Author: George Kitsaras
Editor-in-chief / Psychologist / Doctoral Researcher
Refugees are not a recent phenomenon. Since antiquity there have been many examples of people fleeing persecution and seeking refuge and protection in other countries (Tribe, 2002). Refugees flee war, internal unrest and persecution by their own governments because of their ethnic origin or their political, religious or social activities (Tribe, 2002). Estimates of the number of refugees and displaced people worldwide range from about 23 to 50 million. In the case of Europe the current emphasis is on refugees fleeing countries of the Middle East and Africa predominantly Syria, Iraq and Afghanistan. In 2015 a total of 1.015.078 refugees arrived in Europe, mainly in Greece and Italy (UNCHR, 2016). Alongside those millions of refugees reaching Europe in 2015 there have been 4.000 confirmed deaths mostly during an attempt to cross to a Greek Island or to the shores of Italy. Two major elements fuel this increase in the number of refugees and migrants reaching Europe: on-going social and political unrest in war-torn countries alongside the development and establishment of radical oppressive and terrorist movements across countries of the Middle East and Africa (Amnesty International, 2015).
Refugees differ from immigrants in that the latter have usually made a positive choice to change their country of residence and have been able to plan the move practically, psychologically and systematically over time (Tribe, 2002). Refugees, on the other hand, usually have to flee for fear of their lives at short notice, often to unknown destinations. It is not a decision that is taken lightly and there is a full list of factors associated with this move that can have a tremendous effect on their physical and most importantly psychological well-being. Those factors include traumatic life events, abuse, loss, racism/stigma, uncertainty for the future, financial and educational struggle (Abou-Saleh & Hughes, 2015; Tribe, 2002). All these factors contribute to higher prevalence of mental health problems, substance misuse, social inclusion difficulties and poor physical health for refugees resettling in European countries or elsewhere. Regarding mental health problems, available research studies show consistently increased levels of psychological morbidity among refugees of all ages and gender, especially post-traumatic stress disorder, depression, and anxiety disorders (Abou-Saleh & Hughes, 2015; Fazel & Stein, 2002; Tribe, 2002).
Stories from the frontline
As a result of the increase in the refugee influx, all around the main refugee routes to Europe there is an on-going humanitarian effort in order to provide and support those in need. In this on-going effort to help, support and relief refugees arriving from Turkey and Northern Africa to Europe hundreds of mental health professionals, mainly psychologists, are involved in a tough battle of assessing, supporting and ultimately helping refugees of all ages and gender presenting with different and diverse difficulties. The impact of displacement and travelling across continents to physical as well as mental health for refugees is well documented and researched. Apart from research studies highlighting the difficulties that refugees have to face it is equally important to present stories from frontline mental health professionals and others involved in the provision of care and support to refugees. Due to the enormous workload and the continuous challenges on the field mental health professionals have little to no opportunities of sharing their experiences and raising awareness on both the mental health difficulties that refugees are dealing with as well as on the personal and professional challenges that they have to face with on a daily basis.
In the lines that follow 2 stories from 2 registered psychologist working with refugees in Greece and Germany will be presented. The choice of Greece and Germany was based on the fact that those 2 countries represent 2 distinct points in a long journey. Greece at the moment is the main entry point to Europe for the vast majority of refugees while Germany is the final goal for resettlement for most of them. Both stories aim at shedding light on the day to day struggle, the obstacles, the mental health difficulties that refugees have to face with and finally to highlight the emotional impact of working with vulnerable groups in the peak of an unprecedented crisis.
Greece: a story from first point of contact when reaching Europe
The current rise in the influx of refugees to Europe saw a record increase in people crossing the Aegean Sea from Turkey to the Greek islands, a route full of risks and uncertainty. The vast majority of refugees entering Europe in 2015 and early 2016 came across members of the public and staff of international organizations waiting to help them. One of those organizations is the Social Solidarity Clinic of Thessaloniki an independent initiative established in 2011 with an aim of helping migrants, refugees and other vulnerable social groups in the onset of the on-going economic and social crisis in Greece.
Mrs Anastasia Avramidou, a registered psychologist volunteering with the mental health team of the Social Solidarity Clinic in Thessaloniki shared her personal experiences and the overall sense within the Clinic regarding mental health difficulties that refugees are facing with alongside the toll that the current crisis has on a personal level for those engaging and working with the thousands exhausted and traumatized people.
