This chapter presents a critical discussion on the understanding and access of mental health services by people from diverse refugee backgrounds delivered in a Western cultural setting. Mental health services are heavily influenced by a biomedical approach, but there is a growing understanding of the importance of culture and biopsychosocial approaches. This chapter highlights some of the institutional and cultural issues that need to be addressed for the services to be effective. Practical approaches that have worked in different places are explored and critically discussed. A recovery-oriented model that recognizes that the individual is part of the community and the importance of spirituality are canvassed.
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Mental health work with migrant and refugee communities settling in developed countries like Australia is both challenging and rewarding for the wide range of professionals involved. While all the professional knowledge in mental health is important, the biggest challenges are presented by the diversity of cultures, diversity of prior experiences, settlement challenges, social and political dynamics and the negotiation of divergent worldviews. While cross-cultural mental health work would include working with a wide range of cultures, in this chapter only migrants and refugees are considered, while other cultural groups such as Indigenous people or Lesbian, Gay, Bisexual, Transgender, Queer and Inquiring (LGBTQI) are not considered except in passing where necessary.
Regular migrants and forced migrants including refugees, asylum seekers and undocumented migrants, have radically different issues on arriving at their destination. However, they also face similar issues such as displacement and dislocation, discrimination and a desire to rebuild disrupted lives. A study of migrants in Europe identified eight types of problems: language-based problems, lack of health insurance cover, poverty and trauma experience, lack of knowledge about services, divergent notions of diseases and treatment, unhelpful attitudes among both migrants and staff and missing medical history (Priebe, Sandhu, Dias, Gaddini, Greacen, Loannidis, … Bogic, 2011). Weiss (2015) has noted that in Switzerland migration worsens physical and mental health risks because migrants encounter cultural barriers. At the same time clinicians also experience challenges related to the complicated circumstances of their patients. Considering this is important due to the rapidly growing numbers involved in international migration. The number of international migrants globally reached 244 million in 2015, an increase of 41 per cent compared to 2000, and includes 20 million refugees (UN Sustainable Development Goals, 2016). The main direction is from developing to developed countries but there is also movement of refugees from developing to developing countries; indeed, most refugees are located in developing countries like Pakistan, Lebanon and Uganda. Turkey is the exception, as a European country with very high numbers of refugees.
In Australia, a wide range of disciplines including social workers, psychologists, nurses and psychiatrists assist patients suffering from mental health disorders. For that reason, the dynamics could be described as both multidiscipline and multicultural interaction. Experience with clients of ethnic Arabic people has shown that mental health services may be viewed by migrants with mistrust and suspicion and because of the stigma associated with mental illness, mental health services may be viewed negatively and therefore underused (Al-Krenawi & Graham, 2000). Building trust in this situation is a high priority. Defining mental illness and what is normal or abnormal varies between cultures and a cultural understanding is therefore critical in any mental health intervention (Kleinman, 1988; Weiss, 2015). Migration is stressful and migrants have been reported to be at higher risk of developing mental health disorders. Cultural factors, for example, affect the care-seeking behaviours and attitudes of older Iranian migrants in the United States (Martin, 2009). These older Iranians are reported to mistrust prescribed medication, hold a holistic view about mind body and spirit and their conceptualisation of mental health, including the language used, is at variance with that of service providers.
A recovery-oriented framework is currently supported by the government in Australia. The National Standards for Mental Health Services (2010) defines the principles of recovery oriented mental health practice and notes:
From the perspective of the individual with mental illness, recovery means gaining and retaining hope, understanding of one’s abilities and disabilities, engagement in an active life, personal autonomy, social identity, meaning and purpose of life, and a positive sense of self. (State of Victoria Department of Health, 2013, p. 7)
Recovery is not the same as cure but rather puts the recovering person at the centre of what they want in life. The framework recognises the importance of partnerships between different professionals in supporting the recovering person to achieve their goals.