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Sarah Hanafi: [00:00:05] Welcome to PsychEd, the Psychiatry podcast for medical learners by medical learners. In this episode, we're going to be exploring the mental health of immigrants and refugees. I'm Sarah Hanafi. I'm a third-year resident in psychiatry at McGill University and today I'm joined by a lovely group of experts, Doctors Andermann, Pain, as well as Norma Hannant, to teach us about this topic. And I'll maybe give everyone a chance to introduce themselves.
Dr Lisa Andermann: [00:00:37] Hi, I'm Lisa Andermann. I'm a psychiatrist at University of Toronto and working with immigrants and refugees in two settings: the New Beginnings Clinic at CAMH and also at the Canadian Centre for Victims of Torture. And I also work at Mount Sinai Hospital, where I'm with the Psychological Trauma Clinic, as well as the Ethnocultural Assertive Community Treatment team.
Dr Claire Pain: [00:01:04] My name is Dr. Clare Pain. I'm a psychiatrist. I work at Mount Sinai with Lisa Andermann, and I work in two settings or perhaps even three settings. Most of the week are Canadian patients who suffer from traumatic disorders. But on Thursdays I work at CCVT and our New Beginnings clinic at CAMH, exclusively with refugees, and I'm also part of the Ethiopian project where we, it's different now with Covid, but we used to send about 100 volunteers a year to partner with Ethiopians to teach into their graduate programs. The first program was psychiatry.
Norma Hannant: [00:01:49] And I am Norma Hannant. I'm a social worker in the New Beginnings Refugee Clinic at the Centre for Addiction and Mental Health.
Wiem Sieffien: [00:01:59] Hi. And I'm Wiem Sieffien. I'm a third-year medical student at the University of Toronto.
Randy Wang: [00:02:05] Hi, I'm Randy and I am also a third year medical student at Uoft.
Sarah Hanafi: [00:02:10] So we're very excited to be joined by the team today and over the course of this episode we'll be covering a number of learning objectives. So first, to explore the social, political and legal context of refugees and immigrants presenting with mental health concerns. Second, to appreciate the specific mental health needs of refugee and immigrant populations in Canada. And third, to describe the clinical approach to providing mental health care for this population. Maybe I'll hand it off to to Randy to get us started.
Randy Wang: [00:02:44] Sure, Sarah. So just a bit of a very quick and dirty primer on immigration patterns in Canada. So immigration first started in the 1600s by British and French settlers, and immigration was really predominantly from Europe until the latter half of the 20th century. And nowadays, approximately 20% of the Canadian population are comprised of immigrants and also more recently, we have more visible minorities who come from China and South Asia. So I am curious to know from our expert panel, how have the changing trends in immigration been reflected in psychiatry practice, and how have healthcare professionals adapted to treating more diverse populations?
Dr Claire Pain: [00:03:43] I don't know that I personally see a huge difference in the number of people from different countries. For as long as I've been working in the field, which is about 20 years, CCVT Canadian Centre for Victims of Torture have always seen about refugees from about 150 countries.
Dr Lisa Andermann: [00:04:03] Maybe I'll jump in. I guess it also depends what immigration categories those immigrants or refugees are coming from, because we tend to see in our clinics people who require psychiatric assessments to assist with their refugee process, things that their immigration or refugee lawyer needs to help them prepare for their hearing. So in that case, as Dr. Pain said, we are seeing people from many, many different parts of the world. And as world news and frontline headlines change over time, we tend to see different populations kind of even over the last 10 or 15 years where, you know, now these days we're seeing a lot of people from East Africa, from Nigeria, and in previous years we might have been seeing more people from Colombia or other parts of South America or Mexico. So those are kind of smaller changes that we can see, that doesn't reflect on on a lot of the immigrant population who are coming by choice to Canada and setting up their lives here to go to school, to work and to do all of those other things who may not come under psychiatric observation in any way. So we're seeing a kind of very limited slice of the population. Norma, do you want to add anything?
