1. Immigrants and Equality within the Finnish Mental Health Care and Rehabilitation Ulla Buchert, Mirkka Vuorento Rehabilitation Foundation 27.8.2010

2. Earlier Research Results Immigrants, mental health and mental health service use studied most in the U.S., Canada, and Sweden; methodologically and conceptually problematic area Many immigrant groups face more mental health problems (Simich et al. 2006, Fenta et al. 2004, Hjern et al. 2004, Laban et al. 2004), but use less mental health services than native citizens (Kirmayer et al. 2007, Carta et al. 2005, Pérez- Rodríguez et al. 2005 ) Healthy migrant dilemma (Mossakowski 2007) vs. some groups higher risk of being hospitalised (Saraiva Leão et al. 2005, Cabral Iversen 2003) Limited language skills, economic barriers, somatization, negative attitudes towards medication, prolonged care within family, shame and stigma prevent immigrants from seeking help, accessing and using the mental health services (Whitley et al. 2006, Shin et al. 2002, Nadeem et al. 2007) Mental health services are not prepared to help individuals with differing language skills, severe traumatic experiences or differing concept of mental health and mental health care; developed working models f.e. Cultural consultation model of mental health services (Kirmayer et al. 2003), cross-cultural psychiatric knowledge and training (Boehnlein et al. 2008), knowledge and practical skills of psychosocial work and counselling (van der Veer 2008)

3. Special features of Finland Universal welfare state model: all citizens and permanent residents are guaranteed extensive social rights and entitled to use public health care Mental health services include i.e. preventive mental health work, appropriate psychiatric examination, crisis work, medication, psychotherapy, rehabilitation services and courses, hospital care, supportive housing (Pylkkänen 2007) Short immigration history: began only in the 1970s, immigration outran emigration in the beginning of 1980s, gradually increasing numbers of refugees, asylum seekers, returnees and labour migrants (Pohjanpää et al. 2003) In 2009 share of foreign nationals 2,9%, the five biggest groups Russians, Estonians, Swedes, Somalis and Chinese (Statistics of Finland 2010)

4. Research: Immigrants mental health, mental health care and rehabilitation* Goal to explore factors affecting immigrants mental health and possibilities to benefit from the Finnish mental health care and rehabilitation Research material consists of thematic interviews (n=95) Interviewees experienced professionals working with immigrants by profession psychiatrists, psychiatric nurses, public health nurses, psychologists, social workers, employment officers, rehabilitation advisers etc. work in social and health services, employment offices and NGOs in five biggest cities of Finland eleven had immigrant background Interview themes: immigrant clients mental health and attitudes towards mental health care, immigrant clients in mental health care and rehabilitation, Finnish language in the services, knowledge and expertise in working with immigrants etc. Research method (theory-guided) content analysis by using Atlas.ti * Part of the research project Immigrants as clients in the Finnish rehabilitation services funded by the Social Insurance Institution of Finland in 2009-2011

5. Main themes to be discussed further Main themes experienced professionals related to immigrants mental health, mental health care and rehabilitation Immigration-related stressors of mental health difficult background (war, torture, other traumatic experiences) integration process (language learning, employment etc.) Diagnosis of immigrants mental health problems depression, post-traumatic stress-disorder, anxiety, stress, traumas manic-depression, panic disorder, psychosis, schizophrenia Access to the mental health services immigrants negative attitudes, somatization of symptoms professionals attitudes, limited knowledge of working with immigrants

6. Finnish language, mental health, mental health care and rehabilitation two-way relation between Finnish language skills and mental health lack of Finnish language skills as an obstacle to mental health care and rehabilitation language interpretation within the mental health care and rehabilitation mental health services taking into account weak Finnish language skills Challenges of mental health care and rehabilitation complementary/alternative cures, means outside western medicine diagnosing, medical treatment, conversational vs. functional activities, psychotherapy, physiotherapy, individual vs. group services, hospital care

