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Traumatised refugees lost in public health system

 Hus Forbi (Denmark) 21 March 2019

Traumatised refugees arriving in Denmark are in risk of receiving the wrong medical treatment. The lack of specific training from doctors and social workers to meet the needs of refugees with psychological problems is generating a problem in the public health system. (2205 Words) - By Assia Awad


A Vietnamese school girl often came by and complained about stomach aches when Sisi Buch was working as school nurse at Humlehave School in Vollsmose, in Denmark. Despite several attempts, the doctor had not been able to detect anything physically wrong with the girl, until the day she revealed that she had been gang raped when the boat she fled on from Vietnam had been caught by pirates in the South Chinese sea. Several of the other refugees aboard were killed during the event. After letting the doctor know about this experience the girl was offered psychological counseling.

According to Sisi Buch, who is now working as health counselor in the Health Centre Fyn, this story is not uncommon. Sisi has spent several years working with refugees who have been traumatised by torture, war, persecution, rape and imprisonment in their countries of origin. International surveys assess that more than half of all refugees suffer from trauma. "A big amount of the refugees who apply for asylum in Denmark come from countries where mental illness is a taboo, or where it can not be verbalised, causing mental suffering to be expressed as physical pain instead. Due to this many refugees are misunderstood in the conventional public health care system" explains Sisi. She continues:"They may show up complaining about pain in the heart, liver or other places, while in reality it is their psyche that hurts. If the doctors are not aware of such cultural differences, they may examine the heart or liver of the patient, but when this brings no results the person can be labelled as a hypochondriac and will not receive the type of treatment they really need".


Hidden traumas

In 2008 the Medical Service Unit for Immigrants was established at Odense University Hospital in recognition of the fact that many patients of other ethnic background where lost by the public health system. The patients who are referred to this Service Unit have been living in Denmark for an average of 12 years and were forgotten by the public health and municipal system.

According to the Unit's head doctor, Morten Sodemann, up to 60 per cent of the patients are suffering from war traumas. They will often have experienced bombings, torture, imprisonment and family members being physically abused, raped or executed. In 3 out of 4 cases the traumas kept a secret before the patients started treatment at the Medical Service Unit for Immigrants. "Medical doctors and social workers who are in contact with these patients, must get better at spotting the signals. Could there be a reason why the patient has difficulties learning Danish, sitting in a bus, attending work or treating his diabetes? Could there be something I don't know about the person? Apparently more training is needed" concludes Morten Sodemann.

The Chair of the Danish Association of Social Workers, Betina Post is alarmed by the figures from the Medical Service Unit for Immigrants, and thinks that the responsibility of diagnosing traumas lies with the medical doctors.

"When refugees are facing a social worker, they will do anything they can to demonstrate that they are motivated to be here and wish to integrate. They are also aware of the public debate (about immigration) and know that non-cooperation can cause problems. This makes it difficult for the social worker to know what kind of past experiences they may be struggling with. Simultaneously many of the municipal integration units are closed down, because of the belief that all citizens should be offered the same type of public social counseling. This results in a loss of expertise from social workers with experience working primarily with clients of an immigrant or refugee background."


Calling for attention

In reply to the question of whether the medical doctors are lacking skills in identifying refugees suffering from traumas, chair of the Ethical Counsel of the Association of Medical Consultants, Poul Laszczak, comments:

"Yes and no. Doctors are caught in medical traditions and they do not tend to link sporadic or vague symptoms to a war trauma. This is a very sensitive issue, because only a small number of patients are in fact facing these types of issues. This requires a certain type of attention to be directed towards them. It is probably true that some issues are overlooked".

According to Denmark's Statistics there are approximately 106,000 refugees living in Denmark. Of those, more than half are assessed to be suffering from Post Traumatic Stress Syndrome (PTSS). Often these traumatised refugees are diagnosed more than once. A report from Region South Denmark indicates that approximately 90 per cent have at least one additional diagnosis, and that approximately 85 per cent have two or more. These often concern depression, anxiety disorders, alcohol and drug addiction and personality disorders. There are, however, no figures revealing how many of these psychological problems are left untreated. "The longer time passes before a traumatised person receives treatment, the worse their prognosis becomes", says Annemarie Gottlieb, psychologist and director of the Clinic for Traumatized Refugees in Region Midtjylland. "It is far more difficult to treat a patient who has suffered from PTSS for years, than to treat someone who has been referred early on in the course of their illness. Some are left untreated for so long that they develop psychoses. I recently treated a Palestinian woman who had suffered from anxiety for 20 years, I am not sure whether we can help her at this point" Gottlieb explains.


