Neglected Trauma

NEGLECTED TRAUMA

© Alessandro Penso Asylum seekers in Italy: an analysis of mental health distress and access to healthcare CONTENTS EXECUTIVE SUMMARY 1 INTRODUCTION 3 AIMS 6 METHODOLOGY 7 General purpose and qualitative research tools 7 INTRODUZIONEEXECUTIVE SUMMARY © Sara Creta Qualitative analysis 10 Epidemiological data collected in the MSF project 10 Quantitative analysis 11 RESULTS 12 he many humanitarian crises of Doctors Without Borders (MSF) from to assess the need for mental health Focus groups and in-depth interviews: mental health recent years, the persistence October 2014 to December 2015 during support among the residents of of asylum seekers and access to services 12 Tof conditions of war and the psychological support activities with the centres. The community health systematic violation of human rights asylum seekers resident in the CAS in services often lack the expertise and Quantitative data: the mental health of asylum seekers in many countries have forced millions the province of Ragusa. This provided resources needed to recognise signs according to MSF's experience 23 of people to flee, undertaking journeys a good starting point for identifying of distress among this group. Cultural Difficulties encountered 24 that are often very dangerous. the extent of the problems and the mediators, or other people who could According to data from the UN Refugee potential factors influencing them. help to establish contact and to reduce Risk factors and difficulties of post-migration life 26 Agency (UNHCR), there are now 65,3 cultural distances, are rarely present. million of people who left their home Of the 387 patients analysed in this The length of stays at the centres is DISCUSSION 28 in the world. Recent evidence shows study, 234 (or 60.5%) showed signs of protracted and is often a source of Study limitations 30 an increased risk of mental disorders mental health problems. Eighty-four further distress. among forced migrants and asylum (or 42%) of the patients had complaints CONCLUSIONS AND RECOMMENDATIONS 31 seekers. In addition to the traumatic compatible with post-traumatic stress On the one hand, the results suggest events they may have suffered before disorder (PTSD), 54 (27%) with anxiety high rates of mental illness, especially BIBLIOGRAPHY 32 and during their journeys, some of and 38 (19%) with depression. The among asylum seekers exposed to them show signs of stress and suffering average age of the patients was 23.9 traumatic events, and a negative in relation to their current situation, years. MSF provided care for 199 of impact caused by prolonged stays in ABBREVIATIONS attributable to their exile in a strange these patients, ensuring they were the CAS. On the other hand, the system land. followed up. Of the patients given care, remains unprepared, and local services ASL Azienda Sanitaria Locale - Local Health Center 87% said they suffered from difficulties are inadequate to meet the needs ASP Azienda Sanitaria Provinciale – Provincial Health Center MSF conducted an investigation from related to their current living conditions. of this population. It is necessary to CARA Centri Accoglienza Richiedenti Asilo – Asylum Seekers Reception Centres July 2015 to February 2016 to study the The main difficulties of post-migration provide an integrated response that CAS Centri Accoglienza Straordinaria – Extraordinary Reception Centres mental health needs of asylum seekers life were found to be the lack of daily involves the local health services, residing in extraordinary reception CI Confidence Interval activities, fear for the future, loneliness, mental health departments and also centres (CAS) and their access to local the world of associations, universities CIE Centri di Identificazione ed Espulsione – Identification and Expulsion Centres and concern for relatives left behind in services. The analysis – conducted their country of origin. and public authorities. As part of the CSM Centro Salute Mentale – Mental Health Centre in the provinces of Milan, Rome and response, dedicated multi-professional DSM Dipartimento Salute Mentale – Mental Health Department Trapani, which were chosen because A comparison between the asylum teams should be created that are DSM-5 Manuale Diagnostico e Statistico dei Disturbi Mentali - Diagnostic and Statistical of their large numbers of reception seekers with mental health disorders able to identify specific risk factors Manual of Mental Disorders, Fifth Edition (DSM-5) centres – benefited from a two- and those without, showed that the and provide appropriate therapeutic IQR Inter Quartile Range pronged approach using qualitative likelihood of having psychopathological approaches. and quantitative methods. The use of MSF Médecins Sans Frontières/Doctors Without Borders issues was 3.7 times higher among focus groups and in-depth interviews We know that the data presented here NIRAST Network Italiano per i Richiedenti Asilo sopravvissuti a Tortura – Italian Network individuals who had suffered traumatic with asylum seekers, healthcare events than those who had not suffered refers to a complex situation, and for Asylum Seekers who Survived Torture workers and CAS operators made it any. that the work done by MSF is small in OR Odds Ratio possible to decipher the needs of the comparison to the scale of the needs. PTSD Post Traumatic Stress Disorder residents of the reception centres, the The qualitative study provides a picture However, we hope that this report SPDC Servizio Psichiatrico Diagnosi e Cura – Psychiatric Diagnosis and Treatment Service clinical paths taken where necessary of a system that responds to this can serve as an additional prompt for SPRAR Sistema di Protezione per Richiedenti Asilo e Rifugiati – Protection System for and the response of local health particularly distressed population as reflection for other organisations and Asylum Seekers and Refugees services. The quantitative research if dealing with an emergency, without institutions so that structural solutions was conducted based on the data adequate preparation. In many cases, can be developed in relation to the SSN Sistema Sanitario Nazionale – National Health System collected by Medecins Sans Frontieres/ there is no active screening available mental health of asylum seekers. TSO Trattamento Sanitario Obbligatorio – Compulsory Health Treatment UNHCR United Nations High Comissioner for Refugees, United Nations Refugee Agency Morire di parto Quando partorire diventa un'emergenza 3 Introduzione

INTRODUCTION © Sami Al-Subaihi

he increase in migration towards These additional shelters are known 1. According to the Ministry of Interior, the Europe as a result of wars, as CAS (Extraordinary Reception number of refugees who reached Italian shores in 2015 (as of 23.02.2016) was Tpolitical persecution, endemic Centres), and provide an emergency around 153,842. http://www.interno.gov.it/ poverty and the hope of a better life system for asylum seekers, regulated it/sala-stampa/dati-e-statistiche/trend- has called for Western countries to by temporary agreements with public arrivi-dei-migranti-sulle-coste-italiane provide a civil and political response facilities, private-social organisations According to Eurostat data, the largest 7 groups of asylum seekers who have sought to a problem that has now taken and private entrepreneurs . These protection in Italy come from Nigeria (17,780, on global dimensions. Indeed, facilities are of a varied nature 21%), Pakistan (10,285 12%), Gambia (8,015, although not a recent phenomenon, (hotels, B&Bs, private homes, 10%), Senegal (6370, 8%) and Bangladesh (6,015, 7%). Full report at: international migration is now apartments rented ad hoc, holiday http://ec.europa.eu/eurostat/statistics- centre-stage in world events. Italy, in villages, schools, gyms, former explained/index.php/Asylum_statistics particular, has faced this phenomenon orphanages and public buildings that have fallen into disuse). The operator, 2. UNHCR, Global Trends, Forced Displacement for more than 20 years, since the early 2015. Full report: : https://s3.amazonaws. 1990s, and has received an increasing who has an agreement with the local com/unhcrsharedmedia/2016/2016-06- number of requests for international Prefecture, is committed to providing 20-globaltrends/2016-06-14-Global- Trends-2015.pdf protection in recent years, in parallel a shelter service in return for a fee with the increase in the number of of 30/35 euro per day (or sometimes 3. Circular no. 104. Flow of foreign citizens resident foreign nationals1. The annual even less) for each asylum seeker. requesting international protection. UNHCR report speaks of 65.3 million The management body ensures Identification of reception centres. managerial and administrative forced migrants recorded globally 4. Circular no. 2.204. Reception centres at the end of 20152, an increase of services, general support services following further landings on the Italian 9.7% from 2014, which is the highest for individuals, cleaning and coast. environmental hygiene services, increase ever recorded in a single provision of meals, provision of goods 5. This plan provides for the subdivision of year. 2,390 shelter places between around 60 (clothes, personal hygiene products, provincial capitals. In the above-mentioned The growth in the number of new mattresses, a daily sum of so-called circular, the Ministry also refers to another pocket money equalling 2.50 euros 883 places, as well as to 5,500 places arrivals has seen a gradual saturation already assigned in 115 temporary facilities of places within the first reception and a telephone card containing in Sicily, Puglia and other regions. system and those guaranteed 15 euros) and integration services (information on legislation concerning 6. Circular no. 14100/127. Reception centres under the SPRAR system (Servizio di following further landings on the Italian coast. Protezione per Richiedenti Asilo e per immigration, linguistic and legal Rifugiati – or the protection service support). Unlike the SPRAR system, 7. TThis provision is consistent with Article which is part of the ordinary reception 18, paragraph 9 of European Directive for asylum seekers and refugees). system regulated by the Ministry of 2013/33, which contains the standards for With circular of 8/1/20143 and with the the Interior, it does not provide for a sheltering applicants seeking international subsequent circular of 19/03/20144, protection and allows for the preparation connection with local authorities and the Ministry of Interior requires the of extraordinary shelter conditions provided the construction of projects oriented they meet the essential requirements, prefectures to source temporary towards social and employment as an exception, when the ordinary accommodation capacities are temporarily additional shelters in their areas inclusion. of competence, in response to the exhausted. See Directive: http://eur-lex.europa.eu/legal-content/IT/ almost constant arrivals of asylum Stays in these facilities should be TXT/?uri=CELEX%3A32013L0033 seekers, which are increasingly limited to the time strictly necessary close together5. On 9 April 20146 the to transfer the applicant to "first" Ministry issued another circular that or "second" reception centres of an provided for the expansion of the ordinary nature. In fact, considering "extraordinary plan”. the shortage of places at a national

