March 2016
WPA on migrants and Asylum Seekers

Working Group on Needs of Migrant, Refugee and Asylum Seeker Patients Around the Globe

 

Part of the WPA Action Plan for the Triennium 2014-2017

1Schouler-Ocak Meryam, 2Kastrup Marianne C., 3Wintrob Ronald, 4Moussaoui Driss, 5Villasenor Bayardo Sergio, 6Zhao Xu-Dong

 

1Meryam Schouler-Ocak, MD, Ass. Prof.
Assistant Professor in the Psychiatric University Clinic of Charité at St. Hedwig's Hospital
Chair of EPA-Cultural Psychiatry Section
Große Hamburger Straße 5 – 11,10115 Berlin; Germany
E-Mail: meryam.schouler-ocak@charite.de

 

2Marianne C. Kastrup, MD, Prof.
Chair of WPA- Transcultural Psychiatry Section
Specialist in Psychiatry
Amalievej 23, 1875 Frederiksberg; Denmark
Email: d121304@dadlnet.dk

 

3Ronald Wintrob, MD, Prof.
Past-Chair of WPA-Transcultural Psychiatry Section; USA

Email:rwintrob@cox.net

4 Driss Moussaoui, MD, Prof.
Honorary Fellow, World Psychiatric Association
Honorary Fellow, World Association of Social Psychiatry
Casablanca; Morocco

Email: drissm49@gmail.com

 

5Sergio J. Villaseñor Bayardo, MD, Prof.
WACP President-Elect
President, Organising Committee oft he WACP-Congress 2015
Professor of Psychiatry at the University of Guadalajara
Psychiatrist for the Adult Inpatient Psychiatry Service
at Hospital Civil Fray Antonio Alcalde; Mexico
Email: sergiovillasenor@gladet.org.mx

 

6Xudong Zhao, MD, Prof.
Director of Division of Medical Humanities & Behavioral Sciences
School of Medicine of Tongji University
Director of Department of Psychosomatic Medicine
Shanghai East Hospital Affiliated to Tongji University; China
Email:
zhaoxd62@gmail.com

 

Cultural psychiatry and psychotherapy needs to be included as an integral part of educational curricula from undergraduate level through continuing professional development.

A. What undergraduates need to know

Concepts

  • The concepts of national character features, and their cultural components (including language and religion), from a historical perspective.

  • The meaning of the concepts of culture and cultural diversity, minority groups and ethnic minorities in national populations; the definition of “immigrant”; the meaning of cultural relativism.

  • The concept of cultural identity formation and its modification throughout the life cycle.

  • The meaning of acculturation and acculturative stress as it applies to immigrants, refugees and asylum seekers.

  • The meaning of cultural competence, including skills, knowledge and cultural sensitivity.

  • Knowledge about the purposes and components of the ‘cultural formulation interview’ in DSM-5.

  • Knowledge about the interactions between immigration status (immigrant, refugee, asylum seeker) and social stigma (inequality of), access to diagnostic and treatment services, as well as educational, residential and occupational opportunities (and impediments to) self-esteem and family coping ability.

  • Knowledge about the cross-cultural validation of instruments for diagnosis and treatment.

Mental health

  • Knowledge about the influence of cultural factors on mental health resilience and coping ability and as risk factors for psychopathology, including differences in explanatory models, beliefs and treatment expectations.

  • Knowledge about possible differences in mental health between immigrant and native-born patients, including contributory factors to these differences.

  • Knowledge about shortcomings in using international diagnostic systems with migrant (immigrant, refugee, asylum seeker) patients.

  • Awareness of conceptual and communication problems during the process of obtaining a psychiatric history from migrant patients.

  • The impact of nations’ immigration policies (welcoming or excluding migrants) on the mental health of migrants, and the quality of mental health services for migrants in those nations.

  • Knowledge about the statistical trends regarding numbers of immigrants, refugees and asylum seekers around the world over the past decades, and their main reasons for migration – both voluntary and involuntary.

  • Knowledge about the link between migration (people, goods and ideas) and globalisation from economic and cultural points of view.

  • Knowledge about the relevance of rural/urban migration and its psychosocial consequences (75 million more urbanised people every year in the world).

  • Awareness of the different phases of migration - pre-migratory, migratory and post-migratory - as factors influencing the mental health status of migrants.

Communication/cultural competence

  • General knowledge about the process of inter-cultural communication.

  • Knowledge about inter-cultural competence: who needs cultural competence training, and how does cultural competence training influence treatment compliance, effectiveness and patient satisfaction?

  • Knowledge about how inter-cultural barriers and institutional barriers are defined and what inter-cultural openness of an institution means.

  • Awareness that own stereotyping and prejudices are important when treating minority patients. Knowledge about the mechanisms of discrimination.

  • Awareness of the importance of showing respectful curiosity about cultural differences in patients’ backgrounds, and a willingness to ask questions to help clarify differences as well as to enhance clinical rapport.