“The truth is that in the case of Greece little structured and in-depth from mental health professionals has been carried out with refugees. That is mainly due to the fact that when refugees finally reach Greece they are eager to depart as soon as possible and therefore there is little room for any formal assessment or intervention. Despite that major obstacle, many mental health professionals are involved in independent and international efforts to support and help refugees either in one of the Greek islands or in the land border crossings with Former Yugoslavic Republic of Macedonia (FYROM). Based on my personal experiences, I can say that refugees are not allowing themselves to fully comprehend and experience the enormous difficulties that they are going through. It is as if refugees move on an “autopilot” aiming at reaching a North European country without allowing any element of insight in the meantime. It appears that the majority of refugees have set personal defence mechanisms to protect themselves as much as possible from the terrible realization of their situation. Imagine for example a family that moves from their family house in a small village in the middle of Syria having lost literarily every material possession they had and while undertaking the long and difficult journey of reaching Europe they lose a family member most likely a child. Those people will then have to leave their child, a part of their family, in a foreign land, they will not even have the time to organize a proper burial for him/her and most likely they will never be able to visit the burial site for the rest of their lives. That level of loss and bereavement is not easy to face under normal circumstances nevertheless when travelling through continents in order to reach safety. Refugees have to exceed not only human misery and bereavement but also deep cultural and sacral traditions (like abandoning a dead child in a foreign land without proper burial) in order to survive and complete their journey. In my opinion, all these severe life changes alongside the deep psychological scars will force them to remain silent and distant from any type of self-reflection and insight work with a mental health professional even when they finally reach the end of their journey”.
“Regarding the on-going efforts in Greece, in my opinion, there is an unprecedented level of activities in order to support and help refugees. Those activities are supported by international organizations, solidarity movements and most importantly by local communities in the Greek islands. Especially in the case of local communities there is an unexpected level of empathy and support in every possible level from patrolling the sea with private boats in order to instantly help endangered refugees to cooking meals and open their house to those who arrive to the islands. Everyday citizens of every age and social background from the Greek islands of Kos, Lesbos, Chios and beyond rush to the beach in the cold weather to help arriving refugees. Mothers and grandmothers wash clothes, feed babies and cook meals for those hungry and exhausting refugees. Students, older men and women, staff from police and coastguard hug refugees and cry together next to a dead body of someone who could not make it. People who never met each other, and most likely will never see each other again, share together those powerful moments of lament and fear when facing with death and loss. These scenes are just a few of the daily routine for everyone in those islands. Even though these examples do not include any level of formal psychological assessment or intervention, in my opinion, they are much more important. Their importance is based on the fact that when refugees finally reach Greece they need to be welcomed by empathic people and feel supported for the next stage of their journey. Those refugees are still in a crisis mode and when someone is in a crisis there is absolutely no need for formal psychological work. As a mental health professional I clearly see the complex and severe difficulties that refugees are facing with and I can also understand the short and long-term implication of those difficulties. I did feel a level of incompetence at the beginning of my involvement with refugees since I approached the whole issue with a false perspective of what I can do for them and what those people need from me. Now I finally realized that it is not the formal psychological work that is necessary for those thousands of refugees. All they need is a level of empathy and support because many of them have lost faith in the human race. By reintroducing them to those positive and altruistic emotions we are providing them with a new, more positive, perspective in life”.
Germany: story from the end of the journey
Greece, for the vast majority of refugees, is just a brief stop in a long and exhausting journey. The end goal for many of them is to reach what they perceive as an “oasis” in the shape of a Northern European country predominantly Germany or Sweden. All across Germany different state-funded services as well as services by international organizations are in place in order to help refugees in their settlement and support them with the transition to a new country, culture and way of life. In one of those clinics set up by Doctors without Borders a volunteer registered clinical psychologist and psychotherapist who wished to remain anonymous shared her views on the social and psychological difficulties that refugees have to face with when reaching their goal destination as well as the professional and personal difficulties she has to overcome on a daily basis.
