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Too Much to Handle or just not Important Enough? Mental Health Care for War Refugees in Asylum Seeking Centres in the Netherlands

 

The last two decades found the Netherlands, along with the other Western European countries, facing the challenge of an immensely large influx of immigrants coming into the country, seeking asylum for political and economic reasons or as war refugees. Apart from the physical placement of the refugees, one of the major challenges brought on by this influx is to provide psychological help to war refugees and people who fled their countries escaping political persecution and torture. Subsidized by the state, the Community Health Service for Asylum Seekers (MOA) provides prevention and guidance through the Dutch health care system for refugees in the asylum seeking centres. As the main agency, MOA serves as a bridge for the refugees and the health care system, cooperating closely with Mental Health Care (known as GGZ, formerly RIAGG), which is considered to be the main provider of mental welfare services for refugees. Along with GGZ, a number of independent mental institutions such as De Vonk specialize in treatment of refugees with war traumas. However, the efficiency and accessibility of the psychological help is not clear, especially when considering the ethnic and cultural diversity of refugees, along with the strictness of immigration policies and the deportation policy that often refuses to consider the psychological state of refugees when deporting them. With the Netherlands being a country that claims to adhere to basic principles of human rights, how culturally sensitive and ethical the Dutch government is when dealing with the issue of providing mental health care for these people is an issue with a big question mark confronting the Dutch society.

“When Disillusion Becomes Part of Your Life”

“I have given up on asking help for myself. I’m just too tired and disappointed after four years of going back and forth to MOA and asking them to help me. My only hope now is that my son will be able to receive psychological treatment, so that he can be able to go on with his life.” 

For an educated woman like Carole, life has been anything but easy from the moment she arrived in the Netherlands. A survivor of the Rwandan genocide, Carole has been living in an asylum seeking centre with her son for almost four years now, with her status still pending. (It has to be noted that in the Netherlands, a final decision on an asylum request can take many years, partly because of the many possibilities of appeal.) Carole has been undergoing severe post-traumatic experiences throughout her time in the Netherlands. As we go on with our conversation, she explains that in order to schedule an appointment in the medical centre, refugees need to talk first to the nurse, who then decides if the patient needs to see a general practitioner. After several visits with the doctor, a decision is made as to whether the patient needs specialized help (in this case the help of the psychologist or psychiatrist). No medical help is actually provided within the medical premises in the asylum seeking centres. According to those asylum-seekers who spoke with us, the way the process is being handled is very frustrating. The people at MOA seem to be insensitive to complaints. Carole herself was exposed to remarks by nurses and even the general practitioner such as, “Nothing is wrong with you. All refugees here are going through the same thing; you just need sleeping pills”—which she took for almost two years. However, that didn’t take care of the nightmares, the headaches, the stress, or the fear of receiving negative status and being deported to Rwanda. The centre is only open three days a week, and the office is open one hour a day for scheduling appointments. If one wants to schedule an appointment after that, he or she needs to have a very “convincing” story to get the nurses to listen.  People with language barriers are the ones to suffer most because of their inability to express clearly what is bothering them, and they are misunderstood frequently by the nurses and general practitioners. 

Interestingly, Carole is not especially bitter with the medical staff at her centre. She calls on people not to blame solely the medical staff. They are understaffed, work under pressure, and are not certain if they’re going to have jobs themselves because of the shutting down of centres all around the country. Carole believes that the system is to be blamed because there is too much bureaucracy in dealing with this issue. There is a communication clash between the workers in the centre and the residents on a daily basis. This is directed especially to the centre employees in charge of housing and security, who are employed by the Central Body for Asylum Seeker Housing (COA). Her final words to us when describing COA employees are: “If you’re dying, the security might have mercy on you to call a taxi so that you can eventually make it to the hospital.” One cannot comprehend the feeling of powerlessness and disappointment that her words carry. Yet, she has to live with it and she is not the only one in her struggle. “Talk to other refugees in centres. There are many people who share the same fate as I do.”

