Sondos Zayed is a medical student in the Class of 2018 at McGill University
Raised in an impoverished household, Ms. K was married off at a young age to a man decades her senior. As the years passed, the abuse her husband inflicted upon her escalated until she began fearing for her life. She spent years saving money and meticulously planning her escape, though her departure also meant abandoning her family to the mercy of her husband’s wrath. She eventually sought refuge in Québec, Canada.
With no real proof of identity, she was imprisoned for months upon arrival. Once released, with neither connections nor funds, she was directed to the YMCA Residence (which in 2010 had come to an agreement with the Ministère de l’Immigration, de la Diversité et de l’Inclusion to welcome refugees on Québec territory and assist them with integration by helping secure short-term housing, work, financial assistance, and psychosocial support services). (1)
According to the Canadian Council of Refugees, a refugee is defined as a person who has fled their country for fear of being persecuted and is thus unable to return home. (2) Refugees have access to local settlement services and are granted income support from the Government of Canada via the Resettlement Assistance Program or from the Province of Quebec “for up to one year or until they can support themselves, whichever comes first”. (3)
Despite both the federal and provincial governments having legislation in place to meet refugees’ basic needs, these individuals often face numerous challenges. Their ambiguous legal status is a constant hurdle to their access to healthcare; government assistance covers little more than their monthly rent. Job opportunities are scarce since they are not permanent residents, their previous education goes unrecognized, and employers have myriad prejudiced ideas about hiring refugees. They live in fear of being deported back to the country where they were persecuted. Suffering from Post-Traumatic Stress Disorder (PTSD) significantly hinders their ability to overcome these obstacles. (4)
Ms. K met the DSM-V criteria for PTSD. (5) Recurrent nightmares left her at the mercy of chronic insomnia; crowded areas and physical touch often triggered painful flashbacks, leading to the development of avoidance patterns with hypervigilance and exaggerated startle responses. Mood lability and poor concentration made it difficult for her to find work, socialize, and follow her lawyer’s instructions to gain status and avoid deportation. At her court hearings, she was compelled to recount her painful experiences. In clinic, we scrutinized her scars and asked her to describe the unfortunate events through which she’d acquired them so that we could sketch and detail them in a letter which might turn the tide in her favour in court.
A noteworthy nine percent of adult refugees are diagnosed with PTSD—often with comorbid major depression. Despite being a high-risk population, refugees are known to underutilize mental health services in Canada. (4) This is perhaps due to cultural stigma associated with mental health issues in the context of limited health literacy. Often, they present to a family physician with somatic complaints for which there is no evidence of disease (4). Patients may also fear being judged by healthcare professionals, as strong feelings of shame and inadequacy can plague their sense of self-worth after having survived so much trauma. All of these factors are exacerbated by unemployment, social isolation, and discrimination. (4)
On the other hand, primary care physicians may not feel comfortable treating and managing PTSD in such a vulnerable population given the complexity of extreme trauma in addition to language and cultural barriers. Available screening tools have not been tested for diagnostic accuracy and cultural validity in refugees, so their sensitivity and specificity remain unknown. (4)
The Canadian Collaboration for Immigrant and Refugee Health does not recommend routine screening by primary care physicians for PTSD in refugees given that disclosure of traumatic events, particularly in the presence of family members, may do more harm than good in well-functioning individuals. However, “in the context of unexplained somatic symptoms, sleep disorders, or mental health disorders such as depression or panic disorder, clinical assessment [is warranted] to address functional impairment.” Once diagnosed, PTSD should be treated using a combination of Cognitive Behavioural Therapy (CBT) and/or pharmacotherapy according to the most recent guidelines (though this recommendation is largely based on low quality evidence given the rarity of its implementation in the refugee population). (4) Alternatively, the National Institute for Clinical Excellence has adopted a “phased intervention model” to address PTSD in refugees and asylum seekers. During phase one, when refugees face the threat of deportation back to the traumatic environment, “intervention should focus on practical, family, and social support.” During subsequent phases, status is obtained and settling becomes a priority. Focus is directed towards patients’ priorities such as “social integration and treatment of symptoms.” Importantly, this approach has not yet been validated by any clinical trials. (4)
In 2013, the World Refugee Survey revealed that Brazil was the only country graded “A” in the categories of “refoulement/physical protection; detention/access to courts; freedom of movement and residence; and right to earn a livelihood.” (7) This highlights the insight that an anonymous multilingual survey of refugees and asylum seekers can provide into the pitfalls of the refugee settlement system in Canada, and—more specifically—Québec.
