Refugee policy risks counteracting mental recovery

“It might be a very selected group. But if we look at reports from the conflicts in these areas, we can see how widespread torture also is there in these groups,” he says.

And there is no doubt that torture has a negative impact on mental health.

“Torture is very specifically related to mental ill-health. Having been subjected to torture is a very, very strong predictor of mental ill-health. So it stands out in this context,” he says.

The purpose of torture is to break down a person's inner resources, something which it unfortunately often also succeeds in doing.

“It becomes very difficult to deal with other challenges when you have been subjected to systematic attempts to break down your person,” says Fredrik Saboonchi.

In the group of refugees and asylum seekers from Syria, significantly fewer, 30 per cent, stated that they had been subjected to torture. But what Frederick Saboonchi is primarily able to demonstrate in his report is that as many as one third of all refugees and asylum seekers had significant problems with depression or anxiety, and about as many had symptoms consistent with post-traumatic stress disorder. However, a significant amount of this mental ill-health coincides, meaning that it is the same individuals who both state that they are depressed and suffer from post-traumatic stress disorder. In practice, this means that a large percentage of respondents state that they experience mental ill-health, consisting of one or more problems. This means that many, but far from all, of the refugees who come here have more or less severe mental problems that they need help with.

“Pre-school is often the best cure for newly arrived young children,” says Anders Hjern.

Anders Hjern is a paediatrician and Professor of Social Epidemiology for children and young people at the Department of Medicine, Solna, Karolinska Institutet and has greatly involved himself in the situation of refugee children. But he points out that the Swedish school system has no clear strategy for how these children are to be received, which is also something the National Agency for Education has pointed out.

“Some of the children have a fairly good schooling behind them, such as those coming from Syria. They might think they’ve ended up in some sort of vacuum when they only get to study Swedish when they want to work hard and have high ambitions. At the same time, other children coming from Afghanistan or Somalia have perhaps not had any opportunity to go to school at all. For them, just being able to go to school is a new and fantastic thing,” he says.

Not the case everywhere

Experience and awareness of this in schools around the country varies very greatly.

“Schools in north Botkyrka, Tensta, Rinkeby or Rosengård in Malmö have experience and a way of thinking about this, but this is not the case everywhere. Some places go with a kind of ice bath, throwing children into a normal class straight away. They believe that this is the quickest way to learn the language. So there is no clear strategy,” he says.

He explains that there is a model called Skolfam, developed for foster children, which could be used and which is also used in some municipalities. The model includes a thorough review of the pupil's conditions and knowledge and drawing up a plan to strengthen the pupil's weak sides. But this is not only about knowledge gaps that need to be filled. Some of the children, just like the adults, have experienced terrible things in their home countries and on the journey here. And just as for the adults, this affects their mental health.

“Some have had difficult experiences and have post-traumatic stress symptoms that can disrupt their learning. They are not able to concentrate because there are a load of memories that are in the way. They have such an increased level of stress that they have difficulty sitting still. This is something that is special for this group which schools also have to handle,” says Anders Hjern.

For pupils with such problems, teaching in smaller groups often works better, but this requires resources that sometimes do not exist, something that Anders Hjern regrets.

“From a long-term perspective, it is a bad policy not to invest in these early resources,” he says.

Another question is which schools the children should go to. In a study from 2013, covering more than 75,000 year-nine pupils at more than 1,350 schools, Anders Hjern was able to demonstrate that schoolchildren with origins in Africa and Asia did consistently better in schools with a high proportion of immigrants and that they were often bullied in schools with a low proportion of immigrants.

One in three pupils originating in Africa or Asia who went to schools with a low proportion of immigrants stated that they had been bullied in the past week. The corresponding figure in schools with a high proportion of immigrants was approximately one in ten pupils, which is a fairly common figure for pupils in Swedish schools, as measured using this method. Anders Hjern therefore believes that it may be a mistake to place immigrant pupils in typical Swedish schools with a high proportion of Swedish-born pupils.

