Assessing trauma in a transcultural context: challenges in mental health care with immigrants and refugees

Abstract

The growing numbers of refugees and immigrants from conflict-prone areas settling throughout the world bring several challenges for those working in the mental health care system. Immigrants and refugees of all ages arrive with complex and nuanced mental health histories of war, torture, and strenuous migration journeys. Many of the challenges of addressing the health care needs for this growing population of immigrants and refugees are often unfamiliar, and thus practices to address these challenges are not yet routine for care providers and health care organizations. In particular, complex trauma can make mental health assessments difficult for health care organizations or care providers with limited experience and training in transcultural or trauma-informed care. Using a transcultural approach can improve assessment and screening processes, leading to more effective and high-quality care for immigrant and refugee families experiencing mental health disorders.This paper presents findings from an assessment of current mental health services focusing on current practices and experiences with immigrant and refugee patients and families. The difficulties in developing shared understandings about mental health can hinder the therapeutic process; therefore, it is imperative to ensure an effective assessment right from the beginning, yet there is limited use of existing cultural formulation tools from the DSM-IV or DSM-5. The paper outlines current practices, approaches, challenges, and recommendations shared by mental health care providers and program leaders in addressing the mental health care needs of immigrants and refugees. The results from this study demonstrate that there are many challenges and inconsistencies in providing transcultural, trauma-informed care. Respondents emphasized the need for a thorough yet flexible and adaptive approach that allows for an exploration of differences in cultural interpretations of mental health. Our study concluded that ensuring a mindful, reflexive, transcultural, and trauma-informed health care workforce, and a learning environment to support staff with education, resources, and tools will improve the health care experiences of immigrants and refugees in the mental health care system.

General Practitioners’ Experiences of Clinical Consultations With Refugees Suffering From Mental Health Problems

“…Most GPs in our study stated that they felt their education had not adequately prepared them for working with refugees suffering from mental health problems. Other studies found that clinicians lack a uniform procedure to deal with such consultations (Wylie et al, 2018), lacked support or resources (Begg and Gill, 2005), and sufficient education and supervision (Fuller, 1993). While participants in our study pointed out that their education may not have prepared them for this work theoretically, they believed that their practical experience had.…”

“…Language barriers posed an important challenge both in our study and in previous literature (Jensen et al, 2013;Wylie et al, 2018). The 'circling the undefined' model highlights that information needs to be shared in order for clinician and patient to clarify those issues that are fundamental to the consultation, such as what constitutes health and illness (Rothlind et al, 2018).…”

“…Focussing on what GPs present as already contributing to successful consultations could pave the way for the development of more feasible interventions that draw on the systemic structures as well as clinicians' strengths that are already available. Unfortunately, studies that have explored GPs' experiences of refugees suffering from mental health problems did so prior to the main influx of refugees to Europe (Begg and Gill, 2005;Jensen et al, 2013), which, according to the European Parliament (2019) peaked in 2015, or have not focussed specifically on patients with a refugee background Priebe et al, 2011;Terraza-Nunez et al, 2011;Hjørleifsson et al, 2018;Mollah et al, 2018), mental health (Johnson et al, 2008;McKeary and Newbold, 2010;Robertshaw et al, 2017), or the experiences of GPs (Wylie et al, 2018). Our study sets out to fill this gap.…”

“…While GPs are not typically specialists in psychiatry, they are required to make important decisions regarding patients' mental health treatment. Clinicians have reported feeling they lack the resources or training to meet the demands placed on them by working with refugees suffering from mental health problems (Jensen et al, 2013;Wylie et al, 2018). This may be partly related to practical challenges such as language barriers, working with interpreters, patients' illiteracy, and time constraints (Robertshaw et al, 2017).…”

“…This may be partly related to practical challenges such as language barriers, working with interpreters, patients' illiteracy, and time constraints (Robertshaw et al, 2017). However, implicit challenges such as different understandings of illness and expectations of treatment (Jensen et al, 2013;Wylie et al, 2018), patients' high expectations of health care professionals, and different cultural values (Robertshaw et al, 2017) may also play a role. Health care professionals working with patients with a different cultural background have previously reported feelings of distress, overload, and exhaustion as a result of this work (Terraza-Nunez et al, 2011).…”