Ethical Concerns for Providers when Dealing with Refugee Populations

There is no doubt that mental health professionals and other service providers can help alleviate the effects of trauma, torture and other crimes that are perpetrated against people and communities due to circumstances, religion, war, etc... Throughout this class, I have learned quite a bit about the consequences to both individuals and groups based on trauma/ torture and have even broadened my views of how those terms should be defined. Between therapies that are individualized or set up for groups (such as a family, community or people with the same traumas and problems in common) and interactions that attempt to alleviate suffering through the use of medical training, pharmaceuticals, neurobiological or cognitive therapies, etc... Many groups and professional have been focused on – and continue to try- to help victims and the society as a whole heal, develop techniques for survival and daily care, as well as trying to improve the quality of health and life of those affected. However, there can be challenges as well as ethical problems that the mental health / medical provider can face in these situations.

One challenge can come in the form of using pharmaceuticals to help the patient deal with some of the symptoms that cause difficulty in their lives. While studies do suggest that medication makes a bigger impact on an individual's symptoms, the issue is not that black and white. How the patient and/or their family feels about medical care in general (or mental health medication specifically) has an effect on how the medication is used and therefore, how successful it can be. An individual's culture may also weigh into the decision to use medical treatments/ medicine of any kind. And how the services are provided might also affect the utilization of those services. Language, economics, and other barriers can cause misunderstandings and challenges as well. A perfect example of this problem can be found in the book, “The Spirit Catches You and You Fall Down” written by Anne Fadiman. An amazing and very sad biography.

Another thing that is very important for the provider to acknowledge and understand is that the trauma itself may be what the provider wishes to treat and focus on... but the provider is still treating a person. An individual with different perceptions, biases, experiences and other ways of seeing and moving through the world. And so while trying to treat the troublesome symptoms of the past trauma, it is imperative that the person being treated isn't seen in the narrow sense as a label or a diagnosis. The patient needs to be viewed and looked at in the 'prism' of their views and life... so recommendations and therapies need to be available to the patient in a way that fits their current set of circumstance and needs. I thought of an experience in my life when I had a few sick animals who lived with me and my family in a one room yurt. The vet said that one cat needed to be fed a special food, another cat needed a different special food and the other cats couldn't eat either food. When I mentioned that I lived in one room, I was told to deal with it. I did figure out a solution that worked, but it took a while and I didn't use the resources that had been offered nor have I been back to that clinic. I probably would have felt differently and used the resources offered if the provider had made them seem possible. Just a thought on that topic.... So making sure that the resources used are more helpful than stressful and really address the 'whole person' are needed. That takes more time and energy as well as an understanding of an an attempt to put your own biases, etc... aside. That is a bit difficult to do for most of us. :) Also making sure that the resources are available to use in a way that works for the client makes them more likely to be utilized and more likely to help the patient with lasting change in their lives... which is the goal!

Another important element – which I touched on in the last paragraph is to make sure that a thorough understand of the person and their culture are attained. By understanding what is important to the individual and what they use to not only make decisions but base most of what is important in their life on.... the suggestions and recommendations that are given by the mental health providers are more likely to not only be followed but misunderstandings are more likely to be caught quickly and early in the process. That helps develop the trust relationship between the provider and the patient as well as help the patient to work harder to help themselves because not only does it matter to them as individuals, the provider has shown that it matter to them too. (Aren't we all more likely to accomplish our goals when we have a friendly goal 'buddy'?) So by having decent understanding of the background and viewpoint of the patient, the service providers can make fewer but more meaningful referrals and help keep the patient on task. An example is not suggesting a patient with PTSD have an occasional drink to relax but maybe a cookie or a walk with a friend instead. If the culture sees nightmares and terrors as a curse from God that must be overcome.... then they are much less likely to take the Ambien to sleep nor will their family encourage them to do so. Telling an individual to eat pork or stop smoking for their health when smoking is part of their religious practices or the eating of pork is against their beliefs will either cause total noncompliance or partial uncompliance as the patient will only do it when they feel pressed to do so or have another compelling reason to do so. It is important that the clinician recognizes what his values are and recognize when he is potentially pushing values and cultural norms on the patient and not actual treatment. I know those examples are not mental health related, but I thought they did help me make the point I was attempting to make. :)

Another thing that it is imperative that mental health providers think about when dealing with challenged and refugee populations is to follow the information and tools that have work in the past as evidenced by studies and their own observations and life experience, but to also recognize that the current work that is being done can give good insights into potential therapies simply because if it appears to be currently working, with so few good studies out there.... if every is in agreement to try something new... that has the potential to help victims now as well as future populations. This kind of flexibility to look outside the box but also to be cautious and thoughtful about trying therapies that haven't had a lot of use and study is a challenging but needed trait in these providers. It is also this flexibility that allows the clinician to look at the individual in a well rounded way, and not just the way that they have been taught to see certain symptoms or mental distress.

Lastly, it is important that the clinician recognize and maintain clear boundaries between themselves and their patients so that both parties can work together for improvement and satisfaction. When the boundaries are loosened, both parties may find it very challenging to continue to work together and to work towards progress in the manner that was possible when the division between the two was clearly laid out. Providing services that also allow the individual to have privacy not only from strangers who do not have a legitimate need to know their information, but also family can also help the patient by making things clearer and less likely to be misunderstood through another person's biases and thoughts mixing into the mix. An example could be when the parties involved have a language barrier – a translator from outside the patients inner circle may make a different translation that a family member or a friend who may interpret what the patient is saying or needs based on what they think the patient needs... not quite the same thing. This kind of translation can also compromise a patient's need and right for confidentiality making services more challenging for them to get and undermining the trust needed between the patient and the provider. The provider must also to make sure to care for and recognize problems that may crop up with themselves from working with this population and take care to not allow themselves to become burned out or harmed in the process of helping others... which can cause them to be unable to continue to help or even to cause more trauma to the patient.

To be a provider to such a challenged population comes with both risks and rewards for the clinician and the patients. Understanding the important ethical concerns that should be addressed can help everyone involved do a better job, be safer, and to help people gain more resiliency and a better quality of life through the therapies. What more can we ask for? :)

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