7. References Boehnlein James K et al. 2008: Cross-Cultural Psychiatric Residency Training: The Oregon Experience. Academic Psychiatry 32, 4, July-August 2008, 299-305. Cabral Iversen Valentina, Morken Gunnar 2003: Acute admissions among immigrants and asylum seekers to a psychiatric hospital in Norway. Soc Psychiatry Pychiatr Epidemiol (2003) 38:515-519. Carta Mauro Giovanni et al. 2005: Migration and mental health in Europe. Clinical Practice and Epidemiology in Mental Health 2005, 1:13. Fenta Haile et al. 2004: Determinants of Depression Among Ethiopian Immigrants and Refugees in Toronto. The Journal of Nervous and Mental Disease, Volume 192, Number 5, May 2004, pp. 363-372. Hjern A. et al. 2004: Social adversity contributes to high morbidity in psychoses in immigrants – a national cohort study in two generations of Swedish residents. Psychological Medicine, 2004, 34, 1025-1033. Kirmayer Laurence J. 2007: Use of Health Care Services for Psychological Distress by Immigrants in an Urban Multicultural Milieu. The Canadian Journal of Psychiatry, Vol 52, no 5, May 2007, pp. 295-304.

8. Kirmayer Laurence et al. 2003: Cultural Consultation: A Model of Mental Health Service for Multicultural Societies. Canadian Journal of Psychiatry, Vol 48, No 3, April 2003, pp. 145-153. Laban Cornelis J. et al. 2004: Impact of a Long Asylum Procedure on the Prevalence of Psychiatric Disorders in Iraqi Asylum Seekers in the Netherlands. The Journal of Nervous and Mental Disease, Volume 192, Number 12, December 2004, pp. 843-851. Mossakowski Krysia N 2007: Are Immigrants Healthier? The Case of Depression among Filipino Americans. Social Psychology Quarterly 2007, Vol. 70, No. 3, 290-304. Nadeem Erum et al. 2007: Does Stigma Keep Poor Young Immigrant and U.S. -Born Black and Latina Women From Seeking Mental Health Care? Psychiatric Services, December 2007, Vol. 58, No. 12, pp. 1547-1554. Pérez-Rodríguez Maria et al. 2005: Psychiatric care and immigration. Preliminary findings in a hospital in Madrid, Spain.Eur. J. Psychiat. Vol. 19, No 2, (107-111) 2005. Pohjanpää Kirsti et al. 2003: Maahanmuuttajien elinolot. Venäläisten, virolaisten, somalialaisten ja vietnamilaisten elämää Suomessa 2002. Elinolot 2003:1, Tilastokeskus.

9. Pylkkänen K 2007: Psykiatrian hoitojärjestelmät. In Lönnqvist J, Heikkinen M, Henriksson M, Marttunen M, Partonen T (eds.) Psykiatria. Duodecim, Helsinki. Saraiva Leão Teresa et al. 2005: Incidence of Mental Disorders in Second-Generation Immigrants in Sweden: A Four-Year Cohort Study. Ethnicity and Health, Vol.10, No. 3, August 2005, pp. 243-256. Shin Jinah K. 2002: Help-Seeking Behaviours by Korean Immigrants for Depression. Issues in Mental Health Nursing, 23:461-476, 2002. Simich Laura et al. 2006: Mental Distress, economic Hardship and Expectations of Life in Canada among Sudanese Newcomers. Transcultural Psychiatry, September 2006, Vol 43(3):418-444. Statistics of Finland 2010: Suomen väestö. www.stat.fi Van der Veer Guus 2008: Developing relevant knowledge and practical skills of psychosocial work and counselling. Intervention 2008, Volume 6, Number 2, pp. 132-139. Whitley Rob et al. 2006: Understanding Immigrants Reluctance to Use Mental Health Services: A Qualitative Study From Montreal. The Canadian Journal of Psychiatry, Vol 51, No 4, March 2006, pp. 205-209.

10. Contact: Ulla Buchert Rehabilitation Foundation Centre for Rehabilitation Research and Development ulla.buchert@kuntoutussaatio.fi tel. +358-44-781 3139 www.kuntoutussaatio.fi