INTRODUCTION NEGLECTED TRAUMA 4 5

8. For more details, see: http://www.interno. level and the slowing down of the asylum seekers (with 13% and 12% can influence their physical and service. According to the agreement gov.it/sites/default/files/dati_per_sito_da_ asylum procedures, these times are respectively), followed by Lazio, mental health include separation signed between the Prefectures and marzo_a_dicembre_2015.pdf becoming very long and onerous to Piedmont and Campania (with 8%). from their family and social context; the centres, healthcare should be 9. Refer to: Cantor-Graee E., Selten J.P.: the asylum seeker from an emotional These figures clearly show that, at the loss of support systems; the guaranteed through the facilities Schizophrenia and Migration: A Meta- point of view. present, the majority of the demand possible exposure to trauma during of the Sistema Sanitario Nazionale Analysis and Review, Am J Psychiatry for reception is borne by the CAS, i.e. the journey; the existence of linguistic (SSN), or national health system, and 162:12-24, January 2005. According to figures released by facilities designed to be temporary and cultural barriers; and the the companies managing the centres the Ministry of Interior in December and for emergency use. difficult socio-economic conditions should facilitate the connection 8 2015 , more than 100,000 migrants in which this population often ends between the residents and the local 9 are accommodated in the reception The extensive scientific literature up. Needless to say, people who are services. The contractual terms centres scattered across Italy and confirms that the migratory fleeing their countries having survived signed between each Prefecture and its islands. Of those, nearly 80,000 experience is closely related to armed conflicts or humanitarian the provinces are highly variable, and are distributed within CAS; some mental and physical health. While emergencies are at increased risk of the presence of medical centres and 19,000 are included in the SPRAR migration can be a form of personal mental health problems10. psychological services is not always network; and just over 7,000 are development and help to expand an guaranteed. The lack of a timely Many of those arriving in Italy are located in government centres individual’s opportunities for choice monitoring system and sanctions on refugees from conflict zones or highly for the initial reception of asylum and action, on the other hand it also the part of the funding institution also repressive states. Many passed seekers. Lombardy and Sicily are the exposes the migrant to numerous makes the implementation of these through Libya, where the situation regions with the highest number of strains and risk factors. Factors that services discretionary. MSF conducted has become increasingly chaotic since a study in three Italian provinces 2014, with many leaving their families and loved ones behind. They are a (Trapani, Rome, Milan) known to Table 1. fragile population with special needs. have a significant presence of asylum Type of facilities and breakdown of asylum seekers, Italy, 2015 In addition to the trauma experienced seekers in order to understand their before and during the migratory access to mental health services. The goal of the study was also to Number of Residents/ journey, the discriminatory behaviours TYPE OF FACILITIES % observe the main mental health facilities places they experience once they arrive in their destination countries, associated dynamics of the migrant population. CAS 3,090 76,683 74 with a general lack of opportunities, In addition, critical issues around the extraordinary reception system were SPRAR 430 Projects 19,715 19 can lead to increased vulnerability among these people and facilitate a assessed and their consequences GOVERNMENTAL RECEPTION CENTRES 13 7,400 7 shift towards mental health issues analysed on the emotional states of © Sara Creta 11 the migrant population. TOTAL RESIDENTS 103,798 100 of one form or another . A series of scientific findings from recent years In the first instance, this report Data from the Ministry of the Interior, December 2015 shows an increased risk and a higher attempts to provide an analysis of incidence of mental disorders among immigrants, specifically higher rates the social and personal conditions 10. Steel Z., Chey T., Silove D., Marnane C., Bryant R.A., Van Ommeren M.: of psychosis, depression, PTSD, mood of life in the CAS and the presence of support systems for psychological Associations of torture and other disorders, anxiety disorders and an potentially traumatic event with mental increased tendency to somatisation distress. It goes on to evaluate the health outcomes among populations (whereby psychological distress is availability of local services capable exposed to mass conflict and Figure 1. Residents and places in reception centres, 12 of taking care of the mental health displacement: a systematic review and Italy, December 2015 expressed as physical symptoms) . meta-analysis. JAMA 2009, 302:537-549. These are attributable to individual of migrants, and assesses possible factors, socio-environmental stress support and approaches to care that 11. Aragona M., Pucci D., Mazzetti M., could benefit this type of user. Finally, Maisano B., Geraci S., Traumatic events, Governmental factors and exposure to trauma and adversity accumulated over time. it describes the cohort of patients post-migration living difficulties and post- Reception Centres with mental distress followed by MSF traumatic symptoms in first generation 7% immigrants: a primary care study, Ann. Ist. SPRAR Protection System Many of the reception centres where over the course of a year in the CAS Super Sanità 2013, Vol. 49, N2:169-175. for Asylum Seekers the people seeking international of Ragusa province. The resulting and Refugees protection are accommodated do data is discussed on the basis of the 12. Fazel M., Wheeler J., Danesh J.: not have a psychological support information available in the literature. Prevalence of serious mental health 19% disorders in 7000 refugees resettled in Residents Western countries: a systematic review. and places Lancet 2005; 365: 1309-1314. in reception centres

CAS - Extraordinary Reception Centres 74%

OBJECTIVES Secondary objectives METHODOLOGY Primary objective > To qualitatively describe the mental health General purpose and Sixteen focus groups were held: 10 13. The contract specifications for the services available to migrants both within management of the CAS are absolutely To analyse the mental health needs of asylum the CAS and local authorities, as well as their qualitative research tools with social workers and CAS managers; discretionary and may change from one seekers resident in CAS and to identify any gaps in accessibility. five with asylum seekers residing province to another. By way of example, in the care of patients. An integrated qualitative and in a number of CAS in the province Ragusa province, where MSF has worked > To describe the mental health needs and morbidity quantitative approach was adopted in of Ragusa, where MSF has worked; for many years, the specifications initially among asylum seekers residing in the CAS. included no kind of psychological support order to understand the complexity of and one with the users of the clinic from the facilities. > To estimate the proportion of individuals the migration process, its relationship in Torre Spaccata in the Roma B ASL with mental health needs residing in the CAS with psychological distress, and the (Azienda Sanitaria Locale – Local 14. The mental health department (DSM) is care provided for potential mental Health Structure). Twenty-four the group of facilities and services with investigated by this study. the task of dealing with the demand linked health needs within local services standardised and semi-structured in- > To explore the barriers in accessing mental to care, assistance and the protection and CAS. The research qualitatively depth interviews were carried out with of mental health within the area defined health services. explored the mental health services psychologists and psychiatrists of the by the local health authority (ASL). The available in the area. The aim of this mental health centre (CSM) and mental mental health centre (CSM) is the first health department (DSM)14; with those centre of reference for citizens with mental was to understand how they are health problems. It coordinates all the organised with regard to a migrant responsible for mental health within measures for the prevention, treatment population with specific mental health the CAS; with those responsible for and rehabilitation of citizens who have needs, as well as to understand where psychiatric diagnosis and treatment psychiatric disorders within the local (SPDC) services in the provinces in context. For more information see: responsibility lies within the CAS for http://www.salute.gov.it/portale/temi/ identifying any care requirements and which the survey was carried out; and p2_6.jsp?id=168&area=salute%20 signalling the need for psychological with organisations and companies mentale&menu=rete. intervention13. The investigative tools operating in the area. The sample used were focus groups and in-depth used was purposive. The three Italian interviews, which revealed hidden provinces with the highest presence aspects of the health needs of asylum of CAS and of asylum seekers were seekers and their relationship with selected as study areas. The province health services. of Ragusa was added to these three, and focus groups were conducted there with the migrant population.