Norma Hannant: [00:05:28] Well, I think in terms of, you know, just adapting to like any adaptations to diverse populations, I think also just having, you know, the added benefit within, you know, the New Beginnings clinic as well, to have interpretation services, which I know that that's something that is not readily available in a lot of rural settings. And I know as well, you know, with having IFH coverage and so forth, that can also be a big challenge with a lot of the populations that we see.
Randy Wang: [00:06:07] Okay, great thank you. And Dr. Andermann, I'm really glad that you brought up the different classes of immigrants, because that's actually the next thing we wanted to ask about. So a bit of background for those who are not familiar with the system. In Canada, we have a few different classes of newcomers, so we have economic immigrants, so those who come to work and then we have immigrants who are sponsored by family and then finally refugees. And these people are defined as those who have suffered from persecution for reasons of race, religion, nationality, membership in particular social groups or political opinion in their home country and the process is actually quite complicated. So in order to qualify for refugee status, they have to make a claim at either port of entry or in IRCC office and then later attend a hearing before the government in the end makes a decision as to whether or not they actually get refugee status. And I know this has been touched on already in some of the answers, but I just really want to hone in on any specific challenges that our experts here have identified in providing care to different classes of newcomers.
Dr Lisa Andermann: [00:07:37] Well, maybe I'll just start by saying that refugee claimants, the people who arrive here and then make their claim for refugee protection are under an enormous amount of stress. So in in one sense, they may feel a little bit safer than they did when they were back home because they're now in a safe country, but they don't know if they're going to be allowed to remain in that safe country and that waiting period while they get their paperwork in order and find a shelter or rent an apartment and get a lawyer and start to figure out the process of how they're going to be staying here can sometimes take many, many months or even years to wait for that hearing date that we've mentioned, which sometimes gets postponed or there's not enough information the first time or the wrong interpreter came on that day. I mean, they're, you know, very rare people get their answer that they can stay on the actual day of the hearing itself. And so when people are in limbo, that can definitely add to their mental distress and sometimes even worsening of symptoms the longer that people are here waiting for, for the answer about whether they're allowed to stay. In contrast, government assisted refugees, like many of the Syrian refugees that were brought to Canada in 2016/17 and are some are still continuing to come now are brought from refugee camps either in the country where the problems are happening or somewhere next door where they've sought refuge, to Canada. So when they arrive, they have OHIP, they have funding for their first year and so they have a lot easier time seeking health care, finding a family doctor who's going to accept them. Any family doctor technically should be able to accept the IFH or Interim Federal Health funding, but you'd be surprised how many people are reluctant to do that because they're not familiar with it or because they just don't want to do the extra steps it takes to get that paperwork.
Dr Lisa Andermann: [00:09:39] But these people are entitled to, I mean the refugee claimants with IFH, are entitled to the same health care as as most people who come as government assisted refugees. So for things like obstetrical care, prenatal care, all of those things are are covered. And some mental health care is also very easily covered if you just familiarise yourself with with that system. And then once people become permanent residents, you know, in some ways they know they're here to stay so some of that stress may have dissipated, but then there may be other stresses of adjustment, of acculturation, of worrying about family members who are left behind and maybe are not able to join their families here in a timely way if and sometimes not at all for various reasons. So there are many other kinds of post-migration stressors that come into play for all three categories of these populations and for immigrants, as well as a fourth category, the people even who choose to come here or even who choose to move from one part of Canada to another and settle in a new province, as some of our learners might do when they graduate from medical school, you know, there are still adjustments. You miss friends, you miss home, you miss the food, you miss, you know, a lot of different things. And there can be a lot of nostalgia and sort of feeling torn between two places, um, that can affect people's mood and mental health as well.