B. What psychiatry trainees need to know

General

  • Knowledge about the extent of the numbers and needs of migrants, local laws and rights of immigrants, ethnic minority groups, refugees and asylum-seekers.

  • Knowledge about how to collect accurate data and information on migrants (immigrants, refugees and asylum seekers) and minority groups.

  • Knowledge of demographic/population changes in nations over time, and factors that account for those changes (toward multiculturalism in national populations).

  • Knowledge about the median length of time it takes in a student's country of residence for immigrant families to become economically self-sufficient (i.e. to become independent of governmental financial support) after migration.

  • Knowledge about the link between migration (people, goods and ideas) and globalisation, from economic and cultural points of view.

  • Knowledge about ethical cultural differences that might arise in the assessment and treatment of migrant families at different stages of the acculturation process (years since migration, degree of language fluency, presence of family members, extent of housing and occupational stability post-migration).

  • Knowledge about the relevance of rural/urban migration and its psycho-social consequences (75 million more urbanised people every year in the world).

Concepts

  • Understanding concepts of culture and sub-culture.

  • Understanding concepts of acculturation, acculturative stress and their relationship to nations’ immigration policies.

  • Understanding concepts of multiculturalism, ethnic identity and the possibilities of bi-cultural and multi-cultural identity.

  • Understanding concepts of identity, nation, and cultural components (including but not linked to language and religion) from a historical perspective.

 

Mental Health

  • Knowledge about culture-based medicine; culture-specific, illness-specific and migration-specific aspects.

  • Knowledge of diagnoses and illness behaviors from a transcultural perspective as well as culturally sensitive interventions.

  • Knowledge about the availability of treatment options for migrant patients and minority group patients.

  • Knowledge about public mental health and public education related to migration, migrants, and their needs and obligations.

  • Knowledge about the purposes and components of the ‘cultural formulation interview’ in DSM-5.

  • Knowledge about the interactions between immigration status (immigrant, refugee, asylum seeker) and social stigma, (in)equality of access to diagnostic and treatment services, as well as educational, residential and occupational opportunities and (impediments to) self-esteem and family coping ability.

  • Knowledge about the relationship between cultural perspectives on mental health and ‘person-centered’ mental health diagnostic and treatment services.

  • Knowledge about transcultural and trans-ethnic psychopharmacology, including cultural influences not only on pharmacokinetics and pharmacodynamics, but also other factors such as size and colour of pills.

  • Knowledge about the importance of anthropological/phenomenological approaches in psychopathology and daily clinical/therapeutic practice with migrants.

  • Knowledge about comparative practices in diagnosing and caring for mentally ill patients across the globe, including traditional healing practices.

  • Knowledge about human rights issues for mentally ill migrants, refugees and asylum seekers.

  • Knowledge about the impact of migration on the family members left behind in migrants’ home countries or home towns. Knowledge about the role of family/kinship in mental health of migrants, i.e. in coping with stress, social support, taking care of the mentally ill and so on.

  • Knowledge about national immigration policy and migrants’ rights to (and access to) treatment.

  • Knowledge about the cross-cultural validation of instruments for diagnosis and treatment.

Communication/Competence

  • Awareness of own cultural biases and knowledge of the use of interpreters or culture brokers, culturally different family structures, the effects of discrimination, exclusion, unemployment, intergenerational differences in acculturation, different explanations of illness, symptom presentations and treatment expectations, and idioms of distress.

  • Training in the use of cultural mediation, culture brokers or other models, including interpreters, working with family members or relatives.

  • Training in inter-cultural psychotherapy, including issues of transference and counter-transference, somatisation.

  • Knowledge of how the professional's own cultural background and limitations might influence working relationships with and the effectiveness of treatment they provide for people from other cultural backgrounds.

C. What is required for CME/CPD (Continuing Professional Development)

General

Ensuring that the professional's knowledge is up-to-date on the following issues:

 

  • Legal aspects regarding access to care for migrants (immigrants, refugees and asylum seekers) and minority groups.

  • Laws regarding and rights of immigrants, ethnic minority groups, refugees and asylum seekers. Housing, educational, occupational, medical and mental health needs of immigrants, refugees and asylum seekers and ethnic minorities, as well as on their access to culturally sensitive and appropriate resources.

Mental Health

  • Ensuring that the professional's knowledge is up-to-date on the following issues: Culture-based medicine, culture-specific, illness-specific and migration-specific aspects of medicine which need to be offered to mental health professionals. Transcultural approaches to diagnosis, illness behaviors and culturally sensitive interventions.

  • Transcultural psychopharmacological interventions.

  • Ensuring that quality standards for expert court opinions on minority groups in the context of criminal, civil and social law are available and employed in relevant settings. Interview techniques for ethnic minority groups.