Table 2. List of focus groups, interviews and number of participants Type of qualitative Number of City Session type Facility research participants 1. Social Workers CAS, Nuovi Orizzonti (Poggioreale) Focus Group 4 2. Social Workers CAS, Residence Marino (Trapani) Focus Group 4 3. Social Workers CAS, Hotel Villa S. Andrea (Valderice) Focus Group 4 CAS, Pozzitello Village (Campobello di 4. Social Workers Mazara) Focus Group 4 5. Social Workers CAS, Borgo della Pace (Marsala) Focus Group 8 6. Social Workers CAS, Giovanni XXIII (Marsala) Focus Group 4 7. Centre Director CAS, Giovanni XXIII (Marsala) In-depth interview 1 Trapani and Province 8. Psychologist CAS, Hotel Villa S. Andrea (Valderice) In-depth interview 1 9. DSM Manager DSM In-depth interview 2 10. Prevention Service ASP In-depth interview 2 11. Prefecture Prefect In-depth interview 2 12. Borderline Sicilia Worker In-depth interview 1 13. UNHCR Project Coordinator for Sicily In-depth interview 1 14. UNHCR Psychologist In-depth interview 1 15. SPDC, Service Manager ASP In-depth interview 1 16. Social Workers CAS, Cinque Vie (Modica) Focus Group 4 17. Social Assistant CAS, Libeccio (Vittoria) In-depth interview 1 Ragusa and 18. Social Workers CAS, Villa Tedeschi (Modica) Focus Group 4 Province 19. Migrants CAS, Villa Tedeschi (Modica) Focus Group 8 20. Migrants CAS, Chiaramonte Gulfi Focus Group 13 © Anna Surinyach 21. Migrants CAS, Acate (Vittoria) Focus Group 12 22. Social Workers CAS, Staderini Focus Group 10 23. Social Workers CAS, Codirossoni Focus Group 6 15. Participation was ensured through a An MSF facilitator with the help of a half. The discussion groups with 24. SPDC, Service Manager Ospedale Sandro Pertini In-depth interview 1 preliminary selection of the people to a psychologist conducted the focus the migrant population were carried 25. DSM Manager ASL Roma B In-depth interview 1 be interviewed and included in focus groups and semi-structured interviews out separately from those with the Roma - 26.Psychiatrist working with groups, who were identified on the basis migrants Caritas In-depth interview 1 of the aims of the investigation and were by introducing the purpose of the social workers operating in the centres B ASL 27. Migration Psychiatry Clinic Policlinico Umberto I, Dipartimento contacted with adequate advance notice. research, the use of the information and the centre managers. They were In-depth interview 1 and the process. The anonymity of the also divided up according to the Coordinator Neurologia e Psichiatria information collected was guaranteed. language spoken to minimise the risk 28. CSM Manager Torre Spaccata In-depth interview 1 The guidelines for the topics to be of misunderstandings. The widest 29. CSM Manager Via degli Eucalipti In-depth interview 3 addressed and explored within the possible range of participants15 was 30. Migrants Torre Spaccata Focus Group 10 focus groups and in-depth interviews included to ensure that the voices were developed by compiling a of people of different ethnicities and 31. Social Workers CAS, Fondazione ARCA Focus Group 4 literature review on the subject, which geographic areas were represented. 32. Social Workers CAS, La Vincenziana (Magenta) Focus Group 8 was shared with the participants. The discussions were recorded, with CAS, Fondazione Fratelli S. Francesco the participants’ consent, to allow 33. CAS Vice-Director d'Assisi (San Zenone al Lambro) In-depth interview 1 In the first instance, the semi- greater understanding of the different 34. Psychologist CAS, Fondazione Fratelli S. Francesco In-depth interview 1 structured interviews enabled us to points of view, and were subsequently Milano and d'Assisi (San Zenone al Lambro) map the psychological support services transcribed verbatim. Where Province 35. Psychologist CAS, Fondazione ARCA In-depth interview 1 offered to migrants and the tools used recording was not possible, a manual 36. Psychiatrist Ospedale Niguarda, Etnopsichiatria In-depth interview 1 to address the needs of this population. transcription was carried out that was 37. Psychiatrist Ospedale Niguarda, Etnopsichiatria In-depth interview 1 The focus groups gave voice to those as faithful and detailed as possible. managing CAS in various provinces The anonymity of individuals was 38. Psychologist CAS, Corelli In-depth interview 1 and to the migrants, allowing us to guaranteed and the participants’ oral 39. Centre Administrator CAS, Corelli In-depth interview 1 collect relevant information and to consent was collected. Totals understand the underlying issues of the 16 Focus groups, 135 investigation. The table below shows the distribution 4 Cities 24 in-depth interview Participants of the research sessions with the The focus groups and interviews lasted number of participants who attended for between an hour and an hour and each session. METHODOLOGY NEGLECTED TRAUMA 10 11

16. Hsieh H.F., Shannon S.E., Three Approaches to Qualitative Contents Qualitative analysis Quantitative analysis Analysis. Qualitative Health Research 2005, 15:1277-1288. The transcript of the interviews A retrospective analysis was The information was collected by of patients showing symptoms of hypotheses of psychopathological was analysed through a process of conducted of the routine data psychologists while visiting patients. psychological distress and the group diagnosis. In the multivariate model, 17. Patton M,Q., Qualitative Research and systematic classification and coding collected from 1 October 2014 to 31 The data was entered into an Excel of those showing no psychological we used logistic regression to obtain Evaluation Method, 3rd edition. Thousand Oaks, CA: Sage, 2002. of the text, identifying the themes December 2015. Analysis includes spreadsheet and analysed using distress were compared using the the odds ratios and confidence and recurring trends16. Once all the patient baseline as well as follow-up Stata version 13, Atlanta City, USA. Chi-squared test. A comparison intervals for the relationships 18. The Diagnostic and Statistical Manual of texts were encoded, every trend data. Standardised medical records was also made between the between risk factors and mental Mental Disorders, Fifth Edition (DSM-5) was analysed in light of the research were used to collect information on Starting from the epidemiological frequencies distributions of the health status, controlling for several is a classification and diagnostic tool objectives. The discrepancies were socio-demographic characteristics data collected, different variables categorical variables. The level of socio-demographic characteristics which serves as a universal authority for psychiatric diagnosis. examined. In the first stage of the of the individuals, the length of their were created to describe the profile significance was set at p <0.05. The in the individuals. The results analysis, the codes were developed journey, their date of arrival in Italy of the migrants and the possible qualitative variables are expressed in obtained were presented with a 95% by reading the text of the first six and the potential trauma suffered role of migration in the onset of percentages, quantitative variables confidence interval (CI) and their transcripts line by line. The framework during three distinct phases of psychopathological symptoms. The as mean or medians. A univariate associated p-value. resulting from this first codification migration: in their country of origin, baseline and socio-demographic analysis was conducted for each risk was then used to decode and encode during the journey, and after their characteristics found in the group factor associated with symptoms or the rest of the transcripts. The themes arrival in Italy, with a particular focus and new codes that subsequently on their living conditions after the emerged were incorporated into migratory period. Information on the thematic frame of reference and hypothesis of diagnosis at baseline, related to similar labels. The stage the total number of consultations following the analysis included the conducted and the final outcome, conversion of codes into thematic classified as ‘improved’, ‘lost to follow- categories17. The frequency at which up’, ‘stable’ or ‘worsened’ were also some themes recurred was reported collected. and summarised. Diagnoses were assigned by MSF psychologists according to DSM-518 Epidemiological data and were based on clinical judgment collected in the MSF project as well as on the definition of the outcome, i.e. the observation of From 1 January 2014 to 31 December symptoms, examination of the coping 2015, MSF provided psychological care mechanisms used, their manner of in the CAS of Ragusa province, in a relating, space-time orientation, three-step process as follows: sense of reality, capacity for emotional restraint, resilience and adaptation.  All new arrivals were systematically No validation scale was used to evaluated with the help of cultural decide whether to provide care for mediators through psycho- the patient, as the scales proposed educational group sessions. were deemed to have been calibrated  Individual semi-structured for Western taxonomic needs, and interviews were carried out in therefore provide a poor response to order to identify particular needs. the categories of our patients. Individual psychological follow-up was provided – to those identified in The results here presented highlighted the group sessions, to self-reported an interesting framework to interpret individuals and to others screened the mental health needs of this by social workers. population.  A network was set up, with the support of social workers, for referring the most vulnerable patients to a more suitable reception facility (SPRAR). With particularly vulnerable patients, MSF ensured they received follow- up by local and national health services.

Focus groups and in-depth who are victims of trauma and violence, 1.a Procedures for mental health assessment within We started on our own... without in order to ensure the protection, care any specific idea of how to manage interviews: mental health and psychophysical rehabilitation of the CAS are inadequate or completely absent. of asylum seekers and a centre for migrants. We started extremely vulnerable people, with the Psychological support in the CAS is often improvised and patchy, being access to services support of cultural mediators. to manage in a community style – entrusted to young people with no previous experience working with asylum before that we had no notion of this However, so far, a lack of coordination seekers. Psychologists are not always included within the CAS, which are kind or clear criterion about this Our study identified a substantial between the different parties involved essentially conceived as providers of services – such as meals, supervision gap between the CAS and the health led to a failure to capitalise on and coordination with the police and Prefecture for issuing documents. All type of centres. Now we are slowly services, and a poor – or non-existent the current psychological support is left to the discretion of the centre’s management, and collaboration with getting organised... At first we didn't – relationship between the ASL and the activities. At the same time, the local health services is not guaranteed. There is a lack of shared operational know anything about migration, we Prefectures. In many cases there was economic difficulties facing the region protocols among the reception centres and health services in the areas didn't know what the word migrant a lack of coordination and dialogue of Lazio and ongoing staffing cuts in studied. meant. We improvised a bit, but between the various centres of the mental health services are not helping now we are progressively providing reception system and the local health the situation. services. On one end of the scale are new skilled professionals. the complex and congested cases of In Milan province, by contrast, the ethno-psychiatry experience at Trapani and Ragusa, where the health The psychologist is in the process of services have not yet developed the Niguarda and Sacco hospitals professional skills or operational became the local point of reference gaining the residents' trust. For now strategies in terms of transcultural for psychological support of asylum the social worker mainly deals with clinics. On the other end are the more seekers. Partnerships have been them. We still have to start working structured situations in Rome and established between public social and on a structured and systematic Milan, where there have been attempts health services and the private-social bodies, significant support has been work plan that will be useful for to foster interaction between the addressing any possible mental public health facilities , the private- provided for institutions and reception © Sara Creta social services that treat mental illness centres. Even though the presence of distress... but an initial analysis and the reception centres. However, private-social services in Milan province shows that no one has major shortages of funds and a lack of staff is still limited, it remains an interesting problems in this regard. with the skills to treat victims of trauma model. The ASL is constantly using and experience of working with this cultural mediators and skilled medical 19. Of particular note are the CSM in Torre professionals to identify the clinical A few months ago I started working Spaccata with an Ethno-psychiatry clinic, population make the situation even which created of transcultural listening in Rome and Milan extremely fragile. elements of victims’ psychological in the centre as a psychologist. I group held twice a month, and the CSM in Yet, in Rome province, despite the trauma. However, despite these efforts, work 12 hours a week. I've met half Via degli Eucalipti, which devotes 6 hours a reduced availability of dedicated the response is still insufficient for the of the residents of the facility. I week to transcultural psychology. 19 existing needs in the area. Further, human resources within the ASL and haven’t seen any of them a second 20. The clinic for Post-Traumatic disorders a gradual downsizing of the role of the response has been affected by at San Giovanni Addolorata in Rome public services in this field, a number communication problems following time and at least 30% of those I met served as the Coordination Centre for of positive initiatives exist. These the recent establishment of the CAS should be followed up. I do my best, Nirast, an integrated network of medical managed by the Prefecture. and psychological hospital centres within include the migration psychiatry but 12 hours is not much. They are the National Health Service, located in clinic at the Umberto I polyclinic; the poorly prepared at the CSM, they the cities of Rome, Milan, Turin, Gorizia, transcultural psychiatry clinic at the The results of our study are analysed underestimate our problems and Caserta, Foggia, Bari, Crotone, Siracusa Sant'Andrea hospital; and the centre for following the two main investigative I struggle to get an appointment. and Trapani. However, it closed on 1 criteria: March 2012 due to cuts to health care psychopathology in response to trauma Moreover, there are no mediators and the non-renewal of the Convention at the Gemelli polyclinic. In the private- between the Ministry of the Interior and social sector, too, positive initiatives Access to local health services by available. I believe that we should the National Asylum Commission. We include Samifo (Health Centre asylum seekers residing in the ex- invest in training professionals wanted to mention it here to emphasise the traordinary reception facilities put experience of treatment in this area. for Forced Migrants in ASL Roma A); 1 working in this field. Doctors Against Torture; in place by the prefecture. San Gallicano; the Caritas clinic; and Nirast (Italian Network for Asylum Seekers who Survived Torture)20. The most significant aspects within Initiatives such as these shown that a the reception centres relating to the synergy between private-social and living conditions of asylum seekers public services is vital in creating 2 residing there and the identification clinical pathways for asylum seekers of psychological distress.

