Cultural integration and overcoming trauma

More and more asylum seekers are crossing the Mediterranean into Italy, many of whom have suffered severe mental and physical trauma in their home countries. The cultural and language differences of Italian society have proven to be barriers on the path to recovery. With that in mind, Doctors Without Borders is working on treatment in Rome that uses a combination of physical and psychological therapy and cross-cultural mediation for the treatment of refugee torture victims.

It has been over a year now since Europe was overwhelmed by the spike of refugees fleeing the war-torn Middle East. UNHCR (United Nations High Commission for Refugees) statistics reported over a million asylum seekers arriving by sea in 2015, and the desperate clamber to escape has only continued into 2016. In the aftermath of a controversial deal with Turkey to turn over refugees arriving in Greece, asylum seekers are turning their eyes to Italy.

Italy has been taking in refugees for years, but the increasing pressure from Europe has stretched its capacity to breaking point. Many new refugee arrivals have found themselves in a hostile community, not necessarily in terms of being violence or prejudiced toward refugees, but in terms of being difficult for newcomers to integrate with. The issue is compounded for those who have suffered major trauma; recovery is much harder when living in a community you don’t have any connections with.

According to UNHCR’s most recent factsheet, asylum submissions for torture and violence survivors made up 24% of total submissions last year. This means that, out of the 134’000 asylum submissions last year, roughly 32’000 are requests due to torture. And those are just for the official asylum applications; there’s currently no telling how many among the millions of refugee arrivals are suffering from violence-related trauma.

In an effort to assist with this, MSF (Médecins sans Frontières, known in English as Doctors Without Borders) has opened a torture rehabilitation clinic in Rome. The clinics goal is to provide holistic assistance to people who suffered from violence or torture in their country of origin, or on their journey to Europe. To do this, it uses a two-tiered treatment method of physical and psychological therapy and cultural mediation.

The clinic coordinator, MSF doctor Gianfranco De Maio said it was the first clinic of this type in Italy.

“The treatment here has two aspects: it targets the body and the mind,” Mr De Maio said.

“We have physical therapy doctors, then psychiatrists and psychologists. At the same time we also work for the social inclusion of our patients, assisting them with the opportunity for integration in Italy.”

The clinic is a fairly Spartan doctor’s practice located along a side street across from San Giovanni Piazza in Rome. It has a reception, break room, and about six offices for doctors and psychiatrists. Despite its size, the staff assured me it has the capacity to host more than 30 people.

Photo: Jack Lawrie.
Photo: Jack Lawrie.

“We collaborate with two different associations,” said De Maio.

“The first one is ‘Doctors Against Torture’, and it’s an association of volunteers that was the first one in Italy to work with victims of torture…for us they are really our teachers, as they specialise in these specific therapies.”

“We also collaborate with ASGI (Association for Law Studies on Migration), which is an association of lawyers. In order to provide the patient with complete and efficient therapy, for them to be calm, we need to study the legal situation, and to do that we need lawyers working with us.”

The collaboration with lawyers is part of the practice of using cultural mediators to communicate with traumatised patients.

Ahmad Al Rousan, one of the cultural mediators working for MSF, spoke about the importance of making patients comfortable and at ease as part of his job.

“It’s important that when there is someone that came from the same culture that they feel comfortable to talk with,” Ahmad said.

“It’s not also for language reasons; the first person who speaks to them should be one who can understand their culture, language and even emotional point of view.”

Ahmad is one of the two cultural mediators working at the clinic who specialises in Arabic patients. He has worked with MSF on search-and-rescue operations in the Mediterranean and assisted with psychological treatment of refugees in informal shelters. His work requires him to help suffering people overcome the many cultural barriers in Italy for people of Arabic background.

“In Italy they ask the migrant to make eye contact because for Italian culture, and Western culture in general it is extremely important to have eye contact,” Ahmad said.

“For African or Arabic culture for example, people who don’t look to others in their eyes, it doesn’t mean they don’t respect them. When doctors ask people to look them in the eyes, I explain to them that them not looking you in the eye does not mean they’re not listening or don’t respect you. It’s just because of the culture.”

When patients are have been through severe trauma, maintaining eye contact can be the least of their issues. They can become withdrawn, unresponsive and unable to properly process information.

Jessica Carlsson Lohmann, MD, PhD, manager at Danish Competence Centre for Transcultural Psychiatry says without an early intervention on victims of trauma, patients can become resistant to getting help.

“There can be a lot of things that cause difficulty regarding trauma that might be especially for torture,” Professor Lohmann said.

“People can be suspicious and it takes some time for a person to trust us when we come here that we want to help them. Then for many it’s also on a cultural background an issue of stigma associated with a clinic for mental health problems.”

Lohmann’s research team is currently testing a practical psychiatric evaluation system called the “Cultural Formulation Interview”. It contains a series of questions for psychiatrists to ask when interviewing a patient of another cultural background.

“It’s part of the American diagnostic system that was launched last summer and they have put an interview in that should help you catch important cultural features or information regarding the patient in order to give them a better treatment,” she said.

Many of the questions are about getting the person to frame the problem in terms of how it affects members of their social network. One initial question might be “How would you describe your problem to your friends and family?”

This method can be used by psychiatrists when interviewing anyone of a different cultural background, but the challenge with interviewing a lot of refugees according to Professor Lohmann is many of them don’t have sufficient understanding or acceptance of psychotherapy practices.

“Psychotherapy, is to a large extent a western concept,” she said.

“Everything needs more explanation behind the rational of psychotherapy to people who have sometimes shorter education from their home countries and to try to explain it in an understandable way and what the point is, how it works. A lot of time it takes some effort to explain that it’s the patient that does the work and we don’t have miracle cures.”