“When finally refugees arrive in a German railway station, another similar terminal in Sweden or elsewhere there is a growing sense amongst them that their journey is now over and they can slowly start rebuilding their lives. The truth is that an overwhelming list of problems awaits every single refugee who reaches Germany or any other Northern European Country. Those problems range from social issues regarding adaptation to a new country, stigma and the label of being a refugee in ever changing and more hostile World all the way to mental health difficulties. Regarding the latter, all across the clinics of Doctors without Borders there is an ever increasing need of mental health assessments, support and interventions for many of the refugees who resettle in German cities. Many of the refugees, in line with previous research on the field, presents with severe psychological trauma and post-traumatic stress disorder (PTSD) symptoms acquired both due to the unrest and deprivation caused by the armed conflicts in their countries as well as from the long and difficult journey to Europe. Many of the refugees visiting the clinics have experienced a loss, in terms of human or material loss. Every one of them has lost their homes, routines and in many cases they have lost family members, partners and friends. The loss in conjunction with the difficulties of the journey and the stress of being in a new country they all contribute to other mental health difficulties predominantly depressive and anxiety symptoms. In many cases the psychological symptoms that refugees are experiencing are even greater now that they have the chance to feel more relaxed after a long and dangerous journey. This sense of relaxation allows repressed memories to manifest themselves leading to even greater distress”.
“Even though refugees experience a full list of mental health difficulties, with some of them being quite severe, many of the refugees experience difficulties in seeking and accepting help from mental health professionals mainly due to cultural differences in the perception of mental health problems and the need of therapy/support for those problems. In addition to that, many of the refugees moving to Germany are men leading to even more difficulties in acknowledging psychological difficulties and talking openly about them mainly to a female mental health professional. Many of the refugees who experience mental health difficulties will firstly seek support through a physician and not a mental health professional as a result of the lack of understanding of the route of their problems. After visiting a physical, many of the refugees will receive a referral for the mental health teams. That referral in many cases leads to adverse reactions since mental health problems represent a heavily stigmatized area for refugee communities. Even when a few of them reach a mental health professional a new range of problems arises including language barriers and cultural differences in the expression and manifestation of symptoms. All of these difficulties eventually complicate and hinder the overall therapeutic process despite deploying techniques like interpreters and information packages in the native language. With all these difficulties and obstacles in place every mental health professional have to face with both professional and personal issues when working with refugees. Unfortunately, most days personally I have to cope with the frustration rising from the fact that even though you have so many people with mental health problems in reality you can do so little to help them and that creates a sense of incompetence as well as disappointment”.
“Apart from the lows associated with working with refugees there are cases of being threatened from radical elements in local communities just because as a professional you are working with refugees. Personally I have experienced threats and I have been personally targeted only because I am working in a clinic that treats and supports refugees who recently resettled in Germany. The vast majority of Germans remains at the moment open and welcoming for the millions of vulnerable and fragile refugees who arrive in the country. Nevertheless, as in every society, there are far-right closeminded elements who are opposing Germany’s policy in accepting refugees and provide to them. For every professional and everyday person who actively helps and advocates the rights of refugees the threats from radical elements have, at the moment, little impact. As professionals we have to continue to support and provide to those in need no matter the risks and the threats associated with our professional activities. If we allow fear to overtake and affect our professional activities then there is little hope for the future”.
Both stories that mental health professionals shared have a common thread around the mental health difficulties that refugees face, the day to day obstacles that mental health professionals are dealing with and the complexity of the current refugee crisis in terms of perpetuating factors, impact on lives and reshaping of societies. As highlighted through the stories of professionals and supported by research evidence refugees will unfortunately face on-going difficulties throughout their journey to their new home and the psychological wounds they acquire through that process will for many of them continue to trouble them. Apart from refugees there is a number of professionals and everyday people who face with death and human misery as a result of the current refugee crisis and they are also in need of continuous support and wider awareness of the difficulties that they are facing with. The sheer dimension of the problem, the many different people it affects with refugees in the centre and the enormous impact that this crisis has on people’s psyches requires an even greater and unanimous response in order to tackle the problem through long-term solutions. The current problem is one that threatens the well-being of millions of people and in some cases social cohesion in the receiving countries through the establishment of xenophobic far-right movements across Europe and therefore it requires bold and well-organized decisions in order to tackle.
Abou-Saleh, M. T., & Hughes, P. (2015). Mental health of Syrian refugees: looking backwards and forwards. The Lancet Psychiatry, 2(10), 870-871.
Amnesty International. (2015). Amnesty International report 2014/2015: The state of the world’s human rights. Retrieved from: https://www.amnesty.org/en/documents/pol10/0001/2015/en/
Fazel, M., & Stein, A. (2002). The mental health of refugee children. Archives of disease in childhood, 87(5), 366-370.
Tribe, R. (2002). Mental health of refugees and asylum-seekers. Advances in psychiatric treatment, 8(4), 240-247.
United Nations High Commission for Refugees. (2016). Europe’s refugee emergency response update #19, Geneva: UNHCR.