1.b Identification of vulnerabilities and transfer of 1.c Abuse of emergency services at hospitals and SPDC patients to ad hoc medical facilities is slow and Access to local health services currently operates on an emergency 22. According to data provided by the SPDC often non-existent. There is a lack of early and basis, which explains the growing number of emergency admittances and in Trapani and Rome, this figure has It's my first time working in the increased in recent years. This trend hospitalisations for acute psychiatric disorders among migrants in the regions is also confirmed by other studies in timely identification. 22 field of migration. I arrived in studied . This figure is also attributable to a different mode of accessing care the literature. Morgan, C., Mallett, R., April. Before me, there was no for migrants, in which the SPDC becomes the shorter and easier route of entry, Hutchinson, G., Bagalkote, H., Morgan, psychologist in the centre. I'm trying The measures for identifying the most vulnerable subjects and those with but only when the pathology explodes and is no longer controllable. The use K., Fearon, P., Dazzan, P., Boydell, more or less manifest mental health issues can vary, depending on the type of the emergency services remains the most common practice for a quick J.,McKenzie, K., Harrison, G., Murray, to make myself known and to get to of vulnerability21, and can require, in addition to the disclosure and collection R., Jones, P., Craig, T. & Leff, J. (2005) but unstructured “solution” to the problems. In terms of social and health Sample characteristics and compulsory know the guys. I arranged individual of stories, the observation of behaviour and verbal and non-verbal language. services, there is still a lack of planning, tools and working practices adapted admission: a report from the AESOP meetings, but many of them are Time restraints, often accompanied by a lack of specific training among to individuals coming from very different areas and cultures. This is most study. British Journal of Psychiatry, afraid and reluctant to speak. They psychologists working in the CAS, prevents or slows prompt reporting to the evident in the Sicilian context. 186, 281-289. M. Braca, I. Tarricone, F. Chierzi, V. Storbini, T. Marcacci, D. are afraid their words might be relevant parties for the provision of appropriate care. With a few notable exceptions, in general there is no structured psychological pathway within the Berardi. I disturbi mentali comuni nelle used against them. I tried to explain popolazioni di migranti che afferiscono CAS, nor any clear identification of the preventive actions needed to intercept ai livelli primari di cure: l’esperienza del very carefully that it was simply an the onset of issues or provide timely care for people with serious mental Bologna Transcultural Psychiatric Team exploratory interview. It's difficult to health problems. Cases are only reported to the competent health authorities (BoTPT). Dipartimento di Scienze Mediche carrying out psychological screening after incidents of aggression or when migrants have shown anger or disturbing e Chirurgiche – Università di Bologna. because the guys never turn up to attitudes. Relations with the CAS are almost non-existent. There is no appointments. I'm trying to figure dedicated clinic. The migrants only end up in the emergency room out how to improve this part and and the SPDC emergency department if there are problems or acute overcome their distrust. cases. What is lacking is the opportunity to keep track of the patient and to follow up on their mental health in the absence of a major psychopathological crisis. Talking about the cases that come under the care of our departments, We don't have a very broad user group. Trattamento Sanitario we can say that the greatest Obbligatorio (TSO) – or compulsory health treatment – is often used problems at the CAS arise from improperly and to get rid of people who create problems but do not the shortage of workers, especially have an actual psychiatric illness. When the police have to deal workers and psychologists trained with a patient with inflamed reactions, they take them to the SPDC. in psychology for dealing with Psychiatric definition becomes a way of getting rid of problematic trauma. These centres are very patients... most of the times the issues they have took the form and large and provide minimal levels of characteristics of a psychological distress related to contingent shelter. There is a lack of listening factors (residence permits that never arrive, rejected requests and guidance, and an inability to for asylum, life plans slipping away, the loss of reference points, intercept distress signals before the inability to restart their lives)… This behaviour is more about they become explosive actions and management than psychiatric therapy, and should be treated with a require treatment as such... Who psychological rather than a psychiatric approach. monitors these reception centres now? Who guarantees them? These There is no systemic vision. Everything cannot just be delegated centres have no trained educators. to the reception centre. If the institutions appointed to do so don't strengthen their skills and don't have the necessary human resources, then the problem will persist. We don't always have contact with the ASLs and, unless you know someone within the health districts, you can't do anything, you get stuck. The waiting lists for receiving care are unbearably long, so taking them to the emergency services becomes the simplest thing. 21. For a definition of vulnerability, see http://www.unhcr.org/4317223c9.pdf section 3.4.1 identifies the following The CAS are a collection of dramatic situations. I’m aware that we categories to be used in the procedure for should address their needs and respond to them. The few people determining refugee status: persons with obvious need for protection, victims of who come to us do so from an acute psychological crisis. They tell of torture and people who have experienced extreme situations, and the reception centres only have some of the trauma, women with special needs, unaccompanied or separated children, competencies they need to address these issues. elderly asylum seekers, asylum seekers with disabilities, asylum seekers with medical needs.

1.d Cultural mediation is often absent or else is carried 1.e There is a lack of culturally appropriate human and out by Italian staff within the CAS and local health financial resources and mental health services to services. treat the asylum seekers.

Always having mediators available In some of the CAS visited, the role of the cultural mediator is interpreted A substantial discrepancy was discovered between the need for mental health We fight against their phobias is not easy, especially for some simply as a translator. As a result, the mediation – which should plays a key and the provision of health services offered, which is often due to the lack every day. They believe that languages such as Tigrinya or role in creating a relationship of trust with the patient, to help interpret the of appropriate human resources (workers experienced in the treatment of whatever happens is due to spirits Bambara. I often get by with English cultural and system of the patient's culture of origin – is often absent or is trauma psychology) and adequate financial measures to respond to the needs and rites practiced by someone in and Italian – many of the guys are carried out by Italian staff. In addition the mediators operating within the ASL of migrant patients. The problem was reported by both the CSM and the CAS their own countries. I’ve explained taking courses in Italian. are a real exception, although a communication culturally adapted to the involved in the research. There is no network of health services catering to the to them that they are here in Italy individuals is essential for a quality care giving. real needs of this population. There are no outpatients departments with ethno- and that these things do not exist psychiatric skills which can follow up on the issues related to mental health of There are no cultural mediators asylum seekers and they have no cultural mediators. In addition, there is still a here, but to no avail… in the CSM, and when we have to substantial lack of flexibility in using Western diagnostic categories, which often accompany one of the migrants do not take into account the different cultural layers of an asylum seeker which … The biggest difficulty is resident here, we try to bring could be essential in the interpretation and definition of a psychotherapy. mistrust and getting them to keep our mediators, but it isn't always appointments. They almost never possible. The ASL has no resources. show up. At first, we put notices Given all the needs in the area, it in the main hall but we found would be good to provide a team of them taken down. So we decided mediators. to put the notices in their rooms, but we also found those were The ASP in Trapani has established taken down. It seems that nothing a register of mediators, but it works and it's very tiring. remains insufficient. In case of acute psychological phase of a migrant, the health system gives In general, the public health support to the reception centres services do not have the specific where it is requested. There is knowledge to cope with treating a shortage of staff, so we only the psychopathology of migrants. intervene rapidly on request. The solution would be to create small, specialised, well-trained I speak a bit of English, but not team within the services, which enough for a conversation at a level could perhaps be integrated with that can form a bridge and create a dedicated private-social bodies. relationship of trust, so when I can Education and commitment I use interpreters or mediators, but are the two key words. We need they're not always available. We are to create a local network of also encouraging the guys to learn psychiatric services who are able better Italian. to treat these patients and have training in psycho-traumatology.