“I’m Still Chased by the Demons of my Past”

A quiet woman with a subtle smile in her face, Fernanda gives the impression of a completely normal, happy person. The truth is different, though. Politically persecuted, she had to flee Angola in 1999 after her husband, who is still missing, was taken hostage. Having experienced indescribable horrors, she was going through severe post-traumatic stress disorder. After being placed in an arrival centre (OC), Fernanda was referred to a psychologist. However, the kind of help she needed could not be given to her from a psychologist. Fernanda moved in with a friend of hers in Amsterdam upon leaving the arrival centre. Her friend’s family doctor referred her to a psychiatrist, whom she is still seeing. She has been undergoing psychiatric treatment for three years now. She considers herself extremely lucky for being able to have access to psychiatric help that soon. She got help through MOA while at the arrival centre, but as she refers to her state of mind at that time, she was a total “wreck.” The medical staff recognized this after a month and directed her to a psychologist. Further help was received via external sources, though, specifically through her friend’s doctor.

“After my son arrived in the Netherlands, I was forced by COA authorities to leave my friend’s house and move into this asylum seeking centre if I wanted to be together with him,” Fernanda recalls. After moving into this centre in 2001, she had to go through another procedure of trying to get help from MOA for her son, who was also undergoing severe post-traumatic experiences. She had to wait three years for that help, while her son’s condition was getting worse as he was becoming violent and having problems concentrating in school and socializing. MOA did arrange an appointment with a paediatrician who told her that she should try to talk with her son about what he had gone through. She is convinced that her son needs professional help. 

“There are just too many levels to go through before you are assigned to a specialist,” says Fernanda. “It takes too much time for the procedure to get done. People get tired of waiting, because they know that the medical centre cannot handle every case. There are so many of them in this centre who have just closed themselves up in their shells and prefer living with their problems rather then opening up and telling their stories, only to be told to come in again after a month or so. It’s too painful.”  She doesn’t fail to mention how culturally insensitive the staff can be at times. “The general practitioner chased me away one time saying how I always have something to complain about when I go to see him. It’s so hard being in a foreign country where you don’t speak the language. Explaining your problems is just too hard when you have to do it through a translator over the phone. You’ll often find people using gesticulations trying desperately to explain what exactly they are suffering from. People working with us should be aware of that.”

“Our mission Is to prevent and educate, not treat patients”

The answers of the refugees gave us a grim and very disappointing image of the medical services in asylum seeking centres. Convinced that there is another side of the story, we paid a visit to the MOA authorities to get their version of how accessible the medical service is for asylum seekers. Upon meeting with Ms. Jacobine Glasbergen, the MOA coordinator for the district of Amsterdam, and Dr. Aad Schoenmaker, doctor of social medicine, we became familiar with the MOA mission. 

As a part of the National Health Care System (GGD), MOA operates at the local level throughout the country in asylum seeking centres. Asylum seekers have the same basic health insurance and the right to health care access, as do all other Dutch citizens. The mission of MOA is to work on prevention and on education of people on how to get access to the Dutch health care system and to help refugees with scheduling doctors’ appointments. However, MOA’s mission seems to be misinterpreted by the residents of asylum seeking centres.

“People must understand that we are not working in the centres to treat them,” explains Ms. Glasbergen. “We are there solely to inform them and guide them throughout the system. They should also understand that we are bound to work based on regulations and policies. You can’t just walk in at our offices anytime and ask for an appointment. It’s impossible to do that. We try our best to respond to all demands but people should be aware of things such as [the] culture of appointment and our staff limitations. Nurses are always willing to help the people and address their issues. We just cannot give everybody instant solutions to their problems,” Ms. Glasbergen continues. 

MOA is aware of cultural differences in everyday contact between refugees and the medical staff at the centres. Dr. Schoenmaker explains that the Dutch health care system clearly has weaknesses in dealing with patients. He refers to the saying “Dutch doctors treat only what they can see” to explain that Dutch doctors expect the patients to be very straightforward and explain exactly what their problems are. According to the service providers, the asylum seekers act in the opposite way, often expecting an instant solution to their problems and unwilling to cooperate with the doctors. 

“It is shocking and impossible for us to believe that people have to wait for several years to get treated. We cooperate closely with GGZ and we refer all the patients in need of psychological help there. We do operate on a levelled structure, but this is no indicator that people are being neglected and denied the right to medical help,” says Ms. Glasbergen. MOA does have a check system to catch such problems, and the work in the centres is monitored. Ms. Glasbergen further explains that an inspection was conducted in the year 2003 by IGZ (Health Care Inspection), an independent commission, and a report was issued stating that MOA’s work in the centres is going relatively well.  