Traumas hold back integration

Culture is often made the culprit when refugees and their children are not smoothly integrating into Danish society but in fact, traumas stand to blame, experts say.

Reza Hossien was afraid to go to sleep, because his dreams would always take him back to the Iranian prison where guards tortured him for hours. As a result he only slept a couple of hours per night. During the day he was terribly tired and had flash backs where he experienced the torture again and again.

The flashbacks, nightmares, sleeplessness and tiredness experienced by torture survivor Reza Hossien, make it difficult for traumatised people to handle even basic everyday activities, explains Annemarie Gottlieb. "Traumatised people often suffer from loss of ability to concentrate and memorise, which means that it is difficult for them to learn Danish, and thus to handle a job or an education" says the psychologist.

Lecturer Anders Ejrnæs, who is researching on labour market and integration at University of Roskilde, confirms that traumas do indeed play a significant role in relation to the occupational rate of refugees, which is significantly lower than that of immigrants.

"There is no doubt that those refugees who suffer from war traumas, face more difficulties entering the labour market. The lowest employment rate is amongst Somalis, Palestinians and Iraqis, who are all groups from war torn areas."


Children become victims

Reza Hossien has recognized that his family has paid a high price for his psychological problems. "My children were the biggest victims. For years after the abuses I was filled by an unbelievable amount of hatred and anger. When I watched TV reports about Al Qaeda, I would easily be able to put myself in their place. I understood their hatred. I would often not be able to handle my children. They would upset me incredibly, and I have pushed them around and twisted their arms. Sometimes I felt like I could kill them" he explains.

"In families where either one or both parents are traumatized, the children are often massively impacted by their parents' illness" explains Eva Malte, who has worked with traumatized immigrant families for more then 15 years.

"The children realise that mum and dad are always tired, have a bad temper or loose control. Sometimes the traumatized person is exposing their spouse or children to violence. Appointments at the school are forgotten and so is the lunch box. The parents may express suicide thoughts, they can not stand being around other people and sometimes they pass out. Experiencing all of these symptoms as a bystander can traumatise the children, and makes it difficult for them to concentrate in school. During breaks they end up in conflicts, are reprimanded and end up developing low self esteem. Part of the problems from ghetto areas stem from young people having grown up under traumatic conditions, explains Eva Malte. She further explains:"A big part of the problems relating to integration stem from traumas. Problems in families with an immigrant background are often explained by arguments about culture, but this is a gross oversimplification of reality. The issue at hand is far more complex. There are also young people of Danish background who react the same way, and no one would try to explain their behavior by referring to their Danish cultural background" explains Eva Malte.

Morten Sodeman, who is medical consultant at Medical Service Unit for Immigrants at Odense University Hospital thinks that children in traumatized refugee families are not dealt with properly. "The children grow up in an environment of fear and anxiety. It is expected that mum and dad will take care of you, but they may not always be able to do so. Instead mum may cry, she isolates herself and is anxious. The older children watch as their parents are humiliated and have to handle the authorities" he explains. "This creates a generation of children who I predict will cause great problems, because they have not received the proper attention. The authorities do not have sufficient resources to help these children. When you hear of shootings in Odense, you almost know for sure who the parents of the young kids are. We need to invest in solving this because these children will grow up to be adults in Denmark and will become parents themselves".

Over representation among refugees

Researchers are now more aware of this issue and started analysing the criminal patterns among people of refugee background, in comparison to other groups. In 2006 the Centre of Theory and Methodology conducted an investigation at youth prisons which showed that one third of the youngsters serving sentences were of refugee background and a big part of them had been subject to traumatising conditions growing up. The investigation concluded that the group with a refugee background was far more troubled than the immigrant one or the one of ethnic Danish background. In addition the refugees had generally experienced more broken family relations, more deaths of parents and more psychological illness in the family.

Reza Hossein's children can be considered lucky, since their father has received treatment. When one of his sons one day said that "dad has a murderous look in his eyes", the exiled Iranian realised that he needed treatment and consulted a centre for victims of torture. Today he has retrieved a healthy relationship with his children. "I explained that I was ill, but I still think that it has left marks on them. Today my son is himself having a hard time controlling his anger" he explains.
Reza Hossein is a pseudonym for the Iranian refugee who wishes to appear anonymously.


Translated from Danish into English by Rikke Enggaard Olsen

Originally published by Hus Forbi ©

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