Mental Health Support for Refugees- Integrating Brazilian Perspectives

Refugees show higher prevalence of psychological disorders compared to the general population in host countries. At the same time, there is a lack in the provision of and knowledge about appropriate transcultural mental health support. The overall goal of this thesis was to investigate insider perspectives on the mental health support for refugee patients (MHSR). More specifically, the objective was to obtain insights into the MHSR in Brazil, a Latin-American and developing country. The research on refugees in Brazil is sparse, but the need to provide adequate MHSR is increasing with growing numbers of people who seek refuge in the country. The goal was approached in the first section of this thesis by reviewing and synthesising the existing research. In this, we aimed at obtaining insights into qualitative research findings on the perspectives of professionals and refugee patients concerning MHSR. The section starts with Chapter 2, a qualitative evidence synthesis of ten primary qualitative studies referring to 145 insider perspectives. The main findings highlight the importance of a trusting therapeutic relationship, of the adaptation of therapeutic approaches to patients’ needs and situation, and of psycho-social support, cultural sensitivity, as well as of external support structures for professionals. Negative or hindering aspects were identified as a lack of mental healthcare structures, the impact of the postmigration situation on patients’ well-being, cultural and language differences, and patients’ mistrust. Finally, ambivalences were formulated regarding verbal therapies, trauma exposure, the use of mental healthcare, and the impacts of the work with refugees on professionals. Section I ends with Chapter 3, that critically evaluates the method of a qualitative evidence synthesis and discusses some of its challenges, particularly with regard to the question of how to abstract and merge primary qualitative results without losing their in-depth-meaning. Chapter 3 also poses the question of the universality of the findings of the QES, as no primary studies from non-Western countries were included. The need for a greater international plurality in the research field of MHSR motivates Section II of this thesis. This second section looks at how psychologists in Brazil perceive the MHSR in this Latin- American country. Three different studies were performed for this second section using qualitative semi-structured interviews with professionals and thematic analysis, as well as consensual qualitative research strategies. The first study investigated how psychologists perceive the psychological suffering and symptoms of their refugee patients. It also provides background and contextual information for the following parts, such as concerning refugee patients’ countries of origin. The investigation found that the most frequently described conditions in refugee patients were anxiety and depression disorder and symptoms, grief, and PTSD symptoms. However, the results also showed that the use of manuals for the categorical classification and diagnosis of mental disorders is a debated topic among psychologists in Brazil, since psychiatric diagnostic categories are often perceived to be a poor representation of a person’s experience. Psychologists tended to stress patients’ socio-political suffering and to conceptualise patients’ symptoms as expected reactions to their profound losses and ongoing contextual instability. Participants discussed refugees suffering especially in relation to four clusters: the postmigration stressors, traumatic experiences, flight as life rupture, and the current situation in the country of origin. The second study of Section II explored the perspectives of psychologists on providing “acolhimento psicológico” (psychological care) for refugees in Brazil. It analysed the general experiences, positive and negative aspects, as well as facilitators and necessary changes to better the MHSR. Results showed, that psychologists experienced operating in a novel, precarious and xenophobic context, which led them to move beyond classical psychological work, engage in practical assistance and become very close to clients. Participants reported on a lack of public structures, insufficient competencies of professionals and high levels of staff fatigue. At the same time, they described gaining new perspectives and benefiting from witnessing their clients’ resilience. In terms of facilitating factors for the psychological care process participants pointed to the importance of psychologists being flexible, authentic, of showing a high resistance to frustration, and of making use of group-based approaches. Participants suggested that, in order to better refugees’ mental health in Brazil, efforts should focus on adopting a more social perspective in psychology, developing antidiscrimination campaigns, building policies for refugee’ integration, and scaling up investments in mental healthcare in general. The third study of Section II, retrieved the psychotherapists’ experience of providing psychotherapy for refugees in Brazil. Supportive and hindering elements in psychotherapy with refugee patients in Brazil were identified at eight different levels: the patient, the therapist, their relationship, the setting, the psychotherapeutic approach, the context of the patient, the context of the therapist and the societal context in Brazil. Hindering elements in the therapy included missing preparation for the integration of refugees, lack of interpreters, patients’ mistrust and therapists feeling untrained, helpless and becoming overinvolved. Supportive elements included a trusting therapeutic relationship, therapists’ cultural humility and structural competence, patients’ societal inclusion as well as working with groups and networks. This investigation showed that in light of the enormous structural challenges for the mental well-being of refugee patients, therapists’ flexibility and the reliance on collective work and networks of support is crucial. Finally, Section III, the integrative discussion summarizes, compares and contrasts the results of the various studies of this dissertation regarding, again, helpful/positive, ambivalent, and supportive/negative factors in the MHSR. These synthesised results are subsequently embedded within and discussed in relation to the scientific literature. The thesis closes by considering its limitations and by providing suggestions for future research, as well as an overall conclusion