  • Research on cross-cultural validation of instruments and interviews.

  • Availability of mental health services to refer patients to.

Communication/competence

  • Awareness of own cultural biases and knowledge regarding the use of interpreters or culture brokers, culturally different family structures, the effects of discrimination, exclusion, unemployment, inter-generational differences in acculturation, different explanations of illness, symptom presentations and treatment expectations and idioms of distress.

  • Training in working with cultural mediation, culture brokers or other models of communication, in the use of interpreters, family members/relatives, and other aspects of cultural competence.

  • Updating basic knowledge about patients’ cultural backgrounds.

 

D. Policy Document of the WPA

Preamble

Over the course of globalisation and the movement of people across nations it has become vital that service providers, policy makers and mental health professionals are aware of the different needs of the patients they are responsible for. Global migration and the increasing number of minority groups, including immigrants, asylum seekers, refugees and ethnic minorities, mean that, increasingly, psychiatrists and patients may come from different cultures. The inclusion of cultural psychiatry and psychotherapy is therefore a matter of growing relevance. The WPA should therefore recommend WPA Member Societies (Psychiatric Associations) to systematically include scientific sessions on migration and mental health and transcultural issues in psychiatry and psychotherapy in all their meetings. Furthermore, the WPA should recommend that WPA Member Societies create national branches or sections of Social / Cultural Psychiatry and Psychotherapy if they do not already exist, thereby pushing forward the awareness and knowledge of immigrants, ethnic minority groups, refugees and asylum seekers.

Related to cultural psychiatry and psychotherapy, the WPA outlines some of the key issues.

In this policy document WPA recommends the following:

Service providers should:

  • Initiate changes within their institutions (hospitals, clinics) to make clinical services culturally accessible and sensitive, and applicable to all migrant groups (immigrants, ethnic minorities, refugees and asylum seekers).

  • Provide integrated services as the preferred norm, with culturally specific resources allocated according to patients’ needs.

  • Ensure that appropriate resources are available to meet the needs of all minority groups.

  • Train all staff in cultural competency, cultural empathy and cultural sensitivity as an absolute must.

  • Install regular additional training as part of continuing professional development for all staff.

  • Consider the option of employing culture brokers or cultural mediators, in order to benefit both the clinical team and the local communities.

  • Ensure that qualified interpreters are available for patients who lack fluency in the official language(s) of the host country.

  • Make regular cross-cultural supervision available, either directly or using tele-psychiatry.

  • Include health education as well as prevention and mental health promotion as a part of the overall services provided for minority groups.

  • Provide information for all minority groups by means of pamphlets in their preferred languages, and make these easily accessible and available.

  • Consider having a nominated lead clinician who is responsible for cultural competency training, delivery and assessment in institutions (hospitals, clinics).

 

Policy makers should:

  • Consider mental health issues as being equally as important as physical health in the policy for social development; work for policies encouraging equity in access to and provision of treatment.

  • Cover all minority groups and make sure that there is equality in terms of resources that are made available to meet the needs of minority groups.

  • Take into account socio-demographic factors, including housing and employment, as well as physical and mental health needs of all minority groups.

  • Allocate sufficient resources to support public mental health and public education about all minority groups, as well as their needs and obligations as part of communication strategies.

  • Ensure availability of accurate data and socio-demographic information on all minority groups.

  • Take a lead role in ensuring that clear messages on equality and diversity are enshrined in the law with non-discriminatory health policies.

  • Make ongoing efforts to ensure cultural diversity and cultural competence in all health-related service centers; employ a diversity of administrative, clinical and teaching staff.

  • Encourage a policy of employing culturally diverse mental health staff.

  • Prioritise funding for cultural research, ensuring that quantitative and qualitative research on etiological factors, interventions and outcomes are promoted as a prerequisite for setting up services and that research dealing with the needs of minority groups is encouraged and appropriately funded.

  • Have a duty to inform mental health services about specialised services available for all minority groups.

  • Offer a model with culturally specific resources allocated according to patients’ needs in integrated services.

  • Establish specialised facilities for minority group patients when assessment shows that this is necessary and indicated.

Mental health professionals should:

  • Ensure that cultural psychiatry and psychotherapy are an integral part of all curricula from undergraduate level through to continuing professional development.

  • Educate themselves through ongoing training for all mental health professionals in understanding diagnosis, illness behaviours and culturally sensitive interventions, seeing these as mandatory when needed.

  • Ensure that quality standards for expert court opinions on minority groups in the context of criminal, civil and social law are available and employed in relevant settings.

  • Educate themselves depending upon the needs of local community, acquiring appropriate knowledge about culture-based medicine, culture-specific, illness-specific and migration-specific aspects.

  • Ensure that information is available for minority groups in their preferred languages about their rights, psychiatric disorders and treatment options.

  • Ensure that specific research dealing with the needs of minority groups is encouraged and appropriately funded.

  

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