Who cares when no one cares? When it seems impossible to care? The world of helping patients with depression and other mental health issues is not an easy one. This sector of health care is often an underfunded and undervalued part of the professional world. Psychologists and psychotherapists have to learn how to deal with the harsh emotional aspects of such a profession, but also with a lack of institutional support and a stigma around mental issues.

But what if their patients are more likely to develop mental health pathologies while, at the same time, having fewer possibilities of diagnosis, treatment and recovery? Throw in one of the biggest refugee crisis the world has ever faced, fearful citizens on the receiving countries, securitarian policies happily delivered and gross mismanagement of resources and welcome to the crisis within the crisis, that of mental health among refugees.

We got interested in the work of psychologists and social workers helping refugees arriving to Serbia, Greece or Germany after learning about a “gay test” performed by the Hungarian migration officials in 2015 and now ruled as a violation of Human Rights by the European Court of Justice. Using this “test” as a starter, we wanted to examine the broader issue of mental health among refugees. To do so, we talked with three psychologists who worked with refugees in these countries : Elektra, Slavica and Judith.

“Rorschach must be turning in his grave”

The subject of the exam was a Nigerian man identified only as “F” seeking refuge in the city of Szeged, Hungary, due to persecution in his homeland. Using the Rorschach inkblots test, in which the patient is shown a series of ambiguous or meaningless images, creating themselves the meaning, the state psychologist determined the man’s statements about his homosexuality “lacked credibility”, thus rejecting his claim.

The case was brought to the European Justice Court which determined the procedure “amounted to a disproportionate interference in the private life of the asylum seeker”. Now, according to BBC, the court in Szeged must reexamine the case. Furthermore, with this ruling, EU countries are impeded to use any psychological tests to determine the sexual orientation of asylum-seekers.

When we talked to the psychologists on the field, the feeling of outrage towards this practice was common. Elektra thinks that it is not acceptable that such a test, whose validity “has been criticized by the psychological community for decades” was used, qualifying this practice by the Hungarian Border Police as “wrong and unacceptable on an ethical level, social and scientific level”.

Echoing these comments, Slavica said “that Rorschach must be turning in his grave, knowing what some Hungarian officials are doing with his findings”. As for Judith, she notes that “there are structured interviews for sexual orientation that you could use, but not Rorschach, which has nothing to do with it”. Psychology being misused not as healer, but as judge, is that really something new? The power of science is misused once again by the state apparat, in a gross reminder of the eugenics movement.

Example of Ink Blot used in Rorschach test

“Emotionally, I was burned out from day 1”

Tuning in to the news is something that Slavica prefers to avoid, concentrating on the people in front of her. The feeling of helplessness, fueled by the “reality of news”, is opposed by finding and being together with people who are alike or doing the same jobs, as with Elektra. In her job as a “guardian” for unaccompanied refugee children, she had a pair who was also working in the organization and with whom she “talked every day , giving advice to each other, instead of being all alone in the job”.

Supervisory meetings and a supportive network between the colleagues also helped her to face the “emotional burnout that was there from day 1 until the last day”. To turn anger, sadness or other negative emotions into motivation and will to act required, for Slavica, a bit of skepticism, but also a notion of what is and what is not possible – to a single person – to resolve, including mismanagement and poor allocation of resources, adding to the stories recounted by the asylum-seekers.

All of this is happening in a little country at the border of the European Union, Serbia, still and also on its own process of healing from the “nineties”. An unassuming and tiny word encompassing a traumatic decade starting with the Yugoslav wars, which scarred the people with the traumas and memories of the conflict, sanctions and NATO bombardments of Kosovo in 1999, and its own wave of refugees from neighboring countries.

The power to care is not to care for power, for the system and for the society that produces this wave of refugees and then strands them at the borders of the European Union. In the case of Slavica, change becomes micro-change and, reduced to those in front of her, and her “real” power, that is wanting to help, provide, listen, but most of all, empower and reestablish: humanity, dignity and will to live.

To have your “emotions as work tools”, Judith says, is “really exhausting, as if, by the end of the day my emotional muscles were sore”. In her case and the people she meets, burn out is prevented by giving both the doctor and the patient a professional structure and a sense of normalcy, which is not possible in camps or in the places refugees are passing. There are office hours, a cabinet and appointments, an extravagance and a luxury in those places.

