The trauma of violence, homelessness and war is something Syrian refugees carry with them when the first of the 25,000 are brought into Canada under a federal government program beginning next week. Helping them come to grips with these experiences is crucial if they are to integrate successfully, says one of Canada's leading experts on the mental health challenges immigrants face.
"Dealing with mental health issues among refugees is daunting," says Dr. Morton Beiser, a psychiatrist with St. Michael's Hospital in Toronto and a Professor of Distinction at Ryerson University.
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Dr. Beiser has built a distinguished career studying the mental health of refugees and immigrants, and has written about the experience of the Vietnamese "boat people" who came to Canada in the 1970s. Looking back on that earlier group's adaptation challenges, he says our current mental health services are inadequate to meet the needs of the Syrian refugees.
"Good mental health promotes effective integration. We need funding and political will in order to make sure the refugees who are coming have the best possible chance," he says.
Dr. Beiser points to research that indicates at least one in 10 adult refugees who have resettled in Europe, North America and Australia has post-traumatic stress disorder. Others experience depression and anxiety disorder.
"Among refugee children and youth, the rates for PTSD are even higher — at least 20 per cent," he said.
With that in mind, Dr. Beiser is leading a pilot project in eight Toronto clinics called Lending a Hand to Our Future that offers treatment for refugees with post-traumatic stress disorder, including Syrians. He spoke with CBC News about the therapy model and how it offers hope. Here are excerpts from the interview.
CBC News: Why is it crucial for the Syrian refugees to get mental health support early on?
Dr. Morton Beiser: Refugees learn to use silence as a way to deal with distress, and we in the receiving society become complicit in maintaining the silence.
It's not unusual to have people who were refugees — holocaust survivors as a good example — begin to tell stories about what happened to them many years after they've apparently resettled and made what look like good lives for themselves. When they're asked why they didn't speak earlier, a not-uncommon response is, "it's not that we didn't wish to speak, it's that we knew you didn't want to hear."
Early mental health intervention will help people deal more effectively with all the challenges they're going to have to face in making Canada their new home.
What's distinctive about the trauma of this group of refugees?
Refugees don't suffer one trauma … it's usually a cascade of traumas — exposure to war and danger, seeing people killed and maimed, being the victim of rape and robbery, being cheated by human smugglers and the awful conditions of life in a refugee camp. The physical deprivation is bad enough, but it's the sense of life in suspension that bothers people the most. They can't go back home and they can't go forward. They can only live a boring succession of one day becoming the next. It gives an extra dimension to the phrase "killing time."
Describe the therapy model in your pilot project at St. Michael's Hospital in Toronto.
We call the project Lending a Hand to Our Future (LHOF). That includes screening for the presence of post-traumatic stress disorder and offers a treatment to people found to be suffering from it.
Refugee mental health problems may manifest themselves in the form of unexplained nightmares, or difficult-to-understand changes in behaviour, or poor academic performance, or bullying other kids.
We are using a test to screen for the presence of PTSD. For the people who test positive, we offer an innovative treatment called Narrative Exposure Therapy.
What's innovative about the therapy?
Narrative Exposure Therapy (or NET) was developed in Germany 25 years ago. It has been used to treat PTSD among people in refugee camps in Africa and Asia. It is hardly known at all in North America.
It doesn't focus just on relieving the fear response associated with specific events, but places the events in the context of an individual's life.
I like what the great Danish writer Isak Denisen once said: "All sorrows can be borne if you put them in a story or tell a story about them."
So, Narrative Exposure Therapy is about both gaining some peace by being exposed to fearful memories, and also about allowing people to reclaim their narratives.
How does the act of telling one's own story of trauma help treat PTSD?
Significant memories have two components – physiological and cognitive. We sometimes call the former "hot" memory and the latter "cold."
In traumatic memories, the hot memories are likely to involve panic, sweating, disgust, the sound of bullets and so forth. Traumatic memories are incomplete: they have less cold memory attached to the hot than is the case for pleasant memories. Because of the cold memory deficits, people experience flashbacks. For example, a stimulus in the here and now, like a car backfiring, plunges the person back into hiding in the underbrush with bombs dropping everywhere. People don't imagine themselves back in these situations, they actually relive them.
By asking people to tell their story and to fill in, in great detail, the timing and details about significant traumas, NET helps people to locate the traumatic memories where they belong — in the past.
In addition to that, NET shares common elements with techniques such as prolonged exposure therapy, where talking about horrific events in a safe environment helps to defuse their psychological power.
Severe trauma, whether it's the result of an act of nature or deliberate human cruelty, challenges our assumptions about the control we have over our lives. NET helps people put that into perspective: we may not have complete control over what happens, nor are we totally helpless if the unexpected occurs.
How is it possible you could reverse the PTSD in just eight to 10 sessions?
In the therapy, people are given a pile of stones and instructed to recount each major trauma using a stone. As they talk about each stone, the trauma is diffused.
It takes a great deal of skill and training to help people overcome the first line of defense, which is silence. The eight sessions are often very emotionally charged. It's an extraordinary human encounter .
The program is volunteer based. Who are the volunteers?
Our volunteers are students in medicine, nursing and other health care streams.
We've trained about 60 to date and will probably train another cohort in January.
In your view, what's needed in terms of a national strategy for mental health for the Syrian refugees coming to the country?
We need a triage system for all refugees, including in-land claimants, as well as government and privately sponsored refugees.
We could make our PTSD screening system available for use in specialized refugee health clinics, other primary health care settings, settlement agencies, schools and corrections. Then we could offer the narrative therapy to people who need extra attention.
We've proposed a national Observatory for refugee mental health care. This Observatory could help coordinate and monitor the efforts by various agencies to provide care.
It could also identify social roots of mental health problems. For example, anti-refugee discrimination has grown in Canada. We have to ensure Canada doesn't add to the burden of refugees who have already had more than their share of suffering.
Many of us look back to the way Canada responded to last great influx of refugees – the Southeast Asian refugee "boat people" – as a great success. In many ways it was. But we could have attended to the mental health of these brave people better than we did. We learned valuable lessons from that experience.
In the years since, we have accumulated a wealth of new knowledge about how mental health contributes to successful integration. The challenge is to use this knowledge to do even better this time.