Refugees and mental health
26 August 2022
The UNHCR is the refugee agency of the United Nations. UNHCR has declared the Ukraine refugee situation a Level 3 emergency – the highest level they have. UNHCR is working with authorities, UN agencies, displaced community groups and partners to provide desperately needed humanitarian assistance to displaced Ukrainians.
The latest UNHCR estimates show that 5.6 million people have been displaced from Ukraine, and 7.1 million are internally displaced by the conflict.
Dr Peter Ventevogel is the UNHCR’s Senior Mental Health and Psychosocial Support Officer. Here he talks to Tom Parkhill, ECNP press officer.
TP: Peter, thanks for taking the time to talk to us. As you know, ECNP is undertaking a series of interviews on mental health in Ukraine. Of course, the UNHCR has a worldwide role, so Ukraine is just one of the areas where you are active. Can you begin by telling me a little but about your role, and the role of the UNHCR. How did you arrive in your position?
PV: I’m a psychiatrist from the Netherlands, originally. Even during my residency I worked with refugees, I did some of my internship working with refugees in the Netherlands. I got my psychiatry degree in 2000 and a year later I left the Netherlands to work with NGOs in Afghanistan and then Burundi. I also worked as a consultant with the UN, but for the last eight years I have worked with the UNHCR as their Senior Mental Health and Psychosocial Support Officer.
The UNHCR is one of the larger UN agencies. It has a very specific mandate: to protect refugees and other displaced or stateless people. It’s not a health organisation, let alone a mental health organisation. It’s a general protection agency, working with governments and providing assistance to displaced people where needed. My role is to help the UNHCR, which has around 19,000 staff, to integrate mental health aspects into their work.
I work in the public health section of the head office in Geneva. My colleagues are public health specialists. I’m the only mental health person, so one of my tasks is to ensure that health care for refugees includes a decent amount of mental health care – that refugees can access mental health services when they need, within the health system.
Our focus here is mostly on refugees in low- and middle-income countries, where governments are not able to respond effectively by providing protection and assistance for refugees, and they ask for our support. This means that we have far fewer operations in high-income countries, where the state systems should be able to do that. We focus on primary care. Aside from health, we are involved in many other things, such as child protection programmes, programmes for gender-based violence for refugees, education for refugees, community programming with refugees and host communities. In all those fields you can improve programming by integrating mental health thinking in your work. So, my role is very much beyond clinical health. You could call it public mental health, but we call it ‘mental health and psychosocial support’. The psychosocial support element implies that there are many actions which we can take to improve wellbeing and avoid people developing more severe symptoms.
Can you give me any practical examples of what you do?
I can give you a couple of examples. The first one would be about the integration of mental health into primary care for refugees. This means enabling primary-care physicians to identify and manage the most relevant mental health conditions in refugees. We have a tool called the mhGAP Humanitarian Intervention Guide, which can be used in training doctors and nurses in the essentials of mental health. We organise five-day courses to teach the symptoms of depression, psychosis, post-traumatic stress disorder, anxiety, grief, and teach – in a very competency-oriented way – what doctors and nurses can do to manage such conditions. Most of these courses take place in camps or rural settlements. We developed this tool with the World Health Organisation seven years ago. It’s a very basic document – it needs to be basic – telling primary care clinicians the fundamentals of mental health. It’s available in several languages, including a Ukrainian version, which was made when the conflict began eight years ago in the east of the country.
The second example is related to psychotherapy. One of the challenges we face consistently is that while it is possible to teach doctors how to diagnose depression or psychosis and how to treat it with medication, it proves to be very difficult to integrate the psychotherapeutic parts into the system. There are simply not enough specialists. In many countries, the lack of clinical psychologists is even more dramatic than the lack of psychiatrists. In practice that means that patients with depression and PTSD who were diagnosed in health facilities cannot receive counselling or psychotherapy. So the next frontier was to develop ‘scalable psychological interventions’, which would basically be psychotherapy made simple, through brief interventions (three to eight sessions) using evidence-based methods that are applicable in many different contexts. It has proven possible to effectively build the capacity of non-specialists, such as social workers, nurses or community members, including refugees themselves in delivering such interventions. Some of these tools have also been translated into Ukrainian (see here).