Randy Wang: [00:11:09] Okay. Thank you, Dr. Andermann. And you just keep reading my mind here, because when you mentioned that, you know, the stress doesn't really end after a specific period of time and even after years, you know, people still experience stressors and different kinds of stressors. That brings me to the next thing I wanted to discuss, which is the healthy migrant effect. So the healthy migrant effect is an observed phenomenon where the health of immigrants starts off as better than that of the average Canadian born person, but it slowly declines with years spent in Canada and after 20 years it actually becomes equivalent to the health of Canadians. And this has typically been explained by the social determinants of health and how they really negatively affect immigrants and refugees. A study by Robert and colleagues in 2012 on 7700 immigrants found that upon four years of arrival, 29% of respondents reported what they called emotional problems such as loneliness, sadness and depression. Such issues were found more commonly in females. They also found that refugees were more likely than other classes of newcomers to suffer from emotional problems. And finally, they found that 16% of respondents reported high levels of stress, mainly due to employment and financial concerns. So my question to our experts would be how have you seen the social determinants of health affect newcomers in your psychiatry practice? And what are some ways we as health care workers can mitigate the negative effects?
Norma Hannant: [00:13:04] So, you know, I think advocacy is something that can really help many refugees who are experiencing a lot of distress. I know within our work, like even saying something simply as talking about their rights, particularly around legal aid, for example, we have had a lot of clients that have been really terribly misinformed around their rights to have legal aid if they do have limited income. So oftentimes they might be going with someone that they believe they have to pay, which is, you know, spending thousands of dollars and creating so much more financial stress for them. Also, in terms of their right for housing oftentimes we have stepped in to provide some advocacy for clients that are living in refugee shelters and are being pushed into maybe some rural settings where they won't have access to the mental health supports that they truly need that may not be available there or the limited interpretation services that might be that may not be available in more rural settings. And also in terms of being able to find different forms of employment services that can assist them with those barriers of accessing jobs, which is extraordinarily challenging if you don't have any Canadian experience.
Dr Claire Pain: [00:14:34] You started talking about the healthy migrant effect. It's hard to know, but certainly with the refugee population, it seems that really in order to get to Canada, to work your way through the bureaucracy, the complexity, the danger, the language barrier, you have to be a remarkable person or family, and that may be a kind of bias. So we see refugees anyway who are healthier than the normal population. They may have had hard lives, but they are future directed, hardworking people. I think I'm going to bring my bias in here, what I've learned. So all my population from when I graduated in 1992 were always trauma patients who were Canadians, who weren't immigrants or refugees. And then I started working with refugees and what I realised is, and the literature bears this out, that if you have a childhood where your family respected you and cherished you, whatever happens later as an adult is far less difficult than if you've had a very compromised childhood. I'm not saying that things that happen to adults from good families or well loved children don't struggle and suffer. But there's quite a difference. And I think that the people who come here often are people who have that confidence and that daring to jump into an unknown future. We're always talking about refugee pathology and really the most important thing is to see these people as the true, remarkable new Canadians, if we can help them stay that they are and they enormously contribute to our country. I'm not sure it's pills, therapy and programs. It's more like the individual encounter matters more than one can possibly imagine.
Sarah Hanafi: [00:16:33] I thought that was a really refreshing perspective Dr Pain. I know you know myself, the few patients that I've had the privilege of working with and who are coming from these sorts of experiences, I've certainly been struck by the resilience that they show and I think it maybe challenges us. You know, as you say, we're so stuck on finding pathology, but maybe it challenges us to to work on being promoters of resilience and really looking to to highlight and support individuals and allowing them to kind of reconstitute in the face of what's really remarkable adversity that they face when they are coming to Canada and having to go through this arduous process of, in the case of at least refugee claimants can be a very long period of uncertainty. I think also the point you make regarding the hearing and the challenges around that and the the value sometimes that even having a report from a psychiatrist, I think that'll be an interesting point to touch on maybe later around what's the role that professionals can play in being more of an advocate, whether it's other kind of multidisciplinary team members like a social worker or a psychiatrist in terms of recommendations surrounding their hearing. But it certainly challenges us to work, I think, in different ways.
