7 May 2018

Out of the shadows: refugees’ invisible burden

Sophia writes:*

When Merkel declared her famous phrase: “Wir schaffen das!”[We can do it!] in the summer of 2015, the year that the arrival of asylum seekers hit an all-time historical high at 890,000 [pdf], she might have underestimated the barriers that refugees’ mental health issues pose to successful integration.

Over the past three years around 1.5 million asylum seekers have arrived in Germany. The German Federal Chamber of Psychotherapists estimates that half of those refugees suffer from psychological problems. Most common are post-traumatic stress disorders (PTSD), depression, anxiety disorders and suicidal tendencies. Due to the recurrent exposure to high-risk stressors, mental health issues are overrepresented in the refugee population with refugees being 10 times more likely to suffer from PTSD compared to the general population [pdf]. Pre-flight [pdf] refugees often experience traumatic events involving high levels of violence (war, sexual abuse, torture) and chronic stressors as losses of loved-ones and belonging. During flight refugees face high emotional and physical stress due to travels, separation from family and friends and uncertainty about the future. Lastly, the arrival and adaption in a host-country involves uncertainty about asylum status, economic hardship, cultural loss and adaption and social exclusion.

So far, the German government has failed to adequately address the refugees’ and asylum seekers’ mental health burden. The German Federal Chamber of Psychotherapists estimates that in 2015 only 4 % of arriving refugees received psychotherapy. Despite, EU guidelines [pdf] requiring the identification of vulnerable groups, Germany has no adequate screening procedure for mental health problems. The already overstrained mental health care system was unprepared to deal with the large influx of refugees and lacked mental health professionals, particularly therapists trained to treat PTSD. This resulted in long waitlists and only emergencies getting treated. While in bigger cities like Berlin there exists at least some basic infrastructure, the issue is all the more acute in rural areas. Even if a refugee has access to mental health services, language barriers still pose significant challenges to the therapy and require the presence of a translator, which is often not covered by the health insurance. Moreover, therapists are often not trained for cultural specific modes of expressions, increasing the risk of misdiagnosis. Both language and cultural barriers make it difficult to establish trust between the patient and therapist. Refugees’ low utilization of existing mental health services is also due to a lack of communication about entitlements, unfamiliarity with health care system, cultural norms and stigmatization.

However, addressing refugees’ psychological issues is essential, as the mental health burden does not only rest on the shoulders of individual suffers but affects the well-being of the whole society. Untreated mental health issues can be detrimental to successful integration. Acquiring language proficiency and participating in the labor market requires high-functioning physical, cognitive and interpersonal skills; however, refugees suffering from mental illnesses are often severely distressed and unable to function in daily life  [pdf]. If a PTSD sufferer wakes up three times every night tormented with flashbacks, he or she will have limited energy to participate in language school or job training the next morning. So while the German government offers integration and language courses [pdf], their effectiveness is undermined by the lack of treatment for psychological problems as shown by high-drop out rates of German language courses [pdf]. Difficulties to form trusting relationships and frequent retreat to social isolation further impair integration efforts. The Leopoldina academy of science report [pdf] also argues that the frequent witnessing of violence can lead to normalization and increase violent tendencies and antisocial behavior, particularly in children. Mental health issues are highly prevalent among children with one in five suffering from PTDS. As children experience extreme stressors during sensitive development stages [pdf] the long-term consequences of trauma are severe with potential language deficiencies and increased self-harm and suicide risk. Impaired learning capacities can also negatively influence school performance and pose a barrier to social mobility.
Drawing by a young traumatized Syrian
Early detection and treatment of refugees’ mental health issues is also cost-effective in an economic sense, as failure to treat will increase Germany’s future economic burden. Studies have demonstrated the high economic cost of mental illness and the potential economic benefits of effective treatment. If mental health issues are left untreated is it likely that they will become chronic. Moreover, mental disorder increase the risk for other costly chronic diseases [pdf], e.g. cancer, cardiovascular diseases, obesity, diabetes etc. Undiagnosed mental health issues also manifest in somatic symptoms increasing doctor visits without appropriate treatment. Therefore, refugees’ untreated psychological problems increase public health expenditures in the long run. At the same time, indirect costs occur due to lost productivity. Psychological problems [pdf] can lead to unemployment, absenteeism, under-performance at work, early retirement or premature mortality. Refugees suffering from mental health problems face difficulties to both integrate and participate in the labor market. Besides the lost productivity, the failure to integrate in the job market results in increased welfare payments.