1.f There is a lack of coordination between the 1.g Socio-cultural factors in the migrant population Prefecture, the CAS, the Hospitals, the local are changing. Commissions23 and the ASL. "We have repeatedly and The interviews conducted with both the private-social bodies with A few years ago the patients extensive experience of the psychiatric treatment of migrants, and with the unsuccessfully asked the Engagement with the ASL is critical for ensuring the equity and equality of were strong and we had several psychiatrists working in public facilities revealed a different type of asylum prefecture for a meeting. We services. Yet there is no protocol formalising an agreement between the tools to work with ... Now, and seekers with a reduced capacity for resilience and no clear migration plans. asked to form a working group reception centres, local health authorities, hospitals and the Prefecture especially since 2011 and the so we could tell them about the that includes the different parties involved and coordinates measures with a North African crisis, the refugees things that do not work and multi-sectoral approach. and asylum seekers arriving are create a channel for information. victims of torture and of multiple We wanted to establish a instances of violence. Our staff memorandum of understanding are often unprepared to handle that would allow us to better these complex situations. The define the needs of this population, and to implement a frustration and demotivation plan that can guide the provision of the workers is high, with a and organisation of the services significant risk of burn-out ... by our hospital. To date we have In addition, the economic crisis had no response. does not make it easy for arriving migrants to find a job or settle There are no operational down. protocols between those responsible for the reception It was very hard in Libya and I system and health services in the wanted to get out of there. I did area with regard to giving care... not know I was coming to Italy We carry out an initial visit here, when they forced me onto the but the problem affects those boat. I didn't have a clear plan, who need monitoring and follow- I just wanted to get out of that up ... We never know whether country ... It wasn't easy to get or how they are subsequently here. I saw a lot of suffering and followed up in the CAS. There is a lot of injustices but I don't want no syndromic surveillance24. to talk about it now. The only thing that the prefecture does with people with problems We are facing different or disturbing symptoms is take phenomena to the kinds we them and transfer them from one dealt with in the past. Many centre to another. The prefecture of this new flow of migrants has a mandate to provide shelter started out with limited personal but not to solve future health resources. Often they do not problems. have a migration plan or a social network. The culture shock is huge, leading to isolation and high rates of depression.

23. The Local Commissions analyze the applications for the recognition of refugee status in a decentralized manner.

24. http://www.epicentro.iss.it/focus/ sorveglianza/immigrati.asp

On the critical issues within the reception centres concerning their functioning 2.c Asylum request procedures are slow, and they and the living conditions of the asylum seekers residing there, four main issues were identified. spend long months spent in the CAS with no prospects. At the moment I am following Getting all the answers from the The asylum seekers’ living conditions are very particular: they are living the cases of three boys who frequently in crowded communities and in precarious contexts for extended police headquarters and having expressly asked for an interview 2.a The environment within the CAS is often unsuitable their papers in order becomes and overcrowded. periods for which they are unprepared. Further they often do not have the and who constantly complain necessary legal information for asylum application which is the prerequisite their reason for existence. If about headaches, but I have Many of the workers interviewed complained about the lack of adequate to decisions about their future. they don't manage to get all the facilities and privacy for establishing a relationship of trust with the residents no room to myself where I can of the centre, leaving them unable to provide a level of confidentiality. Some answers they want, they revolt. devote myself to listening and of the facilities are not suitable for accommodating a large number of people. They get depressed. We try to talking. We talk in a room Sometimes they are unwelcoming and unreassuring environments, with bars do everything we can so that amongst the other residents... on the windows and reinforced doors that certainly do not help to provide they understand that it's beyond We don't even have an office in a good reception, especially for those who have experienced traumatic our control and that the system this place where you can sit and imprisonment during their migratory journey. is slow and complex... Waiting talk quietly and privately. with no prospects destroys them.

The work that I want to start with them, from a psychological point of view, is hampered by We are always among each the papers. As soon as I start other. It's like we're still in to gain their trust, to establish Africa. We don't have the contact, they ask me about their papers and we don't talk to certificates and documents. anyone else apart from the Just to give you an idea of how other residents of the centre. slow the bureaucracy is: a girl We don't have Italian friends, discovered she was pregnant we don't talk in Italian and just as she arrived. Six months we have no work. Without later she's still here and they papers we can't do anything... still haven’t identified the SPRAR To go into the city you have to where she will be placed. take a bus. It costs nine euros there and back and we have I can't sleep. Time waits for no no money, so we prefer not to © Sara Creta one, and it passes relentlessly. I go out. have to plan a better life for my future now, before it's too late. I can’t spend a lifetime sitting We have nothing to do here. here, letting one day pass after I arrived seven months ago 2.b Extraordinary Reception Centres are often in another, without seeing anyone, now, and every day is the isolated locations, making integration impossible. without having papers, eating, same. I didn't come here to sleeping, without any change, stay locked in a room. I've Many of the centres are located in isolated, hard-to-reach places, where residents are cut off from normal life and are unable to create connections without any progress. These done nothing but sleep and and social networks within the area in which they are being housed. Their documents are our life. When we eat while I've been waiting for lives revolve around the mattresses they sleep on, the meals they consume 25 get them, everything will be over, the Commission since April. and the television they watch. The only contact they have the outside everything will be better. Without the centre is limited to their fellow countrymen who are hosted in similar centres nearby. papers, you're nobody... You're nobody in front of your friends and your family.... I’ve lost almost two years and still I don't have any papers... Sometimes I feel like 25. The National Commission for the asylum I'm going crazy. application coordinates the Local Commissions, organizes training, updates the components of the same commissions and collects statistical data. It has decision-making powers regarding the revocation of granted refugee status.

2.d Trauma and the difficulties of post-migration life Quantitative data: the mental health of asylum seekers are expressed as physical symptoms. according to MSF's experience In addition to the traumatic experiences they underwent in their countries of origin or during their migration journeys, a number of difficulties concerning life in the post-migration period have been detected. In particular, many of The data analysed and examined in this study are limited Figure 2. Pathway of the mental health cases dealt with by the residents in the centres complained about a high level of intolerance to patients seen and treated by MSF in the period from MSF, province of Ragusa, Sicily, 2014-2015. and loneliness, and a lack of direction concerning their path to becoming 1 October 2014 to 31 December 2015 in the CAS of the well-adapted, socially integrated and building a new life for themselves. The province of Ragusa. Of the 521 people included in the difficulties of life in post-migratory situations can have a significant impact psycho-educational groups, 387 were given an individual idiida ee o iterie on the mental health of asylum seekers and cause secondary trauma. interview. Of these, 153 (39.5%) did not display symptoms rop eio of psychological distress. Of the remaining 234 (60.5%) patients with identified mental health and care needs, 12 (3%) patients were referred to other facilities, 5 (1%) idiida iterie did ot dipa pto refused treatment and 18 (4.7%) were transferred to another centre before the MSF team could intervene. The subject eerred The thoughts crowd in my head. My thoughts become gloomier, of this study will be the 387 patients subject to individual assessment and the 199 patients who had a final outcome oered M reed treatet especially at night when I'm lying in bed... To stop myself from as of 31 December (Fig. 2). The majority of patients were thinking, I read and I try to learn Italian. On Sundays I play football identified by the MSF team (66%), 18% were self-referred, raerred ro te etre and I go to church. I try to do things to stop me thinking. 15% were referred by the operating team in the CAS and the remaining 1% were referred by local health authorities. ie are dri te period ro At first there doesn't seem to be anything wrong but then, after a few toer to eeer days, they start to relax and they feel ill – headaches, stomach pain, Of the patients who underwent a first individual interview, 33 the whole body... It's not necessarily the case that they are really sick (8.5%) were women and 354 (91.5%) were men. The mean ... It might be the body expressing the pain of the soul. They always age was 23.9 (± 5.5) with a range from 3 years old to 45 years old (Fig. 3). Of the registered patients, 78 (20%) were from feel ill and are only happy when they take medicine... Nigeria, 65 (16.8%) from Gambia, 51 (13.2%) from Senegal, Figure 3. Demographic pyramid of the population under study, 47 (12.1%) from Mali and 43 (11.1%) from Bangladesh. There province of Ragusa, Sicily, 2014-2015. It wasn't easy to get here. I saw many people die. I left Senegal in was a smaller percentage of asylum seekers from other 41-45 countries, such as Eritrea, Afghanistan, Somalia, Egypt, Ivory 2011 and arrived in Italy at the beginning of 2015. It wasn’t easy, Coast, Guinea Bissau, Guinea Conakry, Iraq and Ghana. Of 36-40 and you can't explain everything, but a lot of us left our country the patients interviewed, 9.6% (37) were vulnerable. Of these and many didn't make it. The police in Libya attacked ferociously... vulnerable patients, 16 (4%) were unaccompanied children, 31-35 I know that God helped me to get here, but now I hope he will help 10 (2.6%) were pregnant women, 7 (1.8%) were disabled me some more. I want to get the papers, that's my primary concern. and 3 (0.7%) recorded psychiatric problems. 26-30 I am studying Italian and trying to get my life ready, because for the For 210 (54.3%) of the patients, their journey to Italy took more than 12 months. For 70 patients (18%) the journey 21-25 moment I'm not ready to have a real life. I want to get my papers and took between 6 and 12 months. For 78 patients (20%) the 16-20 find a job. journey took between 2 and 6 months. The journey lasted less than two months for just 24 patients (6.2%). Of the 0-15 234 patients who had symptoms of mental distress, 206 I left a country with a dictatorship. I came to Italy because I knew (88.3%) were men and 28 (11.9%) were women. 140 120 100 80 60 40 20 0 20 that there was democracy, and I was disappointed. The reality ■ Females ■ Males that I found is very different. I thought that wherever there was a democracy, you could solve problems by talking, but I learned that that's not how it is. We are very frustrated. Some of us have been here for two years and sit in this centre without doing anything. Put yourself in my shoes: a family man, like many others in here. I left my wife and my three children in my country, and they all depend on me. You want to give them the best: a good education and a bright future...And I've been sitting here with no prospects for two years now. One day my wife called me and told me that tomorrow they wouldn’t have any food to eat... What do you expect me to say or do? What can I say to my wife in these circumstances? If I'm not protected in Italy and I can't get the papers, what can I do? It makes you feel bad, useless, as a man and as a father.