The question of how efficient the system is finds both Ms. Glasbergen and Dr. Schoenmaker shrugging their shoulders and saying: “The system is definitely not flawless. MOA cannot have control of the work in all the centres throughout the country. There are different reasons that can contribute to the flaws and lengthy procedures.” The culture of appointments, for example, is very different with refugees. Patients do not show up for 35% of scheduled appointments. Moreover, the housing policy of COA has a negative effect since people are being moved to other asylum seeking centres constantly without any consultation, leaving MOA unable to trace the movement of the people throughout the country, thus obstructing the process of treatment of the refugees who need to schedule or already have scheduled appointments. Furthermore, according to Dr. Schoenmaker, asylum seeking centres are relatively new, and so is the health care for the asylum seekers. The Dutch health care system in itself is complicated and doesn’t work flawlessly for the Dutch either. Waiting lists are a problem that Dutch people have to deal with everyday as well.

The Efforts Made to Understand the Problem

The working philosophy of employees at De Vonk is different. As a specialized centre for the mental welfare of people suffering from trauma, their primary goal is the disease of their patients, regardless of their status. Operating on an independent budget apart from government research subsidies, this institution has the ability to treat refugees with severe psychosomatic disorders as a result of traumas they have experienced in their home countries and on their way to the Netherlands. Social therapists Peter Rietdijk and Sahaba Van Stijn explained that 90% of the people who are treated at their centre do not have an official status and come from asylum seeking centres. Refugees cannot come to De Vonk directly, since the selection process goes through MOA. Rietdijk and Van Stijn expressed a dose of skepticism that MOA staff does not have the necessary expertise to identify cases that need psychological help. Lack of publicity is also seen as negative because people in asylum seeking centres know little to nothing about De Vonk, and there have been no outreach initiatives between asylum seeking centres and De Vonk to inform people about the work of this institution. Lack of information has also contributed to the reputation of the centre as the “mad-house.” 

“Out of 25% of people that need help, De Vonk receives only 1%,” estimates Van Stijn. One way to help identify cases in need and increase chances of people getting help may be to send De Vonk staff into asylum seeking centres. At De Vonk there are barely any waiting lists with people waiting to get treated, and those on waiting lists usually take around one month to be admitted. Once admitted, people can stay in this centre for around three years and are usually granted permission to remain even if they get a negative status. Rietdijk and Van Stijn explained that there is a tendency for people to take advantage of that opportunity. According to them, no people were deported while under treatment.

Issues that are of concern for these social therapists are related to the deportation policy. They both claim that this affects the psychological state of their patients and makes the treatment much more difficult and lengthy. People become desperate and they lack the motivation to get better when they know that the next step after that is their deportation.

Dr. Hans Rohlof, a psychiatrist working at De Vonk, agrees on this issue as well. Furthermore, the cuts in government funding for translation services and research on minorities are issues of concern. The change in immigration policy has affected negatively the progress in providing more help for the refugees and the study of minorities in the Netherlands, and it limits organizations within the government structure to provide adequate and timely help for traumatized refugees. 

A pioneer in the field of trans-cultural psychiatry, Rohlof explains the efforts that this centre is making to bridge the gap between patients and doctors during the treatment through trans-cultural psychiatry, a field that takes into account the cultural background of the patient when diagnosing his or her problem. 

Dr. Rohlof admits the scarcity of psychiatrists engaged in trans-cultural psychiatry, and he recognizes the need for incorporation of this field of study in the educational curriculum in medical training institutions.  According to Dr. Rohlof, the structure within which health care for refugees is functioning is reliable and the cycle seems to work efficiently. De Vonk is the last resort for patients who go through GGZ, and he doesn’t seem to agree with the idea that De Vonk needs to be engaged in helping MOA staff to identify refugees with psychological problems by sending their staff into the asylum seeking centres. Dr. Rohlof contends, “We are open to public and we’ve already taken initiatives in training nurses for MOA through our training department.”     