While expressing her admiration for the people who work in camps, she recognizes that her role is not the same as a tutor or a volunteer who is a “100% on the side of refugees and when the asylum claim is rejected they are as upset as them”,  mostly because she “needs the distance to work for them”. She further states that for the patient “it is comforting to know that if they are upset it does not mean I have to be upset, that I can be calm and that we can work things out”.

“I imagine doing away with the camps”

In Berlin, most people Judith meets are settled (or in the process of doing so) and living in their own places, although housing, in such a metropolis, is a big issue. When Slavica thought about what would she do if she was managing a camp, her immediate and definitive answer was that “there would be no camps anymore”, and surely not on the periphery of the cities, far away from any possibility of contact, entertainment and integration. The main activity in those places, she points out, not without irony, “is counting cars in one direction, and then in the other”.

It is a whole different world of thought, doing away with camps. A thought that is not only a dream or a hypothesis in places like City Plaza, the bulwark of citizen and refugee resistance to the camps and EU policies, a mark of defiance and anti-racism, a squatted hotel in the center of Athens, where people in solidarity and refugees work, live and fight together.

In a sense, small activities organized there, as in the camps, may become an enabler for getting back a sense of self, away from the traumas of the journey, the persecutions back home or the border crossings: cooking and preparing meals, making decisions in equal footing with volunteers or managers, marching and protesting together. Or, as Francesca – another former member of an NGO who worked in a Serbian asylum center – witnessed, having the possibility of managing a small cafe, where adolescents of both genders, albeit separated, get the possibility to be occupied and get experience and responsibility.

Elektra agrees with this alternative approach for the integration of asylum-seekers and refugees. In her experience, a mix of activities, such as drawing, field trips or visits to the cinema, museums or amusement parks helped the kids to build a relationship with the guardians, in order for them to “feel safe to open to you and explore anything they want to explore”. These are the principles of what she describes as “a person centered therapy” used by the psychologists of the NGO.

city plaza receiving angela davis
Renowned activist Angela Davis visits City Plaza, where refugees live side-by-side with Greek citizens and international activists.

What are the symptoms among refugees?

One question remains: How to be “professional” in such conditions, in face of stories that recall, as Elektra says, “the kind of situations you have seen on films, but you never actually witnessed yourself”? Confidence and trust are not easy to acquire and both take time. “What would happen if you said you are a psychologist?”, I asked Slavica. In the mutual quest for discovering, the refugees she talks to do question more about personal and intimate aspects of her life, skipping over her professional role, helping her to gain their trust and engage in a friendly, rather than a professional, talk.

Her job goes far beyond the tasks a psychologist would perform in an “ordinary” context: she offers her presence, the opportunity to chat, to express their feelings. Because refugees are, according to her, doubly dehumanized: besides the traumas, the distance and isolation often faced, the conditions in the camp for those who want and can stay there are, not rarely, degrading. For those outside the camps, conditions are often much harder.

Among the refugees stranded in Serbia, two feelings, she admits, are mostly prevalent: feeling stuck in the country and being ready to do everything to leave, even putting one self’s life at risk. Cases of self-harm among teenagers are reported, as well as the consumption of marijuana or alcohol. Many women also suffer psychosomatic episodes, such as hair falling or weak nails, burdened with the feeling that they cannot take care of their children, gender-based violence, risk of human traffic, lack of participation in decision-making in their families and many other factors.

In a video entitled “Games of Violence”, by the Médicins sans Frontières (MSF), refugees trying to cross the many borders erected at the edge of EU can be seen in despair. One of the asylum-seekers interviewed is recorded saying that he asked one of the Hungarian border guards to “pick up his gun and kill” him. Due to stress, he adds, “many people take knifes and cut themselves with blades”.

In Greece, back in 2015/6, Elektra recalls that “there were some children who were having post-traumatic stress, maybe nightmares”, while also feeling “fear and anxiety and crying all the time, some showing signs of depression”. As she states, it is not possible, nor desirable to generalize, but as in Serbia, some kids “were trying to hurt themselves” or, in fortunately rarer cases, even trying to commit suicide.

As Judith witnessed, even after reaching Germany and when they already “live in their own apartment and their kids are going to school, and everything should be good, they still collapse completely”. Before that goal (of reaching the country), “there was no chance to have feelings of weakness, because if you give up, there is no way, no one is doing it for you, you have to function”. So feelings are suppressed and disappointment is not always avoidable in the hosting society, where you might be facing the anxiety of the asylum seeking process, issues with housing, job or previous traumas.

lives in limbo irish times
Frame from “Lives in Limbo“, with Noreen, asylum-seeker in Ireland, discussing her depression and stress-related loss of hair. From the Irish Times.