Dr Lisa Andermann: [00:17:58] Yeah. I have another example I can add to that and I agree with everything that Clare and Norma have shared already. You know, it's very hard to separate the topic of social determinants of health from this healthy immigrant effect because, you know, when people come and their expectations are high that the future is going to be bright here and then they may find themselves unemployed, their credentials unrecognised, unable to achieve the kind of things that they did back home or having to retrain or work overnight factory shifts and PSW jobs exposed to Covid and all these other things. The unhealthy diet that comes with that, the poverty, the the housing stresses, you know, make it very difficult to achieve a sense of wellness, even if the goal of being now established in Canada is met. And there are also a lot of pressures to maybe support family members back home and send money back even from, you know, the pittance of OW or even ODSP to scrape together children's tuition fees when single parents are here on their own and supporting family members can be very, very difficult. So the one example I wanted to share was of a woman who had been in detention in her country. She had had some experiences in jail that were very traumatising and then here in Toronto, the only place she could afford to live in was a basement apartment with no windows, which was hugely re-traumatising for her. And she's referred to me as a psychiatrist, of course she has PTSD symptoms, of course she has nightmares and re-experiencing when really we have to work with social workers to get her into a second-floor apartment with a window. You know, it's very important to have this kind of teamwork because she doesn't need Prazosin for nightmares, she needs, you know, a balcony and and fresh air from a window. It's not a medical solution to these kinds of problems.
Sarah Hanafi: [00:20:04] Maybe on that note, I think it'd be helpful to hear a little bit more about how these patients are typically presenting and the clinical realm. I think Wiem had some questions on that regard.
Wiem Sieffien: [00:20:15] Yeah. Thank you, Sarah. So I think I wanted to kind of I was a question I asked was kind of what kind of presentations do people from immigrants and refugees and newcomers present with? And I did a little search on that, and I found that the most common mental illnesses in this population are depression, anxiety and PTSD. And what I found actually, that they experience very similar distress to Canadian born individuals but what struck me is that despite having similar levels of distress, they're a lot less likely to seek or be referred to mental health services and that was was very surprising for me. And then I wanted to kind of look more into that. And it seemed to be there's a lot of barriers that this population face that are unique to this population, including some cultural and linguistic barriers as well, and stigma, obviously. So I wanted to ask our panellists here, what type of barriers do you see in your line of practice that prevents people from seeking care?
Dr Claire Pain: [00:21:15] So this is where we get all muddled up, I think, because people have distress and suffering and then suddenly they're diagnosed with depression, which means pills, admission, therapy in our in our culture. But I think that feelings of depression and as Lisa said, the awful feeling of, for everyone refugee or immigrant, the huge deal is you've lost everything you've ever known and valued, maybe because you have to. But there are enormous amounts of emotions around that and uncertainty about the future. But I think sometimes we over-diagnose, those are legitimate feelings but the treatment may absolutely not be psychiatric as Lisa just said, good settlement services, proper housing, ESL. So again, the great, great privilege of working at the two clinics that we work in is that we have wonderful social workers and settlement counsellors and a huge amount of treatment is not psychiatric. We get the referrals because we're psychiatrists, but the treatment is within the social determinants of health. A non-psychiatric treatment to manage a psychological presentation.
Dr Lisa Andermann: [00:22:46] Maybe to follow up on on Wiem's barriers to seeking mental health care. You know, I think many of the patients that we see from many parts of the world have no experience of the formal mental health care system, of a psychiatrist, of knowing what a psychiatrist does. And in many parts of the world, you know, where there is psychiatry, it's kind of reserved for the most severely psychotic and maybe behaviourally disturbed kinds of of patients that do exist all around the world in the same percentages as they do, because these are universal diagnoses like schizophrenia, bipolar disorder. We can find them all around the world. Um, but those aren't the kinds of patients that were mostly seeing here. We're seeing regular people who had normal lives and families and got caught up in some kind of, you know, war or terrorist problem or family problem or they're LGBT in a country that doesn't allow LGBT. They're just normal folks who were in the wrong place at the wrong time and had to leave and find safety here. So not people that were ever really going for counselling or knowing what that is. So psychoeducation and explanations about who all of our different roles and what we do is very important and when lawyers send referrals for psychiatric assessments, most of the time the person we're seeing has no idea really why they're coming to see a psychiatrist at all. And so explaining to people a biopsychosocial model of assessment and treatment and including cultural elements to try to understand how people are connected here, what are the stressors and supports that people are connected with or not, you know, making sure everybody has a settlement agency, community support, inquiring about family supports both here and far away, those religious supports are also hugely important to people. And if they're not connected to those things, it's our it's our job to try to help them connect to to some of those things, because that will go a long way to improving their mental health.
