Interview with Marie Høgh Thøgersen, clinical director of DIGNITYs rehabilitation clinic

More research is essential for developing effective interventions for vulnerable refugee populations with mental health problems


Main theme: Psychiatry at war

 

Timely treatment and more research are essential if we want effective interventions for trauma-affected refugees with mental health problems arriving in Western Europe.



You are the Clinical Director of DIGNITYs rehabilitation Clinic, a highly specialized treatment center for trauma-affected refugees in Copenhagen. How does your center collaborate with similar centers in Denmark?


DIGNITY heads The Danish Trauma Database (DTD) which is a national collaboration between seven clinics providing outpatient treatment for traumatized refugees. DTD is formed on the recognition, that each clinic cannot produce enough empirical data individually needed to enhance the field. For an annual flow of 1200-1400 patients, DTD harvests standardized clinical data in a shared digital system. DTD data is also combined with data from the Danish national registries, enabling documentation of refugees’ life trajectories before and after treatment. The hope is to transform our knowledge about treatment effectiveness and societal implications of treatment for refugees in high-income countries, through the representative clinical data, and the unique Danish registries.


We have witnessed how trauma effects not only the individual trauma-survivor, but the whole family. We hope that DTD will shed new light on the transgenerational transmission of trauma that we experience in our family treatment. DIGNITY has recently published a study of female survivors from Kosovo and their children born after the war. All the women had experienced sexual violence / torture during the Kosovo war. The study sheds light on the biological processes whereby the negative effects of trauma are past from mother to child.


DIGNITY has extensive experience with treating trauma-affected refugees. Do you find that there are communalities in their symptom presentation?


Refugees are a very heterogenous differing in cultures, languages, educational backgrounds, and socio-economic status. This makes it very difficult to standardize treatment and to conduct research in the field and to document symptom patterns across the group. Trauma-affected refugees are one of the most vulnerable groups of mentally ill patients in Denmark. Those referred to the Danish Trauma Clinics are characterized by a very low level of functioning and severe physical and mental symptoms. On average trauma-affected refugees have been in Denmark 10-15 years before they receive specialized treatment. The lack of timely treatment, the fact that many have endured many years with untreated PTSD and untreated psychosis, explains some of the severeness of their symptoms at the first encounter.


In DIGNITY we treat the entire family simultaneously through a multi-disciplinary approach, in contrast to many other treatment facilities. The initial meeting with the whole family provides a unique opportunity to develop a realistic treatment plan, that considers the concrete situation of the whole family and can facilitate positive and sustainable change.


Coming to the invasion of Ukraine: have you seen refugees from this war at DIGNITY?


So far, no Ukrainian refugees have been referred to the Danish Trauma Clinics. With the Syrian refugees our clinics did not see the first arrivals before a year after they had arrived in Denmark. Moreover, often the first wave of refugees is more well-functioning, and less trauma-affected than later waves.


A key risk factor for many of the Ukrainian refugees is that they are separated from their families. In our clinic, we have experienced, time and again, how a well-functioning family can be a central protective factor for refugees. A united family can be a buffer for trauma and can better adapt and even welcome change. The war in Ukraine takes a heavy toll on children and families who are been torn apart. A large proportion of the Ukrainian refugees have left family members and the uncertainty regarding their destiny is burdensome and a heavy stressor that must be delt with. Furthermore, many may have different health problems so it would be beneficial to carry out a routine health screening including a screening for mental health problems.


A protective factor for the Ukrainian refugees arriving in Europe, is the warm welcome they have received. Syrian refugees in Denmark who are highly represented in the Danish Trauma Clinics, saw a very different reception than the Ukrainians are experiencing - consistent with the experiences other non-Western refugees have faced when trying to reach Europe. We plan to establish a national cohort of newly-refugees coming from the Middle East and Ukraine respectively to follow over time and to study how the reception in the host country and other processes interact to inform and eventually predict, long-term individual and societal adaptation in terms of mental health and cultural integration.


You have recently visited the region. What was your impression?


DIGNITY was contacted by OSCE to assist with crisis intervention following an evacuation of several hundred staff-members from Ukraine. Together with OSCE emergency team, and local staff in Moldova, DIGNITY carried out a crisis-intervention. We, as a team, intervened with defusing and individual crisis-management The experience revealed that mental health expertise is essential and very helpful also in the very early stage. The local (Ukrainian) staff had been separated from their families by the borders. This separation was experienced as chaotic and traumatic, not only for the involved, but for those witnessing the separation. This separation of families will perhaps be a key traumatic experience for Ukrainian refugees, like the crossing of the Mediterranean Sea, has been from many non-Western refugees in recent years.


In the light of the experiences working with this population for years what are some key messages?


Refugee mental health is far from a high profiled research area, and this means that the field is methodologically and clinically underdeveloped which comes at a very high price for the afflicted individuals and their families, who risk further marginalization. We believe research in the area is essential for the development of effective interventions.


It is important to think in holistic and long-term solutions and recognize that trauma is passed from one generation to the next – there is a vicious cycle that has to be broken – the sooner the better. Generally, three things are central for most trauma-affected refugees settling in new countries. These are; getting a job, learning the host language and receiving timely trauma treatment. In Denmark very few interventions succeed in addressing all of these, equally important, issues. Often one issue is addressed at the expense of the other. We hope future interventions, to a higher extend will be able to address all issues simultaneously.