Difficulties encountered

26. Note that the definition of torture used is Among the subjects interviewed, the In total, 37.6% of the population Figure 5. Type of traumatic events experienced by asylum seekers, before and during the migratory journey, province that provided by the ICRC: https://www. majority of the disorders detected were analysed said they had suffered of Ragusa, Sicily, October 2014-December 2015. icrc.org/eng/resources/documents/faq/ attributable to anxiety (n= 130, 33.6%), traumatic events in their country of torture-icrc-definition-faq-2011-06-24. followed by post-traumatic stress origin and during their migratory htm. disorders (n=63, 16.3%), depressive journey. For patients affected by ter 1 disorders (n= 46, 11.9%), personality traumatic events before or during Other 1 Conﬂict between disorders (n= 8, 1.8%) and cognitive their migration journey (n=144), the families 1 eua vioene etention disorders (n= 3, 0.7%). Of the 387 median delay in being given care after idnapping 5 patients seen during this period, 189 their arrival was 80 days and the IQR Physical Violence ami memer idnapped events imprionedmied events (48.8%) were victims of traumatic [45-128]. eperienced by Witnessing the eperienced by events before the journey and 319 asylum seekers, asylum seekers, death of someone ored aour 5 (82.4%) during the journey (Fig. 4). The socio-demographic characteristics before te during te Life risk migratory itneing te deat migratory of the sample are described in table 3. ourney ourney The traumatic events most frequently An analysis of the group affected by o omeone recorded before leaving the country mental symptoms and a comparison Involvement orture omat of origin (Fig. 5) were: having witnessed with the group of patients with no in ﬁghting the abduction and incarceration of a symptoms did not reveal any significant Family members killed ituation 12 kidnapped/imprisoned 2 ie ri 10 family member (n=52, 28%); conflicts differences in terms of age, marital between families (n=58, 31%); and fear status or duration of the journey. that their life was at risk (n=13, 7%). However, significant differences were The commonly recorded traumatic revealed in relation to gender, the state events from the migratory journey of vulnerability, nationality, the waiting were: prison and detention (n= 113, 35%); time before being seen by a specialist, Table 3. Socio-demographic characteristics of the patients in a first individual baseline interview, province of Ragusa, Sicily, involvement in fighting (n= 38, 12%); and the traumatic events that occurred October 2014-December 2015. forced labour (n=17, 5%); torture26 before or during the migratory path. (n=27, 9%); sexual violence The presence of traumatic events has Patients without any symp- Patients with symptoms of Total toms of mental distress P-value (n=13, 4%); and constant fear that their a significant impact on the existence of (n=153) mental distress (n=234) (n=387) life was at risk (n=33, 10%). psychopathological symptoms. Gender Male 148 (41,8) 206 (58,2) 354 Female 5 (15,2) 28 (84,8) 33 0,003 Age groups 0-15 0 1 1 16-30 141 (40,2) 210 (59,8) 351 0,5 31-45 12 (34,3) 23 (65,7) 35 Marital status* Married 36 (36,7) 62 (63,3) 98 Figure 4. Frequency of traumatic events suffered by Widowed 0 1 1 0,7 asylum seekers receiving care from MSF, province of Single 113 (40,5) 166 (59,5) 279 Ragusa, Sicily October 2014-December 2015. Separated 2 (33,3) 4 (66,7) 6 Duration of journey** < 2 months 6 (25) 18 (75) 24 Post migration life difficulties 2-6 months 35 (44,9) 43 (55,1) 78 0,5 7-12 months 28 (40) 42 (60) 70 Potential Traumatic eents > 12 months 82 (39,1) 128 (60,9) 210 during the ourney Vulnerability Potential Traumatic No 151(43,1) 199 (56,9) 350 eents before the ourney Yes 2 (5,4) 35 (94,6) 37 0,000 Traumatic events*** No 122 (51,1) 117 (48,9) 239 0 20 0 0 0 100 120 Yes 31 (21,5) 113 (77,8) 144 0,000 * The di culties encountered in the post-migration period have only been Waiting time † calculated for the 199 patients treated by MSF (171/199) < 2 months 41 (30,2) 95 (69,8) 136 ≥ 2 months 109 (45) 133 (54,9) 242 0,005

* 3 missing data ** 5 missing data *** 4 missing data † 9 missing data

Risk factors and difficulties who did not experience any. Among the Of the diagnoses27 most commonly "the inability to integrate and feel 27. Following the indications of the DSM-5, traumatic events suffered before leaving found among the patients cared for integrated"(7.7%), "prolonged waiting the diagnoses were classified as follows: of post-migration life acute stress disorders, complex post their country of origin, those who had a by MSF (n= 199), 42.2% (84) was for times for the Commission's outcomes" traumatic stress disorders, psychological family member kidnapped or imprisoned disorders related to traumatic and (5.5%), "lack of daily activities" (3.9%), In the multivariate logistic regression stress and post traumatic stress disorder stressful events, especially PTSD, "a sense of loneliness and boredom" related to traumatic and stressful model (Table 4), inclusive of were 6 times more likely to have psychological distress OR= 6.11 [CI: 2.5- followed by 27% (54) for disorders (2.2%) and, to a lesser extent, other events, moderate and severe depression vulnerability, sex, waiting time before due to anxiety, 19% (38) for moderate difficulties such a widespread sense of in bipolar disorders, anxiety and 14.5] than those who did not suffer any somatoform disorders, psychotic disorders, accessing care and traumatic events depression and 4% for personality injustice and feeling unable to control suffered, the variables associated with injury. Those who experienced conflicts dissociative and cognitive disorders, between families were 2.2 times more disorders. Of the patients given care events. In general, patients complained personality disorders (sleep disorders). a mental psychopathology, adjusted for by MSF, 65% (130/199) showed a of a variety of difficulties in post- potential confounders, were found to likely to have psychological distress than those who did not experience any dual diagnosis of psychopathology. migration life, for an average of 6.3 (± be vulnerability OR = 9.1 [CI: 2.1-39.9] PTSD as a primary diagnosis (n= 84) 4.6). The traumatic events suffered and traumatic events OR = 3.7 [CI: 2.3- trauma OR= 2.2 [CI: 1.06-4.7]. Among the traumatic events that occurred often coexists with anxiety disorders during the migratory journey equally 6.1]. However, the sample of variable (n = 57/84, 68%) and with moderate contributed to PTSD disorders (94% vs during the migratory journey, those who 'vulnerability' is negligible enough (n= depression (n= 34/84, 40%). 3.5%, p= 0.02) and depression (84% vs were incarcerated were 5 times more 37) to be deemed as imprecise with a 10.5%, p = 0.02). likely to have mental health disorders large confidence interval. The median number of sessions in the that those who did not OR= 5.04 [CI: period between 1 October 2014 and 31 The majority of patients (n= 134, 67.3%) The probability of having 2.04-12.4], and those involved in fighting December 2015 is 4 [IQR= 2-6], with showed an improvement at the end of psychopathological disorders was 3.7 were 3.2 times more likely to have a range from 1 to 20. No particularly the therapy, while 4.5% (n= 9) showed times higher among individuals who mental health disorders than those who significant association was found no improvement, 21.6% (n= 43) were experienced traumatic events than those were not OR= 3.2 [CI: 1.1-9.2]. between the number of sessions and transferred out of the centre before the final outcome of the therapy. MSF could intervene, and 4.5% (n= 9) were referred. Among the patients cared for by Table 4. Risk factors for mental health, Ragusa Province, Sicilia, MSF, 86.9% (173/199) said they had Figure 6 illustrates the different october 2014 -december 2015 difficulties in post-migration life categories of outcomes for the three and this distress was significantly major recorded psychopathologies: Mental Health Disorders associated with a diagnosis of PTSD PTSD, depression and anxiety-related Variables Non Adjusted Adjusted (42.2% vs 22.2%, p= 0.05), followed disorders. Patients with PTSD and OR (95% CI) OR (95% CI) by a diagnosis of anxiety disorders depression showed improvement in Sex (28.9% vs. 22.2%, p= 0.05). The most more than 60% of cases, and 80% Males 1 1 common difficulties in life during the of individuals with anxiety disorders Females 0,2 (0,09 - 0,6) 0,4 (0,15 - 1,19) post-migration period were found to be showed improvement. The highest "the feeling of uncertainty and fear for proportion of patients who did not p-value 0,001 0,08 the future" (18.8%), "concern for the show any improvement were found to Vulnerabilities family back home" (13.8%), "conflicts be those with depression (8%). The No 1 1 within the CAS" (11%), "fear of the highest percentage of referred patients Yes 13,2 (3,1 - 56,0) 9,1 (2,05 - 39,9) asylum request being rejected" (8.8%), was recorded among subjects with Likelihood Ratio Test (p-value) 0,000 0,006 "the feeling of being neglected" (7.2%), PTSD. Waiting Time < 2 months 1 1 ≥ 2 months 0,5 (0,33 - 0,82) 0,6 (0,38 - 1,02) Likelihood Ratio Test (p-value) 0,08 0,06 Figure 6. Final outcomes for the total number of patients given care and for the three major types of psychopathology, province of Ragusa, Traumatic Events Sicily, October 2014-December 2015. No 1 1 100 Yes 3,8 (2,3 - 6,09) 3,7 (2,3 - 6,10) 90 Likelihood Ratio Test (p-value) 0,000 0,000 Traumatic Events in the Countries of Origin 80 No 1 1 70 Family member killed/kidnapped/imprisoned 5,8 (2,4 - 13,9) 6,4 (2,7 - 15,5) 60 Conflict between families 2,5 (1,2 - 5,2) 2,2 (1,07 - 4,8) Life risk 4,1 (1,03 - 16,2) 4,6 (1,1 - 18,4) 50 ■ Improved Likelihood Ratio Test (p-value) 0,000 0,000 40 ■ Stable Traumatic events during the migratory journey 30 No 1 ■ Referred Detention 3,7 (1,6 - 8,6) 5,04 (2,04 - 12,4) 20 ■ Transferred Life risk 1,6 (0,5 - 4,4) 1,7 (0,5 - 5,2) 10 ■ Lost of follow up Combat situation 2,5 (0,9 - 6,5) 3,2 (1,1 - 9,2) 0 Likelihood Ratio Test (p-value) 0,000 Total PTSD Depression Anxiety Disorders