Sarah Hanafi: [00:25:08] It's been very helpful to learn from all of our experts about the unique approach to caring for newcomers with mental health concerns and trying to take more of a resilience-based approach and to think much more broadly in terms of the social context and to work within teams to try and support patients in having access to to necessary services and try to address many of the adversities that they're facing as they're adjusting to their new life in Canada. Now, one thing that we were actually hoping to touch on within the clinical approach is maybe some more practical concerns. So, you know, as as I think, Norma, you mentioned interpretation services is definitely something that can be very hard to come by for some of these patients. For many of them, it can make a huge difference if they're able to express themselves in their mother tongue. And I was wondering if you could all give some a few practical tips for working with interpreters, because I know, at least in my experience, I've seen some huge variation in how people approach this.
Norma Hannant: [00:26:14] Well, I think one that we try to do within the clinic is always having a professional interpreter and again, we do have the luxury and the funds to be able to provide that. Whether it is I mean, obviously right now regarding Covid, we're not doing any in-person appointments unless it's an emergency situation. But to be able to provide as much, you know, in-person, also asking someone in terms of who they would feel more comfortable with oftentimes as well is to, you know, there have been times where family members will also want to interpret, so really discouraging that letting them know that, you know, they can be part of maybe the the end of an appointment if the client consents to that to be able to add some feedback. But that can add a lot of discomfort for someone who's coming in to tell really personal information about their lives. And also maybe, you know, letting clients know about what it entails to have an interpreter confidentiality, because oftentimes there is a fear that someone is within their community and will be spreading this information to other people. And again, that is a luxury that we have. I know that that is not often the case in smaller settings. And one thing that we've also been able to provide for a lot of clients as well is with Ontario Works, for example. So they will be given an interpreter for the first the initial assessment and then after that, they have to actually find someone. So there has been some pretty difficult circumstances where someone might be isolated and they'll be using their neighbour as their interpreter to find out about very personal financial information about them or someone in their family who they really don't get along with, and they really don't want them to know this specific information but have no one else. So often times we've been able to organise that through our clinic to have an interpreter available for them and coordinate that in our services.
Sarah Hanafi: [00:28:08] Okay. And I'm wondering actually, you know, because as you mentioned, ideally you want a trained interpreter, but one might not always have access to that and certainly an interpreter that's used to facilitating mental health assessments. I'm wondering what kinds of instructions you might give to interpreters who are participating in an assessment.
Dr Lisa Andermann: [00:28:31] Well, I think a mental health assessment requires a very careful translation of what the patient's words are, because we pay attention to cadence, rate and rhythm of speech. We want to know about thought process, disorganised thoughts and so we do want to make sure that the interpreter is not inadvertently or trying to help us by cleaning up the way that the patient is speaking, by editing or making things sound more organised than they are. This is especially important when we're trying to rule out a diagnosis of psychosis and then being able to get at the exact words that we're trying to use to find out about perceptions, paranoia, delusions, hallucinations, you know, asking someone, are you hearing voices? You know, can be a very confusing kind of question if it's not translated properly and then translated back to you in English. There's a lot of room for confusion. And on top of that, there are also the whole cultural overlay of what these things mean to that person. If it's part of a religious understanding or if it's part of a kind of cultural understanding of how things work, maybe after a person's died that you may hear their voice, something that could be very normal, but that we could misconstrue as a symptom of mental illness. And so there's another kind of of interpreter, not just the language interpreter, but also getting the advice sometimes of a cultural interpreter who can give us a sense of whether some of these beliefs or behaviours are actually making sense in the person's culture. And so the typical language interpreter may not be comfortable to share their opinion on that. They're there to kind of simply translate what's going on in the session. But it can be very helpful maybe to contact a community agency or a worker from a settlement agency who may know something about where the person's background is from, and to be able to give some idea. I mean, the family can also provide some of that background of whether this person's behaviour or presentation would make sense in their culture and how they would understand it.
