Refugees and asylum seekers : their social networks and encounter with the mental health services

Abstract: Background Migrants run a greater risk of poor mental health than host populations, but there are large variations depending on diagnosis, pre- and postmigration experiences, gender, and regions of origin. Some studies show lower suicide rates for refugees than for host populations, whereas other studies indicate that asylum seekers have higher rates of suicide and suicide attempt. Little is known about the contexts of the suicidality of asylum seekers and about what happens in the encounter with mental health services, including cultural aspects of the encounter. There are few studies of how refugees themselves perceive changes in their social networks through the migration process, and on how this is related to their health situation. Aim The overall aim of this project was to study postmigration conditions for refugees and asylum seekers with respect to their social networks, and their encounter with health care when they had mental health problems, with a special focus on the presumably vulnerable group, asylum seekers who had attempted suicide. Methods Studies I and II were studies of the medical records of asylum seekers assessed in mental health services after a suicide attempt. In Study I, 88 asylum seekers were compared with 88 matched controls with respect to known risk factors for suicide, and to the assessment and treatment offered after the suicide attempt. In Study II, the medical records of 18 of the asylum-seeking women were analysed, using qualitative content analysis, with a focus on their communication with the clinicians. Study III and Study IV were part of a larger two-phase study of two populations of resettled Iraqi immigrants with an interview study followed by a survey. In Study III Iraqi refugees were interviewed about migration experiences, perceptions of illness, health care consumption, and traumatic experiences. A biographic network map was drawn and three health assessment scales (CES-D-20, PHQ-15, MINI 5.0.0) were administered. The interviews were analysed with a focus on the refugees’ perceptions of changes and challenges to social networks and social supports, using thematic content analysis. In Study IV, surveys of 410 resettled Iraqi refugees were analysed with a focus on social determinants of health, including social support, resilience factors, including cultural perceptions of illness, mental health, and acculturation. The participants in both phases were convenience samples, part of which in Study III was recruited in primary care or psychiatric services where the subjects were patients. Results In Study I, the asylum seekers showed about the same burden of earlier mental health problems, including suicidality, as the controls, whereas there were differences in clinical pictures and other diagnoses. The asylum-seeking women stood out as having more severe conditions requiring more treatment. Yet, both asylum-seeking men and women were followed up at a less specialised care level. Analysing the communication between asylum-seeking women and clinicians in Study II, we found that the clinicians had difficulties decoding the women’s languages of distress. Neither trauma nor the meaning of the suicide attempt were explored. The perspectives of the women and the clinicians were never combined, and there was a mutual sense of powerlessness expressed in the records. Both studies on Iraqi refugees showed a weakening of the personal network, with the family being the most important provider of all kinds of social support. The participants found it difficult to form new social contacts, and authorities were often perceived as negative. Language difficulties were the most reported barrier to integration. In the interview study 61% of the participants screened for mental health problems. Family issues was the subtheme most strongly related to mental health problems. The most common perceptions of mental illness were social and situational, but not related to the premigration experiences. Conclusions The results of the studies of the asylum-seeking suicide attempters indicate a lack of health equity in Sweden. The analysis of the communication between clinicians and asylum-seeking women suggests that clinicians would be helped by increasing their awareness of the asylum seekers’ living conditions, cultural languages of distress, traumatic experiences, and of the subjective meaning of the suicide attempts for their patients. The studies of the Iraqi refugees give voice to the participants’ subjective experiences, describing the challenges of disrupted social networks and the difficulties of building new networks. The results suggest the importance of facilitating the building of new social networks for refugees, and the importance for authorities to build trust with the newcomers. A conclusion from the four studies is the value of adopting a broader view of health as a social process, and for professional helpers to address the subjective experiences of the persons they want to help. In clinical contexts, such an approach amounts to applying and integrating the concept of person-centred care with a focus on persons’ narratives. Clinicians need time and empowerment, training providing both knowledge and experiential learning, and support in the emotional work of following this path.