The availability of emergency and emergency mental health services was better in all age groups than non-emergency services.
Migri and reception centers have responded to the prevalence of mental health problems among asylum seekers. The mental health working group, coordinated by Migri since 2016, brings together authorities and professionals familiar with the specific issues of asylum seekers, refugees and victims of human trafficking. The group monitors and directs the implementation of services and plans development activities.
In a publication brought out in 2018, Turvapaikanhakijoiden mielenterveys- ja suun terveydenhuollon palveluiden sekä tartuntatautien ehkäisyn toteutuminen 2017, THL listed that an enhanced support unit (Tehostettu Tuki, TeTu) has been set up for asylum seekers who need special support. Mental health skills have also been taken into account in recruitment and training: the publication states thattwo of a three reception centers have staff specializing in mental well-being and the treatment of mental health problems, and the reception centers provide regular mental health training.
Promoting the health and well-being of asylum seekers seems to be also pursued in national research and development projects. THL states that the well-being of asylum-seeking families and the development of children will be promoted in a project that utilizes the ‘Lapset puheeksi’ method. You can also read about how National Development Project of the Primary Health Inspectorate (TERTTU) created a model for identifying the health and well-being of asylum seekers and the need for services. The National Refugee Mental Health Development Project (PALOMA) has also compiled evidence-based good practices to promote the mental health of asylum seekers.
Asylum seekers are a population group with special health service needs. Monitoring the implementation of the health and services of a population group is hampered on the one hand by the lack of a personal identification number and on the other hand by the implementation of services by several different service providers. Ongoing research projects provide valuable additional information on the occurrence of health problems of asylum seekers and their results can be further utilized in the design of services.
Mental health risk factors related to asylum
In general, factors affecting mental health can be divided into risk factors and protective factors. Risk factors increase the risk of mental malaise and illness and exacerbate symptoms. Protective factors strengthen mental health, functional capacity, and thus life management, which supports survival even in difficult stages of life. Central to mental health work is the effort to strengthen protective factors and reduce harmful factors.
Refugees involve specific risk factors that can be divided into three different phases, listed and freely translated from Mieli Ry:
• Events experienced before the escape in the home country: several countries from which asylum seekers come are lengthy states of war. Many refugees have personal experiences of persecution and violence. In addition, refugees are always associated with experiences of loss and associated grief. Leaving home means losing everything safe and familiar and many have also lost loved ones.
• Things experienced during the escape journey: The escape journey involves several risk factors as well as difficult conditions that can be traumatic.
• Conditions in the host country: Immigration is a mental process involving various stages. Asylum seekers, on the other hand, are uncertain about the future and the asylum process. Studies have shown that asylum seekers and refugees are more likely to have mental health problems compared to other immigrants or the native population. An estimated 9% suffer from a traumatic stress disorder and 5% from major depression. Traumatic disorders from war zones, such as Syria, are even more common.
No good news
Things seem to work on a basic level, but how about from a worker’s perspective? We interviewed Anna Hyytiäinen from Sininauhasäätiö and Mosaiikki, who shared her thoughts with us and agreed to let us use her name in our blogposts.
How is the mental health in Mosaiikki?
“Almost everyone shows signs of being depressed. It’s kind of natural when you think about it: you have been here for five, six years without any residence permit and just waiting for any kinds of decisions. It’s very difficult to get help for that and many of our clients are really depressed. Many have had suicidal thoughts and tried to kill themselves. It is very difficult to get treatment, therapy, meeting nurses – or anyone. There can be meetings once or twice but usually that’s it and they get antidepressants as a treatment.
“I have called for an ambulance or sent some to a hospital, but the clients are there for only a couple of hours and then they get sent home. Most are lonely and depressed. Global Clinic, however, offers some nurses and psychologists, but we have to remember that they’re also busy and not available for regular meetings, especially during the current pandemic.”
No way to get to the municipal health care?
“No. There are some nurses in the immigration units and a couple of clients have met with psychiatrists. The Helsinki Immigration Unit is perhaps in the best position as there are a couple of psychiatric nurses there and they also offer their services to the paperless clientele. There are cases where a client has had to be in a closed ward for a couple of months. But it has been really difficult [to get help].”
That is, you can’t get help until…?
“Many cannot. And not necessarily even then, which of course also applies to Finns also.”
How can you support an asylum seeker?
So, you’re probably burdened by this point – as asylum seekers are burdened by uncertainty about their own situation and residence permit. The asylum process can take a long time and the waiting time seems difficult. In the case of asylum seekers, it is important to maintain and support the ability to function, so that the asylum seeker can use his or her own resources in a difficult life situation.
Getting enough information about the asylum process and its duration reduces uncertainty and gives a sense of control. It is also important that the asylum seeker is heard and confronted with his or her experiences.
Here are excerpts from the instructions, freely translated from Mieli’s guide for those working with immigrants:
• Make room for discussion and questions: there is no need to answer everything, but what is important that it is shared
• Discuss expectations and realities in the new country
• Support in concentrating resources to this moment
• Allow room to mourn the past, but also support turning your gaze to the future
• Everyday routines and a regular daily rhythm help you cope: support regular eating, adequate rest and exercise
• Support in learning a new culture and language
• Support setting realistic goals and achieving them in small steps
• You can start exploring a new country from the surrounding area.
• Participation in and encouragement of various events and activities
• Participate in events or association activities
• Support the asylum seeker’s own resources and normalize the emotions evoked by the process
For those who develop a mental health problem, the prognosis for overcoming the problems themselves or through the help of a professional is told to be ‘quite good,’ as Mieli states in the guide, though I couldn’t really find proof of this. This, of course, can be due to the fact that you get antidepressant pretty easily in Finland and therefore, you’re not considered a threat to yourself.
It is important to strive to identify clients who need special occupational mental health care and to provide them with appropriate care.
Be understanding. Be kind.