© Francesco Zizola © Francesco Zizola © Sara Creta NEGLECTED TRAUMA 28 29 DISCUSSION 28. See: Tol W.A., Barbui C., Galappatti A., The findings of the qualitative research, seekers, various interventions that As we noted in discussions with members who remain in the country of Silove D., Betancourt T.S., Souza R., Golaz the characteristics of the patients included a component of psychological migrants and CAS workers, it can origin. A., Van Ommeren M.: Mental Health and psychosocial support in humanitarian observed in our project in Sicily, and and therapeutic support showed be a stressful experience to live in settings: linking practice and research. the literature review, all combine to promising results in terms of stress reception centres that are designed Many of the CAS are located in Lancet 2011, 378: 1581-1591. Van Ommeren suggest that exposure to violence reduction and the strengthening as emergency measures and are often remote areas, far from towns and M., Saxena S., Saraceno B.: Mental and and traumas suffered by the migrant of compensatory strategies and limited to ensuring basic services, cities, meaning integration with the social health during and after acute 29 emergences: emerging consensus? Bull. population during the migratory resilience . Our data concerning the with no clear plan for inclusion in host native population is impossible. As World Health Organ. 2005, 83 : 71-76. journey and complex situations cohort of patients followed throughout society, and where asylum seekers such, social relationships are limited experienced in the period following 2015 seem to confirm this trend. spend the entire duration of their stay to residents of the centre or similar 29. Moro M.R.: Psychiatric interventions in crisis situations. The Signal 1994, 2 :1-4. their arrival are a major source of until they receive hearing with the facilities, causing a strong feeling of psychological distress. A high prevalence of difficulty in post- local commission, and with no clear marginalisation and a lack of access to 30. See: Silove D., Sinnerbrink. I., Field migration life was found in parallel future prospects. In addition, living in services. The forced inactivity to which A., Manicsvasagar V., Steel Z., Anxiety, The repertoire of psychopathological with the traumatic experiences in the this kind of limbo, without any useful people may be subjected for several depression and PSTD in asylum seekers: association with pre-migration phenomena appears to be broad home country and especially during employment, could exacerbate old months at a time brings feelings of trauma and post-migration stressors. and is expressed on different levels. the migratory journey. The literature traumas and increase the risk factors apathy and depression, as well as a British Journal of Psychiatry, 170: 351- Among the subjects analysed who has amply demonstrated that having of secondary trauma. The long wait sense of worthlessness, dependency 357. Aragona M., Pucci D., Mazzetti were diagnosed with symptoms related an accumulation of this type of for the preliminary examination of the and frustration. M., Maisano B., Geraci S.: Traumatic events, post-migration living difficulties to traumatic and stressful events experiences carries an increased risk application for international protection and post-traumatic symptoms in first and PTSD, the co-presence of other for refugees and asylum seekers of through the C3 form can take several The characteristics of the facilities generation immigrants: a primary care disorders such as anxiety, depression, developing PTSD in the host country weeks from their arrival at the facilities, themselves often represent a risk study, Ann Ist. Super. Sanità 2013, Vol. 49 personality and cognitive disorders was and of experiencing greater difficulties and in some cases even months (as factor for the onset or aggravation N2:169-175. often found. with social integration30. According is the case in Trapani). This already of psychological suffering. Many 31. Robjant K., Hassan R., Katoma C.: Mental to a systematic review, PTSD was represents a cause for destabilisation structures are improvised in Centres health implications of detaining asylum Although there is a need for further predominantly diagnosed in asylum for the applicant, which is worsened by (in some locations, for example in seekers: systematic review, The British rigorous evaluation, psychological seekers with previous traumatic history, additional waiting for the call to attend Sicily, the centres are converted Public Journal of Psychiatry (2009) 194:306-32. support showed a beneficial effect while the stay in the reception and the hearing at the local commission. Welfare and Benevolent Institutions on the treatment of trauma, both in detention centres acted as a current (IPAB), and assistance is offered contexts of humanitarian crisis and trauma for other categories of mental The testimonies of the CAS workers and to the elderly and migrants in the among the asylum seeker and refugee distress31. especially the residents themselves same building), and staff confuse population28. Among the asylum have confirmed these criticisms by the complexity of the asylum seekers highlighting the extent to which the hosted with other individuals with draining wait for a summons and a different needs. When a person response from the commission is a key who has survived violence or has factor of instability for asylum seekers. been the victim of inhumane and It also has an effect on workers, making degrading treatment is forced to management of the CAS tiring and live in overcrowded or unsuitable distressing. Asylum seekers residing in conditions, they are even more at risk these extraordinary facilities often lose of developing psychological symptoms their concept of time and live in limbo. related to their previously experienced Their days are always the same, and are trauma, or of developing symptoms only marked by the alternation of the connected to the dynamics of social meals as they await the commission's exclusion, isolation and prolonged decision to interrupt their alienating cohabitation for a significant period of rhythm. This waiting phase, which can time. last from a few months to over a year depending on the case, only serves The staff working in the CAS are to increase the fragility of the asylum not always adequately prepared to seeker's condition, as someone who meet the demands and needs of this has just completed a journey under population, a significant portion of extreme conditions, fled a dictatorship whom may have complex personal or a desperate situation and has often stories from having been a victim left a family behind. If the state of of trafficking, or having suffered or uncertainty and the transient situation witnessed terrible violence. Throughout experienced by asylum seekers lasts the centres visited, especially those in for months, it can lead individuals to the south (the provinces of Trapani and a state of psychological instability in Ragusa), links with the local area are addition to the trauma suffered during completely absent, and the support the migratory journey. Their thoughts and care activities are delegated to are caught up in their most pressing private-social bodies, where they exist. concerns: getting hold of the right the Moreover, the reception conditions in documents and the wellbeing of family these facilities often make it difficult to

32. http://www.interno.gov.it/it/notizie/ promptly identify the migrants who are Study limitations sistema-accoglienza-oggi-rapporto- in a state of psychological distress and CONCLUSIONS AND RECOMMENDATIONS qualificato-e-aggiornato-aspetti- in need of urgent care. The situation A number of limitations must be taken procedure-e-problemi The above results highlight the need 1. The competent Prefectures should is different in Rome and Milan, but the into account with respect to the results commitment of addressing the mental to reform the approach to the issue of formulate strict selection criteria for 33. See: Doctors Without Borders, Out of of the study presented. The data shown mental health treatment in the context the recruitment of cooperatives and sight. Asylum Seekers and refugees needs of asylum seekers is still too in the quantitative analysis are based in Italy: informal settlements and unstructured. The training of workers of migration in Italy. The widespread institutions managing the centres, social marginalization, 2016. Ministry on routine data collected in the project absence of professionals with as well as the staff employed by of Interior, Report on International in dealing with asylum seekers who are run by MSF in the province of Ragusa. suffering from mental illness is still not expertise in the context of migration them, to ensure the presence of Protection in Italy, 2015. http://www. As such they suffer from the lack of an is undermined by the frequent lack skilled professionals with experience interno.gov.it/sites/default/files/t31ede- widespread enough and the available initial epidemiological design based rapp_prot_int_2015_-_rapporto.pdf human resources are not sufficient. of cultural mediation figures, even in the area of migration. on a clear investigative hypothesis in the public referral facilities, with 2. Public facilities, with particular and on a direct comparison with a In fact, the system developed harmful consequences for the early reference to the Mental Health control sample. Despite the efforts and essential identification of cases Department and Mental Health in 2014 and coordinated locally and measures taken to standardise the by the prefecture has now given of mental distress among the hosted Centre, should hire staff trained evaluations and the definition of the migrant population. in the context of transcultural rise to a parallel mechanism that cases, the turnover of psychologists places people seeking asylum and psychology and/or ethno-psychiatry. may have potentially caused Multidisciplinary and multicultural In addition, creating departments international protection in a wide inconsistencies in the assignment of variety of facilities. These centres teams should be present in order to specialising in cross-cultural diagnosis and outcomes. Given the take all the dimensions involved into psychology and ethno-psychiatry have much lower reception standards type of data collected, it was not compared to those ensured by the consideration. At present, the existing at the facilities would also be possible to assess the evolution of the facilities are inadequate, and in the beneficial. SPRAR system, and are not required therapeutic outcome attributed. These to provide individual integration majority of cases they are managed by 3. The Ministry of Health, at the results should to be understood as a non-profit organisations. The role of national level, and the ASL, at plans. A report by the Ministry of the proposal for a hypothesis, and need to Interior32 confirms a picture of an the national health service is limited, the local level, should designate be confirmed by a properly designed and the local health authorities are not a advisor in the area of migration. asylum seekers reception system build longitudinal study. The selection of on heterogeneous structures and a prepared to respond to requirements This person should be responsible CAS in the provinces of Milan and of the reception centres under their for coordinating the response of complex management including a wide Rome for conducting the interviews 33 regional responsibility. local health services, at different range of stakeholders . It paints a and focus groups was made based on picture of a system whereby measures levels, as well as the mental health the indications of the prefecture that The emergence of disorders connected departments, reception centres, are primarily aimed at finding quick authorised the visits. This may have fixes and spaces in which to place to trauma related to the context of associations, social services and caused a selection bias by including the origin and migration thus requires universities. This would ensure that asylum seekers during the long wait more virtuous CAS while preventing the for the commission's responses a structured and comprehensive patients with complex needs are participation of the more problematic approach. This should be the result of systematically provided with care. to applications for international ones. However, in many cases the open protection. synergistic coordination between the The public health services should atmosphere of discussion allowed for a different parties involved in responding provide medical centres integrated transparent debate and the expression to the issue of migration, which with the private-social organisations of criticism, including severe criticism, requires more than merely temporary for the assistance and psychological of both the system and the Prefecture. or emergency solutions. It has been rehabilitation of the asylum seekers. shown that, in order to effectively 4. In order to reduce the risk factors treat asylum seekers who have often of psychological stress and the been victims of traumatic events, it is re-traumatisation of asylum seekers necessary to put in place an integrated associated with the conditions of the reception system involving both public reception centres, the Prefectures institutions and private-social services, and local health authorities should and to work on supporting individuals ensure systematic joint monitoring to be resilient as soon as they arrive34. of the facilities and detailed monitoring of the quality of the In light of the above, MSF deems services provided. it appropriate to put forward 5. The Ministry of Health and local recommendations aimed at defining health authorities should develop concrete solutions to the issues appropriate guidelines addressing identified in this study, with the hope mental health of asylum seekers that that the institutions and competent capitalize on the existing experience authorities will find food for thought and best practices within the Italian that may be useful for making the territory. These guidelines shall necessary changes at the legislative respond in particular to a migrant level. context currently undergoing 34. Geraci S., Aragona M., Mazzetti M.: significant transformation which Quando le ferite sono invisibili. Vittime In particular, MSF recommends that: requires new tools to understand its di tortura e di violenze: strategia di cura. full complexity including the mental Rome, October 2014. health aspect.