Both examples relate to task sharing, which is a central concept in global health: in situations where the numbers of specialist are grossly insufficient, the smartest way to make decent mental health available is through enabling non-specialists to do part of it – this is called ‘task sharing’. This does not make the psychiatrist or clinical psychologist redundant, on the contrary I would say. But their roles will change: a psychiatrist can spend a good part of time on training and supervising others. This obviously, inevitably, leads to a certain loss of quality, but it increases coverage enormously.
I guess that your first action is to get in touch with the health authorities in an affected country, and then they put you in touch with the people you need to train. What are the difficulties you meet in a war situation?
In a war situation everything is difficult, but the main issue in many settings of armed conflict and displacement is that existing systems have collapsed or are not available. So while we try to strengthen the existing national systems to cope with additional needs, it is often necessary to take a hands-on approach and use twin tracks. I’m not especially talking about Ukraine here. It means that while the goal remains that of strengthening the ability of national systems to work with refugees, we sometimes need to provide services directly. UNHCR funds NGOs to do this. This often occurs in resource-poor settings when refugees assemble in remote corners of the country and there is not much of a national system.
So you are saying that it is essential that refugees are integrated into health systems in host countries?
Absolutely. That’s important in all countries, and surely in high-income countries such as the countries in Eastern Europe hosting Ukrainian refugees. Many of these countries are part of the European Union and have functional health systems; the main goal should be not to set up a parallel system, but to help the existing systems cope with the needs of refugees.
How is the humanitarian assistance for Ukrainians organised?
The humanitarian system involves many people. First and foremost of course the national governments in the countries that are impacted by the crisis. Many of these governments get direct support from other governments or through the European Union. Second, a significant part of the external humanitarian assistance is channelled through the United Nations agencies such as the World Health Organization, UNICEF, UNHCR (the refugee agency of the United Nations), the World Food Programme and others, including non-governmental organisations. Third, there is a large informal system of community groups, local organisations of citizens of Eastern European countries and Ukrainians.
I know most of the second part: the formal humanitarian aid system led by the United Nations. Mental health and psychosocial support (MHPSS) has been identified as an important issue and has been fully integrated in the major planning documents. For the situation within Ukraine, the key document is the Ukraine Humanitarian Response plan (see here). For the Ukrainian refugees in the neighbouring countries the leading document is the Ukraine Regional Refugee Response Plan (see here). Both documents pay significant attention to mental health and psychosocial wellbeing.
When there’s a refugee or conflict situation, there are some general things that people have to deal with, trauma, anxiety, etc. But then these will change over time. I imagine this is generally true. Can you tell me a little bit about what you see generally, and then tell me if you are seeing the same things in Ukraine?
That’s a good question. In the initial stage of humanitarian crisis you see massive mental health needs. That first phase may last days to a couple of weeks. This is where they have acute reactions and you have to stabilise the situation economically, socially, and medically. Everyone is worried, anxious, can’t sleep well, and so on. Those are normal reactions in abnormal situations such as acute stress responses or grief reactions. Stress is often massive and acute because the situation is changing so drastically. All the things which anchored you are just not anchoring you anymore, because you have lost them. Grief is so important because people have lost so much. Sometimes this includes the loss of people because they died – sometimes through killings – but losses in refugee situations are much broader than that. I have seen many refugees who are not traumatised in the psychiatric sense of the word – they have not experienced a traumatic event that got imprinted in their mind – but I’ve never seen a refugee who has not faced loss. By definition every refugee faces loss; loss of your country, loss of your status, loss of your social networks. I call this grief because it’s very much related to the reactions to the loss of a loved one. Those two reactions, acute stress and grief, are not necessarily pathological. They can create huge suffering, they can morph into other things, but in itself this is distress, and not yet disorder.