“There is some hope left…”

“My experience with the MOA staff has always been positive. They were the ones that approached me when they thought I needed help, which I did, and referred me to a psychiatrist. It saved my life and helped me move on.” Speaking with a deep and very optimistic voice, André, now a Dutch resident from West Africa, has only nice words about MOA at the Almere asylum seeking centre, where he lived for a year during 2001-2002. His first contact was with a nurse who referred him directly to a psychiatrist within a week. Undergoing a five-month long therapy with a psychiatrist twice a week, André was helped to face and overcome his traumas. He is very grateful to MOA staff at the centre for being so helpful and professional in dealing with his case. He recalls that in general MOA staff were friendly and helpful to the other residents at the centre, although he does consider his case a “special case” since not very many people receive help that fast. The COA (housing and security) people are a different story. “They were always indifferent towards us residents. Our impression at the centre was that they just wanted us to leave from there. They tormented the people in the centre by transferring them from one centre to another, considering them ‘problematic individuals.’  Sadly, those were people who were undergoing psychological disorders and needed help the most, and they were chased away, which of course wasn’t the solution to the problem.” André firmly believes that MOA’s reasons for not being able to respond to the needs of all the residents comes from the fact that they are extremely short-staffed and working under intense pressure. “It’s almost impossible for a staff of not more than 20 people to work for 800 people and be able to deal with each case individually and on time. The government should invest more and provide more staff to MOA offices in asylum seeking centres.”

Who is to be Blamed?

Based on the interviews and research conducted, we come to realize that the government policies are the main reason for the occasional malfunctioning of the health care system for traumatized refugees. The strict asylum policies introduced in the Netherlands, specifically the deportation policy and the cutbacks in funding, seem to be detrimental and have a tremendous negative effect on the entire refugee health care system. The deportation policy affects the treatment of refugees to a large extent by worsening their psychological state and breaking the continuity of their treatment. In an article by Andrée van Es, the coordinator of GGZ for the Netherlands, she reports a tremendous increase in the number of people who are undergoing severe acute psychotic disorders as a result of the deportation policy. The refugees stop going for treatment and just escape illegally, fearing that they will be deported once their treatment is done. There are numerous cases of refugee suicide attempts and violent behaviour in their living environment reported as well. The lack of coordination between COA on one hand and institutions like MOA and GGZ on the other hand contribute to the despair of refugees to a great extent. Psychological treatment of refugees takes a long time and by forced movement traumatized people are thrown aback. GGZ staff is never informed about the movement of refugees, and this leaves them in a helpless situation, uncertain as to the further treatment of their patients. The cutting of funds for refugee services affects translation services, housing, and staff shortages in asylum seeking centres, and this makes refugees increasingly likely to see escaping into illegality as the only solution. 

The government should fund training of MOA staff nationwide and place its focus on supporting extensive research in pioneering medical fields such as trans-cultural psychiatry. For the majority of refugees, the Netherlands is their last resort, their only hope for a better life and a safer future.

Failure to help these people get back on their feet and overcome their traumas while waiting for their status is a failure from the side of the Dutch government to fulfil its moral obligation, and it is also a failure to recognize these people as human beings who are suffering and who rely on this country to lend them a helping hand.          

 

References

Interviews

Carole, real name withheld, personal interview, June 24, 2004.

Fernanda, real name withheld, personal interview, June 25, 2004.

André, real name withheld, interview by telephone, June 26, 2004.

Sahaba van Stijn and Pieter Rietdijk, social therapists at De Vonk, personal interview, June 25, 2004.

Jacobine Glasbergen, MOA-coordination for the region of Amsterdam, and Dr. Aad Schoenmaker, doctor   

of social medicine, personal interview, June 25, 2004.

Dr. Hans Rohlof, psychiatrist at De Vonk specializing in trans-cultural psychiatry, personal interview, 26 June 2004.

Articles

Es, Andrée, van, Uitzettingsbeleid van overheid veronachtzaamd geestelijke gezondheidstoestand, Volkskrant, 30 July 2003.

Keken, Kim, van, Getraumatiseerde asielzoekers moeten binnen 48 uur weg, Volkskrant, 7 October 2003.

Websites

www.rohlof.nl

www.centrum45.nl/deVonk 

www.igz.nl/bestanden/Jaarrapport%20IGZ%202003.pdf

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HIA Program:

Netherlands Netherlands 2004

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