1. Aragona M., Pucci D., Mazzetti M., 11. Lester H., Tait L., England E., Tritter 22. Silove D., Sinnerbrink I., Field Maisano B., Geraci S.: Traumatic J.: Patient involvement in primary A., Manicsvasagar V., Steel Z.: events, post-migration living care mental health: a focus group Anxiety, depression and PTSD in difficulties and post-traumatic study, British Journal of General asylum seekers: association with symptoms in first generation Practice 2006; 56: 415-22. pre-migration trauma and post- immigrants: a primary care study, 12. Llosa E. A., Ghantous Z., Souza migration stressors. British Journal Ann. Ist. Super Sanità 2013, Vol. 49 R., Forgione F., Bastin P., Jones of Psychiatry, 170: 351-57. N2: 169-75. A., Antierens A., Slavuckij Grais 23. Sironi F., Psychopathologie des 2. ASGI – Associazione Studi Giuridici R.F.: Mental Disorders, disability violences collectives, Essai de sull’Immigrazione, Il sistema and treatment gap in a protected psychologie géopolitique clinique, Dublino e l’Italia: un rapporto in refugees setting. British Journal of Éditions Odile Jacob, 2007. bilico, Open Society Foundation , Psychiatry, 2014; 204: 208-13. 24. Steel Z., Chey T., Silove D., Marnane 2015. 13. Mazzetti M.: Strappare le radici. C., Bryant R.A., Van Ommeren 3. Beneduce R., Jourdan L., Psicologia e psicopatologia di M.: Associations of torture and Raeymakers T., van Vlassenrot K.: donne e uomini che migrano, other potentially traumatic event Violence with a purpose. Exploring Harmattan Italia, 1996. with mental health outcomes The decision to launch a MSF Mission in Italy, as for other European countries, has the functions and meaning of 14. Medici Senza Frontiere, Fuori among populations exposed to been reached by the end of 90s. At this time, Medecins Sans Frontieres realized that violence in the Democratic of Congo, Campo. Richiedenti asilo e rifugiati mass conflict and displacement: the same people we assisted at thousands of miles away in other continents were Intervention. International Journal of in Italia: insediamenti informali e a systematic review and meta- Mental Health, Psychosocial Work the same we met here, in Italy and Europe, very often in extremely precarious and marginalità sociale, Marzo 2016. analysis. JAMA 2009, 302: 537-49. and Counselling in Areas of Armed vulnerable conditions. 25. Tol W.A., Barbui C., Galappatti Conflict, vol 4 (i), p. 32-46. 15. Medu - Medici per i Diritti Umani, Today MSF continues its work with the migrant population through several projects: Fuggire o Morire. Rotte migratorie A., Silove D., Betancourt T.S., 4. Bhugra D., Gupta S., Bhui K., in Gorizia, at the northeastern border with Slovenia, where we provide medical care, dai Paesi Sub-Sahariani verso Souza R., et al.: Mental health shelter and first assistance for the hundreds of asylum seekers who remained excluded Craig T., Dogra N., Ingleby J.D., and psychosocial support in l’Europa, luglio 2015. from the institutional reception system (in partnership with the local health authorities Kirkbride J., Moussaoui D., Nazroo humanitarian settings: linking 16. Miller K.E., Rasmussen A.: War J., Qureshi A., Stompe T., Tribe R.: practice and research. Lancet 2011; and the Red Cross); in Rome, where in April 2016 we opened a rehabilitation center exposure, daily stressors, and WPA guidance on mental health 378: 1581-91. for torture and ill-treatment survivors (in partnership with the NGOs Doctors Against and mental health care in migrants, mental health in conflict and post Torture and ASGI- Association for Juridical Studies on Migration). In Rome we are also 26. Tribe R.: Migration and mental World Psychiatry 2011; 10: 2-10. conflict settings: bridging the divide carrying out an echocardiographic screening activity aimed at identifying positive between trauma-focused and health, in Migrants and mental 5. Cantor-Graee E., Selten J.P.: cases of rheumatic heart disease within migrant population living in informal sites. psychosocial frameworks. Soc. Sci. health: working across culture and Schizophrenia and Migration: A In Trapani MSF teams of psychologists and cultural mediators provide psychological Med 2010; 70: 7-16. languages. Edited by Bhugra D., Meta-Analysis and Review, Am. J. Gupta S., Cambridge University support to asylum seekers hosted in extraordinary reception centers (CAS) of the 17. Morgan C., Mallett R., Hutchinson Psychiatry 162: 12-24, January 2005. Press; 2011: 261-273. province. G., Bagalkote H., Morgan K., Fearon 6. Dauvrin M., Lorant V.: Adaptation P., Dazzan P., Boydell J.,McKenzie 27. UNHCR, Global Trends, Forced Further, since the end of April Mission Italy is coordinating the search and rescue of health care for migrants: whose K., Harrison G., Murray R., Jones Displacement 2015. activities of the Bourbon Argos vessel, one of the three MSF ships prepositioned in responsibility? BMC Health Services P., Craig T. & Leff J.: Sample Rapporto completo su:. international waters north of Libya for actively searching for boats in distress. On Research, 2014; 14: 294. characteristics and compulsory https://s3.amazonaws.com shore, MSF mobile teams are working in Sicily and in Southern regions’ ports, at 7. Fazel M., Wheeler J., Danesh J.: admission: a report from the AESOP unhcr-sharedmedia/2016/ critical landings related to shipwrecks and incidents at sea, to support psychologically Prevalence of serious mental study. British Journal of Psychiatry, 2016-06-20-globaltrends/ and give first assistance to people who survived such traumatic events. health disorders in 7000 refugees 2005, 186 (4), 281-89. 2016-06-14-Global-Trends-2015.pdf resettled in Western countries: a 18. Moro M.R.: Psychiatric interventions 28. UNHCR, Operational guidance, sistematic review. Lancet 2005; 365: in crisis situations. The Signal 1994, Mental Health and Psychosocial 1309-14. 2: 1-4. Support Programming for Refugees 8. Geraci S., Aragona M., Mazzetti M.: Operations, Geneva, 2013. We would like to thank everyone who participated in this study and who made it 19. Patton M.Q.: Qualitative Research Quando le ferite sono invisibili. possible. Special thanks in particular go to: the doctors working in mental health centres and Evaluation Method, 3rd edition. 29. Van Ommeren M., Saxena S., Vittime di tortura e di violenza: and with local health authorities, for their active contribution and for the time and Thousand Oaks, CA: Sage 2002. Saraceno B.: Mental and social strategie di cura, Pendragon, 2014. health during and after acute expertise they devoted to this project; to the private social workers and organisations 20. Reed R.V., Fazel M., Jones L., 9. Hsieh H.F., Shannon S.E.: Three emergencies: emerging consensus? we consulted, for sharing their experience with us; to the operators and managers of Panter-Brick C., Stein A.: Mental Approaches to Qualitative Contents Bull World Health Organ 2005, 83: the extraordinary reception centres (CAS), for welcoming us; to Missione Italia, for their Health of displaced and refugee Analysis. Qualitative Health 71-76. organisational support in the research management, and especially to the Pozzallo children resettled in low-income Research 2005, 15: 1277-88. and middle-income countries: risk 30. Ventevogel P., Van Ommeren team, for their valuable contribution; to the residents of the CAS we visited, for their 10. Jones L., Asare J.B., El Masri M., and protective factors. Lancet 2012; M., Schilperoord M., Saxena S., willingness to tell their stories and their strength in overcoming unspeakable difficulties. Mohanraj A., Sherief H., Van 379: 250-65. Improving mental health care in Ommeren M.: Severe mental health humanitarian setting, Bull World 21. Santone G., Gnolfo F.: Immigrazione disorders in complex emergencies. Health Organ, 2015; 93: 666-666A. e salute mentale. Eventi psico- Lancet, 2009; 374: 654-61. traumatici nel percorso migratorio. Conferenza Europea SMES, Roma 2008. ART&DESIGN - ROMA ART&DESIGN

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Médecins Sans Frontières (MSF) is the largest independent medical humanitarian organization in the world. Founded by doctors and journalists in 1971, MSF delivers emergency aid to people affected by armed conflict, epidemics, malnutrition, exclusion from healthcare, and natural disasters in almost 70 countries. MSF offers independent and impartial assistance to those who need it most. MSF reserves the right to denounce forgotten crises, combat the inadequacy and abuses in the aid system and publicly support a better quality of treatment and medical protocols. In 1999, MSF was awarded the Nobel Peace Prize. www.msf.it

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