This stigma against psychological treatment is common among Middle-Easterners; both Professor Lohmann and Ahmad talked about how difficult it is to encourage those people to seek psychiatric help in a Western country.

“The cultural groups that we treat here, mainly from the Middle East, they kept it as a secret from the family if they had mental health,” Professor Lohmann said.

“Either you’re healthy or you’re insane and there’s nothing in between.”

For Ahmad, it was one of the asylum seekers he worked with for a different project last year at an informal shelter for people transiting from Sicily into northern Europe.

“I met a very young Eritrean guy who was speaking in Arabic,” he said.

“He came to me and we started to speak in Arabic; we spoke about everything, about Italy, the possibility of getting services in Italy, his journey over.”

“He started to feel more comfortable talking with me and explained what his experiences were during the journey. He was a very young man, travelling with a lot of Syrians. They left from Egypt; he saw with his own eyes a very young, 11 year old Syrian girl who died in the boat over; he was 16 years old. He told me that for days he was thinking about what would happen to him. Before he talked to me, he never spoke to someone else, not while he was in Italy, or while he was travelling. For days and days he used to think about the image of this young girl in the sea, with fishes eating her body.”

Ahmad described how the boy refused initially to seek psychiatric help when he arrived, due to the stigma against psychiatric help in Eritrean culture. It wasn’t until talking to Ahmad that the boy was able to get the assistance he needed to move on from his ordeal.

While the boy had not experienced torture per se, his reluctance to seek help is shared –and often even stronger- by victims of torture.

The boy became traumatised by his experience crossing the Mediterranean; a treacherous journey that many fleeing persecution have risked. Photo: CAFOD Photo library (Creative Commons)
The boy was traumatised by his experience crossing the Mediterranean; a treacherous journey that many fleeing persecution have risked. Photo: CAFOD Photo library (Creative Commons)

Many of the torture methods employed by Islamic State and similar groups in the Middle East are intended to break the recipient and make them less likely to move, talk or take action. Sometimes it can be pure punishment, other times there is a clear goal of physically and mentally hobbling them.

“There are a lot of methods where the person is tied up, leaving them with scars on their wrists and ankles”, said Mr De Maio, describing the physical torture methods the clinic doctors have examined.

“There are also very visible injuries such as cut fingers, or also signs from being suspended from the ceiling, which can cause circulation problems from staying tied up in one position for a long time. In some methods, people are tied from behind, causing blood circulation problems.”

“There is a specific example called ‘Falaka’ where a person is beaten under his feet, causing cists on the feet and preventing them from walking.”

Professor Lohmann says there is a serious risk of patients deteriorating if they can’t get treatment in time.

“If they need treatment and don’t get it, their symptoms can get more chronic,” she said.

“We don’t know these thing scientifically, but the theory is they get more difficult to treat if they have severe mental health problems and don’t do anything about it.”

But seeking psychiatric help isn’t always simple; many new refugee arrivals in Europe come with few belongings or connections with their arrival country. Most of them are forced to stay in overcrowded public reception centres awaiting resettlement. The vast majority of asylum seekers face that challenge, whether they are dealing with trauma or not.

Italian refugee centres have been criticised for their lack of services, overcrowding, poor hygiene and poor cultural integration with the Italian community.

MSF announced at the end of last year that it would cease activities in Italian refugee centres until conditions improve. In a report published by the group, they condemned the deteriorating, overcrowded nature of many of the facilities in Italy. Their issues included cockroach infestations, overcrowding, lack of adequate gender segregation, dirty toilets and showers, leaks and mould in sleeping areas, and poor communication with the outside world.

Ahmad said the poor conditions of refugee centres was one of the biggest obstacles to doing his job, calling the system in Italy a “disaster”.

“Some of the centres are overcrowded, like the one in Sicily, which is a huge centre for asylum seekers,” Ahmad said.

“The centre should be for 1600 people, there are now more than 3000 people inside. Most of the centres are like this and there are also small centres in Italy, but what they don’t have are Italian courses, language courses, legal assistance. The refugees should be prepared go in front of the Commission to look into the possibility of international protection.”

According to MSF’s report, poor medical services hurt their ability to identify vulnerable people. These issues with public refugee centres were part of what prompted them to open the specialised clinic in Rome.

Gianfranco De Maio subtly rebuked the Italian government when asked if they were providing any support for his clinic.

“No”, he said flatly.

“We want them to know about our intervention but we’re not consultants. In some cases we could establish collaboration, but it has to be bilateral.”

Cultural integration of refugees into their new countries of asylum is a difficult, but necessary process. Fortunately, Italy has seen success in the past few years; reports coming out of villages in Calabria such as Riace and Satriano illustrate how the newcomers have helped revitalise Italy’s struggling rural Southern communities. In Riace, the new arrivals are filling jobs and providing schools and shops with new business. In Satriano, refugees are taking menial work and apprenticeships. The relationship is symbiotic; the school in Riace has taken in 6 non-Italian children, helping them integrate at a young age. The small jobs can help the newcomers afford to settle down in the empty village houses and start building a life in their new country.

But out of the thousands of refugee arrivals in Italy, not all can be so lucky. There are many suffering from mental trauma, unable to integrate into the new climate while struggling with the physical and mental wounds of the past. And while Italy’s public refugee services remain so poor, their situation will only continue to get worse.

“You can imagine what can happen to people who are victim of torture who don’t receive treatment,” Ahmad said, when asked what could happen to traumatised refugees that slip through the cracks.

“Unfortunately there are a lot of people who have to leave asylum centres who will end up in the streets.”