Is there a stigma among asylum-seekers to talk about mental health?

And while, as Judith rightly remembers “psychologically it makes a difference if you risk something for your political ideas or got into a mess without actually having made a decision about it”, to deal with those feelings is not easy due to the stigma against mental issues. “It’s indeed scary to realize, in some way, you are not functioning as well as before”, she says. The usual reaction is to counter and say “I am not crazy”, especially among men. Elektra tell us that she “witnessed a bigger stigma among these population. Possibly, because of the masculine stereotype that they have to be strong”.

“Children”, unlike men, she admits, “don’t have this kinds of judgment or expectations about themselves, so it is easier for them to seek and receive help”. According to Slavica, even if most refugee women are suffering, they are able to recreate small activities that recall them from home, such as sharing tea or coffee, cleaning or sharing a conversation, which might help them in dealing with harder issues. “

“Mental health is often prioritized last”

At the beginning of March, Kevin Love, an NBA champion, revealed his struggle with anxiety attacks, after another NBA player, Demar DeRozan admitted he’s struggling with depression for years. As Love writes, “for 29 years, I thought about mental health as someone else’s problem”, adding that on basketball teams “nobody talked about what they were struggling with on the inside”. These are stark reminders that mental health is something hard to deal with in any society, even among citizens who enjoy relative well-being, success and safety.

Therefore caring about refugees’ mental health needs is a double struggle. Particularly when in Europe walls are being built to prevent refugees from coming, keeping them exposed to all sorts of violence and trauma at its borders. Elektra’s final words help to sum up the current situation of refugees:

“Sometimes even if a group of people or an NGO wants to help and are really concerned about the mental issues of refugees, they have to prioritize other things. Prioritize, first of all, a place to stay, they have to make sure they have food and clothes and that they are safe, so the mental health is important, but it’s often prioritized the last”.

Change has to happen, and sometimes change is that we are able to talk about mental health openly among families, peers and friends. Or that we, as a society, create the social resources to diagnose and treat mental issues. Or that we view refugees for what they are, people who had to flee due to persecution or violence.

Story: Alexandre Fonseca, EVS Volunteer at Volunteers’ Centre of Vojvodina with the project “People BeyONd Borders” (Erasmus + Program).  

With special thanks to: 

Elektra Diakolambrianou, Slavica Kovačev and Judith Appel who greatly collaborated on this story, as well as to Francesca Fornari and Ida Boka for the final edition.

Elektra worked in the Guardianship network from 2015 to 2016 in Athens, after completing a PhD in Psychology, at the peak of the current refugee crisis. Her job consisted of providing support and being a helping hand for unaccompanied refugee kids arriving to the country. The job was exhausting, physically, mentally and emotionally, but if asked if she would do it again, her answer was an undeniable yes.

Slavica worked with the Novi Sad Humanitarian Center providing first psychological help for mothers and children, as well as unaccompanied minors, from October 2015 to January of 2018. She was located in Berkasovo, Adaševci, Šid, Belgrade and Subotica in Serbia. In her work, she was cooperating with the Serbian Commissariat for Refugees and the Miksalište refugee center in Belgrade. Her job included psychological support, but also providing useful information, working on integration and distributing food and clothes. She also contributes to the project Exhale Exile, which organizes events about the refugee crisis and the way it affects women.

Judith was, at the time of our talk, completing an internship in a Trauma Therapy center for survivors of war and torture in Berlin, Germany, an institution created in 1992 and born out of the will to provide mental health care to people who had been political prisoners in during the German Democratic Republic and, afterwards, to people fleeing their countries during the Balkan Wars. While she does not differentiate her work with refugees from any other position in mental health care, she does admit that working with interpreters for languages such as Farsi and Arabic is unusual, but it is also a very enriching experience.

For more on the issue: 

Lives in Limbo –  video and article by The Irish Times

Brain Drain: the neglected mental health of refugees in Europe – article by Irin News

‘I feel like my life is empty:’Refugees suffer from mental illness on Greek Islands – video and article by ABC News

The Silent Crisis of Mental Disorder in Refugees – article by UNA – UK

The Contemporary Refugee Crisis: an overview of mental health challenges – article on World Psychiatry

This Doctor Is Tackling Refugees’ Unseen Struggle: Mental Health – article on Fast Company

After Fleeing War, Refugee Children Face Lasting Psychological Trauma – article on National Geography

How we can bring mental health support to refugees – Ted Talk