Mental health of migrants and refugees Halima ZEROUGVIAL

Mental health of migrants and refugees Halima ZEROUG-VIAL, psychiatrist Samdarra Network Birmingham 2 to 9 November 2010

French context Ø France has always been a country of migration Geographical situation, historical links with former colonies Contradictory and restrictive policies, Since September 11 2001 an increasing tendency to limit entry and to guard borders Voluntary migration/involuntary migration

French context (2) Ø 5 M migrants: 35% from EU countries Ø 42 Ø 31% North Africa Ø 12% Sub-Saharian countries Ø 17% Asia (includes Turkey) 000 asylum seekers (AS) in 2009 (Iraq, Russia, Somalia, Afghanistan, Serbia)

Psychopathological specificities Ø Exile: § § § § § Loss of … home (in abstract and concrete sense), continuity, social, cultural dimensions, seat of family life and experiences, locus of identity, roots, security base family status, political and ideological affiliation, sense of belonging, perceptive dimension; sounds, smells, tastes, feel (climate, clothes) Ø Exile: Restructuring of identity, need to adapt to a new environment

Psychopathological specificities (2) The migration trajectory: pre- and postmigratory experiences Psycho-social effects: § § § insecurity, (material, living conditions, legal backround) isolation unemployment (non-recognition of qualifications) discrimination lack of self esteem, lack of sense of self worth Language barrier

Psycho-pathological specificities to be taken into account (3) Ø Culture-specific dimension: representation of the disease and of its treatment, a specific way of expressing distress. Ø Language interpreters: cultural mediators rather than translators, facilitate mutual understanding.

Psycho-pathological specificities (4) Ø Vulnerabilty: § propensity to suffer damage or loss and to find it difficult to recover § a tendency to be hurt by lack of supportive and/or protective factors.

Psychopathological specificities (5) Ø Migration: a vulnerable state? Ø Vulnerability Ø Importance factors Ø Danger and resilience can coexist. of social, political, economical of generalising and neglecting the uniqueness of the individual.

Mental health of AS and refugees Ø Ø Epidemiology : Post Traumatic Stress Disorder (PTSD) (30% to 80%), depression (30% to 60%) Psycho-traumatism: trauma - from the Greek to pierce, wound, injure. PTSD: introduced in 1980 in the third version of DSM(Diagnostic and statistical Manual of mental disorders ) by the American Psychiatric Association, mainly concerning US soldiers in Vietnam Psychotraumatism is not limited to PTSD

Mental health of AS and refugees(2) Ø Nature of psychotraumatism: organised, extreme, and repeated violence, torture, genocide. Ø Torture: intentional acts of humiliation, being forced to break cultural taboos, the infliction of extreme mental and physical suffering. Ø Psychological effects of torture: mental death, destruction of the feeling of social, psychological & physical integrity. Feelings of guilt and shame. Destruction of the victim’s identity.

Mental health of AS and refugees(3) Ø Ø Ø Psychiatric disorders: depression, anxiety, somatisations, cognitive disorders (concentration, memory) Weakness of the current nosography: PTSD complex or DESNOS: Disorder Of Extreme Stress Not Otherwise Specified. DESNOS: Anger attacks, autodestructive behaviour, alteration of the belief system, despair, hopelessness, mistrust, loss of ability to project into the future, pervasive anxiety, insecurity, sense of unreality, loss of sense of familiarity, lack of confidence, cognitive impairment, emotional disfunction, impulsiveness, personality change.

Mental health of AS and refugees(4) Ø Post-migratory stressors: social precariousness, length of the procedure, uncertainty, risk of having to leave the country, unemployment. Ø Pre-migratory factors: forced exile, dispersed family, lack of family news. Ø Cultural dimension

Health care system Ø Care rights: AME, CMU Ø Special needs: interpreting, difficulty of access to the public health system Ø Transcultural mental health units (of which very few - Paris, Bordeaux, Strasbourg) take the cultural dimension into account , work with interpreters. Their theoretical basis is for the most part ethno-psychoanalytic. Ø Units for victims of torture and forced exile : very few(Paris, Marseille, Lyon)

Conclusion/Discussion Ø Specific needs? Ø Specific mental health units/Public mental health system? Ø Differents fields overlapping global care, multidisciplinary approaches Ø Enhance partneships Ø Sensibilization, Ø Share specific training practices, collaborative approach, new refferal pathways