Brazil is also known for its Mental Healthcare Program specializing in the treatment of refugees and asylum seekers, which specifically targets the psychosocial needs of this population and treats them with the objective of attaining self-sufficiency. Several Brazilian organizations have created health campaigns raising awareness about refugees to help alleviate the discrimination they face when searching for work or housing. (8) These are examples of successful interventions which can be adapted to the Canadian context.
Perhaps if Ms. K’s PTSD was treated with a phased intervention model by specialized healthcare providers in the context of a discrimination-free environment and more compassionate legal process, she would be better equipped to overcome the struggles of resettling. Physician advocacy for the time, resources, and policies to help address PTSD in refugees is therefore of the utmost importance.
Acknowledgement: The author would like to express her gratitude to Dr. Faisca Richer for her editorial comments.
Note: All characters in this work are fictitious. Any resemblance to real persons, living or dead, is purely coincidental.
- The YMCAs of Québec. Housing Services. Retrieved from http://www.ymcaquebec.org/en/Community-Programs/Housing-Services
- Canadian Council for Refugees. (2010, September). Refugees and immigrants: A glossary. Retrieved from http://ccrweb.ca/en/glossary
- Government of Canada. (2017, April 3). How Canada’s refugee system works. Retrieved from http://www.cic.gc.ca/english/refugees/canada.asp
- Tugwell, P., Pottie, K., Welch, V., Ueffing, E., Chambers, A., & Feightner, J. (2011). Evaluation of evidence-based literature and formulation of recommendations for the clinical preventive guidelines for immigrants and refugees in Canada. CMAJ, 183(12), E933-E938. doi:10.1503/cmaj.090289
- Merali, Z., et al. (2016). Post-traumatic stress disorder. In Toronto notes 2016 (pp. 1208-1209). Toronto, ON: Toronto Notes for Medical Students, Inc.
- Carlson, J. M. (2005). Mental health and health-related quality of life in tortured refugees. Copenhagen, Denmark: University of Copenhagen.
- Becker, E. (2015, November 3). The four ‘best’ countries for refugee resettlement. UN Dispatch. Retrieved from http://www.undispatch.com/the-four-best-countries-for-refugee-resettlement
- Moreira, J. B. & Baeninger, R. (2010, July). Local integration of refugees in Brazil. Forced Migration Review. Retrieved from: http://www.fmreview.org/disability-and-displacement/julia-bertino-moreira-and-rosana-baeninger.html
Sondos, I am so pleased to see you have continued doing wonderful and thoughtful work since our paths parted 6 years ago. All the best to you as you embark upon your new career.
This is an important article. Post-traumatic stress conditions, if left untreated, lead to increases in violence, morbidity and mortality.
Sadly, most patients with complex traumatization do not receive phased treatment, or often any meaningful treatment at all. This occurs despite many professional guidelines that emphasize the importance of phased treatment, and attention to the body and nervous system (as well as safety and stabilization strategies), e.g. http://www.ukpts.co.uk/links_6_2920929231.pdf
Unfortunately, there remains a great deal of resistance to adopting even trauma-informed care in our Canadian health care system, let alone allowing skilled clinicians the opportunity to teach medical students and physicians.
Slowly, over time, this culture of resisting is changing, but it is often too late for veterans, first responders, child abuse survivors and refugees, who may go on to suicide, addiction, imprisonment and shortened lifespans.
Refugees and victims of childhood and adult trauma deserve much better. I do hope that your generation of physicians and health care providers will continue to advocate for better access to trauma treatment programs and to the addition of understanding psychological trauma to medical school curricula.
Rudy Ramchandar M.D.
Great expose of a topical issue and legal quagmire. Brilliantly, sensitively and empathetically written!