ZONAL SIMILARITIES AND CHALLENGES IN EUROPE I

Zonal Similarities and Challenges in Europe: WPA Athens 2005 Marianne Kastrup Centre for Transcultural Psychiatry Rigshospitalet Copenhagen Denmark Overview Presentation  Globalization challenges  WHO Mental Health Action  Topics of concern in the zone  European 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 Globalization may result in insecurity, unpredictability most people cope with it with difficulty  Certain populations run particular risk during this transformation • Gro Harlem Brundtland 2001  Change 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 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 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 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 Zonal Similarities  Value systems: – Moral and ethical principles guiding a profession – Social values of an organisation – Dynamic values of society Zonal Similarities  Prevalent values that the European region can adhere to: – Fairness – Equality – Solidarity 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 WHO Mental Health Action Plan for Europe 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  Promote 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  Issues of Zonal Concern  Migration  Stigma the workforce  Recruitment of Psychiatrists  Reintegration into Collective Violence terrorism, violent political conflicts  State-perpetrated violence e.g. torture, repression, disappearances  Organized violence e.g. banditry, gang warfare – WHO Violence and Health2002  Wars, 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?  Immigrant Adaptation Process  Multivariate model taking into consideration: – Pre-migratory conditions – Characteristics of the individual – Post-migratory factors in new country • Goldlust & Richmond 1974 Migration and Mental Health  Existence of PTSD associated with postmigratory 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 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 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 Migration and Mental Health    Post-migratory conditions Initial information Accomodation Material assistance Language Education Income support Employment Health care    Practical needs Torture-trauma counselling Legal aid Community development Religious expressioin Leisure Becoming part of community Support to special groups            – Australian Refugee Council 2002 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 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 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 Marginalized Populations  Summarising: problems of marginalized groups have severe social consequences  Far-reaching as some may have impact on second generation  Mental 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 Marginalized Populations  Transformation from traumatized to empowered survivors may take place: – National level – Community level – Individual level 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 Marginalized Populations ¤ ¤ Empowerment At community level we may work for information  Support to local activities,incl.migrant friendly CMHC  Establishment of psychoeducational programs  Formation of self-help groups, mentor networks, etc  Dissemination of Marginalized Populations  Empowerment At individual level we may: – Facilitate individual healing and counseling – Strengthen coping abilities of traumatized refugees and their immediate families Implication for Psychiatrists 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  The Improving Cultural Competence        Recognize that culture goes beyond ”skin color”- others may identify with religion, gender, etc Find out each patient’s 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) 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 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    Equity as a Right care as ethical breach  Obligations for psychiatrists to participate in public debate  Certain diagnostic groups without strong lobby  Equitable allocation of resources  Withholding 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. Equity as a Right 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.  The 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. implication of this positive health concept is that we add life to years by letting people utilize their resources in all aspects of life.  The 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. patients whether they are institutionalized or not should be guaranteed all basic human rights.  Disabled 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 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 State-perpetrated Violence  Individual Characteristics – defense and coping mechanisms, e.g. humour, sublimation – subjective meaning, making sense – dissociation, daydreaming – social networking, supportive family 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 Refugee Experiences  Pre-Migratory experiences – – – – – – Torture Rape Ethnic cleansing Detention Persecution Disappearances Refugee Mental Health 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  Pre-migratory Refugee Experiences  Post-Migratory – Severe losses, e.g. family, country, status – Racism – Language barriers – Work/housing problems – Health – Safety – Discrimination 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 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 Marginalized Populations  Summarising A number of factors, e.g. migration, preand post-migratory adversities, racism, consequences of globalization may be associated wtih development of mental and behavioural disorders Marginalized Populations 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  Trans-generational 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 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 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 crosscultural situations – Cross et al (1989) 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) 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 individual’s culture and increase the quality and appropriateness of health care and outcomes and lower costs • King Davis (1997) 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