“You might think that this makes it easier to get Swedish friends, but it is not a given. On the other hand, it may happen that you get a better education if you attend a school with more Swedish children. I hope to be able to find out what it means for school success if you go to such a school compared with schools predominantly attended by other children of a foreign origin. As far as I know, no one has studied this in Sweden,” he says. Since school is such an important key to integration, it is very important that there are no mistakes. There is also a passion in many refugee children that it is important not to extinguish.

“A general experience from schools is that these are young people with a high study motivation, especially the unaccompanied ones who have an enormous drive and really want to learn,” says Anders Hjern.

Essential to handle the situation properly

Sweden has every opportunity to harness the potential there is in all the new people who have come here, but it is then essential to handle the situation properly.

“It is often a very strong group coming to Sweden, people who really want to achieve something and have a strong desire to live. It is a group that has many health factors and at the same time very many risk factors that also accumulate and perhaps reinforce each other,” says Anna-Clara Hollander.

A highly important question then is how we best take care of refugees and help them with their risk factors so as to prevent future problems of both a mental and physical nature.

“We cannot undo the horrific experiences that people arrive with. What we can do there is provide adequate care and treatment to address the consequences. But we can influence living conditions after they come to the host country. This is very much about creating environments and conditions that do not result in additional strains but that can be supportive,” says Fredrik Saboonchi.

He highlights how important it is to create a sense of security, participation and belonging for the refugees that can make their mental ailments fade with time.

From this perspective, he believes that the Government's legislative changes that only grant refugees temporary residence permits instead of permanent ones, and that reduce the possibility of uniting their families, counteract the opportunity for healing.

“When legislative changes lead to people experiencing greater uncertainty, less participation and greater isolation, it is obviously nothing that is favourable to mental health. The legislation depletes natural sources of recovery, such as being with family, which for many people can mean everything,” he says. There is a risk that this will lead to an increased risk of mental ill-health among refugees in the future,” he believes.

“The asylum seekers who have come in recent years, who are not included in our report, might carry with them different and perhaps more difficult experiences. At the same time, they are now facing a situation in which the wait during the asylum process is considerably longer and they are coming to a social and political climate that casts suspicion on them to a higher degree. This means that it is important that the healthcare services have sufficient resources. But the specialist centres that we work with already have long queues. You have to wait more than a year to get in,” he says. He emphasises that it is not the role of researchers to solve these problems, it is the task of politicians and other societal actors. But it is the responsibility of researchers to call attention to their findings.

“The important thing is increasing awareness about the great risk of significant mental ill-health among these people and that we perhaps should pay more attention to it and not just think that we can leave it to itself,” he says.

Prevent the mental problems

The major increase in asylum seekers needs to be matched by greater efforts in the healthcare system that will as far as possible prevent the mental problems they are now experiencing from developing into something more serious. To then have regulations that do not allow asylum seekers to receive anything beyond the most basic of healthcare while the asylum examination periods are increasing dramatically is hardly a good approach.

“No, limited access to healthcare is perhaps the last thing you want. If you think about the risks this entails and that you can help at an earlier stage with a smaller investment, maybe you should think a little more long-term,” says Fredrik Saboonchi.

But this is up to the politicians.

However, it is possible to do quite a bit of good on a small scale. Using simple means, the situation of asylum seekers and newly arrived people can be considerably improved.

“The general advice is to be active, be outside, try to find things to do and learn things. Sitting alone at a reception centre is not good for anyone; you need some type of behavioural activation so as not to break down,” says Anna-Clara Hollander.

“Here, there are many voluntary organisations that do really great work,” she says.

“I do not think you can overstate how important this is. It is precisely these things that get society to open up to you, riding around on a bike and getting an idea of what the city looks like, meeting other people and playing football. All these things make an enormous difference,” she says.

In schools, there are also simple things that can improve integration considerably,” says Anders Hjern.

“Sports, music and chess are three activities not requiring that much linguistic competence where refugee children have found a way in,” he says.

The important thing is to see the potential in the people who have come here, but to realise that many of them need help to get up and running, both professional help and also help of a simpler kind.

“Society has a chance to prevent mental ill-health. There are already many who work with this in voluntary organisations, but much more could be done to prevent mental ill-health in a group that has a lot of risk factors, but also many health factors,” says Anna-Clara Hollander.