The second phase lasts weeks to months, when there is a certain stabilisation of the situation. People have a safe place to stay, most of the basic needs are met and they have some sense of safety back in life. They can move out of the ‘emergency mode’, and you see people are adapting. Many people are then able to cope, if they are given opportunities to go back to work, to send their kids to school. Kids especially are often very resilient.
But some people cannot cope, obviously, which brings us to the pathologies. In the second phase you see people with depression, people with PTSD, people with anxiety disorders, the whole range of common mental disorders. There is a big debate in humanitarian mental health over the relative importance of depression versus PTSD. I don’t care – they are both important! Actually, that’s not completely true: I think that depression is more relevant because of the things I have just said. What you also see when the situation stabilises is that some people are not able to cope, so you get psychotic reactions as well, perhaps amongst people with severe mental disorders who get unstable in their symptomatology, for many reasons, most importantly because the social environment is turned upside down. Someone who can cope in a stable situation may not be able to cope if you put them in a bus and bring them to a different country where they can’t speak the language. This is something I want to highlight: let’s not just focus on the common disorders such as depression and PTSD, and let’s not forget the people with severe mental disorders, like psychosis or bipolar disorder. First of all because their suffering is enormous and they are really at risk, they are very vulnerable. But secondly the situation means that numbers go up. In acute displacement settings the numbers can rise by 50% (admittedly from a small baseline).
Then there’s a third phase, which we measure in years – we’re not there yet in Ukraine, and hopefully we can avoid that – when you get a set of people who start to lose hope, because they are in limbo for a long time. This is where you see increases in mental health issues, particularly related to negative coping mechanisms. You see increased suicidal behaviour, substance-use problems, social problems in families. People frankly give up. We see this in some of the protracted refugee settings in places that the world seems to have forgotten and where people have few perspectives that their life will get better any time soon.
A last question, what can the European psychiatric community do?
You can do a lot. Firstly I think that issues around capacity-building and training are important and here European psychiatrists can play a major role. I’ve met so many great Ukrainian professionals – I’m sure you have too. Help them, strengthen what they can do. But it is essential to use a long-term perspective and not to teach what you know but to teach what they need to know. We should only introduce tools and skills which can be sustained. In general, I am reluctant to introduce the newest psychopharmacological medicines in conflict settings, because the supply lines are not guaranteed or the medicines are too expensive in the long term. And of course we need to avoid fancy equipment, which can be easily destroyed in a conflict situation.
Secondly, is there an opportunity to use this horrible crisis to modernise the mental health systems in Ukraine, but also in nearby countries such as Poland and Romania. That’s partly a political question. Some of these systems are still based on the heritage of the old Soviet-style psychiatry. These countries are trying to de-institutionalise the mental health care system, to decentralise services. The current crisis can provide an impetus to do more. We see that for example in Poland, where the government has been working on changing the financing of local mental health institutions, to give them more autonomy. This is an excellent opportunity, with additional funding coming in, with expertise coming in, to accelerate those processes. A country like Moldova had a really very old-fashioned mental health system, but they have tried to decentralise it. And the Ukraine crisis has put Moldova in the spotlight. Quite a lot of funding is now becoming available to help Ukrainians in Eastern Europe and those in Ukraine. If we can use funds in a smart way, to improve the systems, then we will be doing good and leave a legacy.
Thirdly, put your money where it can best be of use. Often in the past people have shown support by ‘going there’. In Ukraine, the volunteer response has been enormous, unprecedented. And this was very rapid. There were many situations where the volunteers were there before the professional organisation (including the UNHCR), and this is great. However, at a certain moment you need to see that this help shouldn’t be charity – this has given me mixed feelings. I’ve seen doctors at the Polish border who had come from the United States for a week or so, trying to help, but if you ask even the most basic questions such as “Do you know the nearest referral hospital” you’d be met with “We don’t know, we’ve just arrived”, and then they would say that they would be leaving the next day. I admire the good intentions but is it helpful? I’d say, don’t go for a charity approach, but donate financially to professional aid organisations.
Thanks for talking to us.
The UNHCR’s tools and documents are available here.