Telemental health care provides much-needed support to refugees

To the editor — There are over 82 million displaced people in the world at the time of writing, and this number is expected to increase to 1.2 billion by 2050. The need for mental health care in emergency situations has grown substantially, considering the extent of conflicts, disasters, climate emergencies and war in the context of global population growth¹. The Russian invasion of Ukraine has certainly captured the attention of the world, and nobody knows how the situation will resolve. However, with over 5 million refugees having already fled Ukraine, and millions more internally displaced, mental health support will be urgently needed in the affected areas².

It is extremely important to form a trauma-informed mental-health response in trauma-afflicted areas, and technology can have a key role in addressing this need. In times of war, almost all who flee experience some form of trauma. The conditions that cause the trauma include preflight fear that puts the brain in a fight-or-flight mode, followed by the actual displacement causing stress owing to the uncertainty of the outcome and challenging living conditions. These dramatic changes in the environment can lead to a fear response that becomes intense and prolonged³.

War zones and refugee camps often are inadequately equipped with mental health professionals to respond to such situations. For example, in Syrian refugee camps in Turkey, Lebanon and Greece in early 2012, at the onset of the crisis there were thousands of refugees who lived through the horrific trauma of bombings and killings without a single trauma-response professional on site. One camp in Turkey had one psychologist who responded to hundreds of individuals per day. This caused burnout to the staff⁴ and untreated symptoms fostered violence, depression and behavioural problems among refugees⁵. A decade later, with the return of the Taliban to power in Afghanistan, hundreds of thousands of Afghan individuals fled their homes — some hanging from aeroplanes. Some ended up in massive camps, lacking enough counsellors to address the collective trauma that they lived through. In February 2022, millions of Ukrainian individuals fled their homes, leaving behind their family members to fight, and ended up in neighbouring countries awaiting an uncertain future. Again, the psychological needs trail behind the physical needs, buried away, leaving the brain in constant survival mode. This can cause serious disorders later, such as post-traumatic stress disorder (PTSD)⁶.

In several refugee mental-health projects that we have been involved with, telepsychiatry or teletherapy have been an effective means of meeting the acute need of responding to immediate mental stresses such as the trauma caused by displacement among refugees. These are combined in the term ‘telemental health’ services, which provide clinical psychotherapy and related interventions using communication technology⁶. These services can be provided through group or individual sessions using video-conferencing technologies and aim to identify, treat and educate individuals. Telemental health services provide immediate mental health care, knocking down barriers such as access to professionals, cutting costs, and overcoming geographical limitations⁷.

Telemental health or telepsychiatry has been used as an effective alternative to face-to-face interactions since the 1950s. It was introduced in Nebraska, where video conferencing was used for group therapy. Recent advances in communications technologies, their ease of use and almost global availability have put telemental health services on the forefront of medical interventions. The COVID-19 pandemic and wars have prevented mental health professionals from reaching the most vulnerable individuals in person. This has transformed telemental health from an alternative means of access to an essential service to treat patients worldwide. The positive results of immediate intervention by telemental health include reduced PTSD symptoms equivalent to face-to-face care⁶, which is an important factor for refugees even years after resettlement⁸.

Our own experience stems partly from our involvement with Glocally Connected, a California-based non-profit organization. In collaboration with other partners, we contributed to the ‘Peace of Heart Initiative’ project, which provided teletherapy by experienced psychiatrists to Syrian refugee women with the help of interpreters. Teletherapy alleviated some of the initial stressors of flight that these women experienced in a Syrian refugee camp in Lebanon. We found that the intervention led to less withdrawal from the activities of daily life by the women, and continued therapy sessions increased solidarity and resilience. Similarly, in September 2021, a licensed clinical psychologist and somatic experiencing practitioner provided trauma-informed skills-building group workshops to Afghan newcomers in USA, and the programme continues to grow. The clients report positive outcomes, such as reduced stress and anxiety symptoms.

In the context of the war in Ukraine, social media groups such as ‘Humanitarian Coordination for Ukraine’, ‘Psychologists for Ukrainians’ or ‘Mental Health Resources for the Crisis in Ukraine’ provide resources such as clinical psychologists to connect to those affected by war via teletherapy sessions. Glocally Connected, in collaboration with the International Blue Crescent, is also getting ready to connect to Ukrainian refugees in Moldova through similar teletherapy programmes.

What is happening in the world right now is not unprecedented. Wars and pandemics have long existed, and the toll on mental health has always been heavy. However, the use of technology to help large numbers of people by providing immediate and sustainable mental health treatment is a new opportunity in war zones to prevent the detrimental long-term effects of trauma, especially on refugees.