On the bright side, The World Health Organization argues that the improvements in labor force participation and productivity due to investment into mental health treatments outweigh the costs. As affordable and effective treatment methods exist, there is the possibility to minimize long-term consequences with early treatment. NGOs have started to propose low-level interventions to address the inadequate mental health care provision for refugees in Germany. Interventions with refugees as peer-counselors, sharing language and cultural backgrounds, have shown promising results. The trained peer-counselor works under close supervision of a therapist, who can treat more severe cases, and provides self-help programs and group therapy, which might also show refugees that they are not alone with their problems.

Bottom line: Hundreds of thousand asylum seekers and refugees arriving in Germany over the past years suffer from psychological problems, which are often invisible to the eye. Refugees’ mental health is usually not considered a priority by the German government as shown by the great shortage of adequate mental health services. However, untreated mental health problems pose great barriers to refugees’ integration in society and labor market. Furthermore, by failing to address mental health issues immediately Germany accepts the long-term economic burden of increased future health-care costs, productivity loss and increased welfare payments. To minimize potential long-term harms to integration and economic efficiency the government needs to pick up the pace and start addressing refugees’ inadequate mental health support.

* Please help my growth and development economics students by commenting on unclear analysis, other perspectives, data sources, etc. (Or you can just say something nice :)


Mike Fagan said...

Sorry, no. Not having any of that. The refugees have no business being in Europe in the first place, as the nearest safe country for most of them was Turkey.

The largest problem to their integration, besides government incompetence, is their own criminal tendencies made worse by the poison of Islam and the cultural frames of reference they bring with them. I'll grant that the West should have stayed out of the Middle East altogether, but that doesn't alter the fact that these people simply do not belong in Europe. How anybody can see Merkel as anything other than the single most irresponsible European leader in half a century is beyond me.

Mike Fagan said...
This comment has been removed by a blog administrator.
Lucas said...

Hey Mike! Do you mind to share any references or material to your claims regarding the 'criminal tendencies' or the 'poison of Islam' being an impediment to refugees' integration?

Further, when mentioning Turkey as a better option, I don't quite agree that this is the case. There have been repeated reports showing that the conditions in Turkish refugee camps are awful, as the country is overwhelmed and under-resourced to deal with these issues. (https://rechten.vu.nl/en/Images/UlusoyBattjes_Migration_Law_Series_No_15_tcm248-861076.pdf & https://www.hrw.org/news/2018/02/03/turkey/syria-border-guards-shoot-block-fleeing-syrians).
Moreover, there have been some discussions that even in Turky there are issues with the cultural integration of refugees (https://www.economist.com/news/europe/21724413-if-syrians-become-permanent-underclass-country-headed-trouble-turkey-taking-care). For both the absence of integration and sufficient care of refugees the Turkish 'government incompetence' is often cited.

This is why it seems to me that refugees do have business being in Europe as their options for a dignified livelihoods are severly limited due to the geographical location and violence at home.

Mike Fagan said...

Dear Lucas... these cases are in my news feed (i.e. not the BBC) on an almost daily basis. Understand? Cases of illegal immigrants ("migrants") committing violent crimes are being reported on a *daily basis* across Europe, and have been for quite some time. Some are truly horrific. There have been mass protests across the UK, France and Germany with people shouting from the rooftops about these crimes. Assuming you live in Europe or have some connection to one or two European countries (as I do) it beggars belief that you are not already acutely aware of this.

Your request for references is dismissed - you do not need me to find these cases for you, they are innumerable and continue to grow every day.

David Zetland said...

Hi Mike -- your newsfeed does not constitute data, and thus your claims are also dismissed.

I suggest that you take your inflammatory accusations (and lack of reasoning) elsewhere, as my students appear to have better training than you do when it comes to discussing trends and topics.

Please note that I will delate all your future comments if you do not adhere to polite and reasoned discussion.

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