Sarah Hanafi: [00:30:42] So it sounds like, you know, beyond actual interpreters, there's also utility around having cultural brokers to help understand more of that cultural context and the information that's being provided. Um, I think it's really helpful to hear that piece and I'm sure there's also a lot of advocacy that's done by health care workers surrounding access to interpretation services. Um, I've also kind of wondered and had some experiences myself when it comes to advocacy around legal status and immigration status. I know this past year with some of the patients I was working with who were refugee claimants, um, there were requests by, by lawyers to write letters and support for their hearing, as well as recommendations surrounding accommodations to the refugee hearing in light of their symptoms. I was actually hoping to maybe explore some of your experiences around this. Are there any practical tips for how our listeners can effectively advocate for their patients in these circumstances?
Dr Claire Pain: [00:31:51] All the time one wants to write in a report, "this is the most remarkable person who's been through terrible times, but who's clearly on top of things or who's struggling a bit, but who has every we have no reason to expect they won't find their feet and do well". But you can never write that in a refugee report. If you advocate in any way for a refugee, any good lawyer knows that that's death to the any kind of psychiatric report that will be taken seriously by the system. So it's important to know when not to write down the kinds of things that we might want to. I mean, I think it was mentioned earlier about advocating for housing, advocating for for a bunch of other things. But certainly in a report, it's very important people know that. Sorry there were just two little things I wanted to add to the interpreter thing. One is if you don't have the luxury, as we do of professional volunteers, when you have to work with volunteer interpreters who aren't family, you're often dealing with the same group of people who've suffered torture or imprisonment or. And I think it's worthwhile to always be quite respectful that you may be dealing with somebody whose own family members may have gone through the same thing or they may have. So I think that kind of appropriate checking that they're okay and if they're not, that we can guide them to services or debrief with us. The other thing I mean, Lisa's completely right, cultural brokers are so useful. But sometimes I hope this sounds all right. I found I had a complex woman from the islands and one of my colleagues, dear friend and colleague at work, you know, within the bounds of confidentiality. I said, what does this mean? And he immediately knew. So people who come from a similar culture or community, we all come from somewhere, right? Most of us have roots elsewhere.
Sarah Hanafi: [00:34:07] No, I think it's helpful to hear how how we also bring in our own lens and our own understanding from our from our personal backgrounds as well as like how do we ensure the safety of all who are involved in the assessment. I wonder, though, like specifically, say, around a hearing and those who might have a trauma history, how like the way in which the hearing is conducted affect like the reliability of the report, if they have certain symptoms related to PTSD, how do you maybe prepare patients for that?
Dr Lisa Andermann: [00:34:43] I think that kind of gently with reviewing the basis of claim narrative and going through it with people will give you a sense of how they will be able to speak about those events at the hearing. And so it gives you a chance to notice if there are any gaps in the story, if there are times when people need to pause and maybe need extra time to collect themselves, to have a break, to have a glass of water, to to kind of have a support person coming with them to the hearing. Those kinds of things are the sorts of accommodations that you can advocate for and you can also do some psychoeducation to the the hearing to explain that people who've been through trauma and many people have been through more than one event and they may be recounting events, let's say, in the case of somebody who's escaped a situation of domestic violence. There have just been so many incidents like dozens or hundreds of incidents over, you know, the 5 or 10 or 15 years that they've been married and kept in a home, you know, where so many things happened. You can't possibly remember each event, what day it happened, which time you went to the police station to report it and which time you just, you know cleaned yourself up at home like there are just so many. And to translate that into like a sequential narrative with dates and times is very difficult. So being able to explain that, you know, the way our memory works when there's been a trauma may be, you know, to go into a flashback, when you're talking about a piece of the story that you're not there to remember, Oh, it was two men in a green car, it might have been five men in a black car. Like your life was in danger, it wasn't about taking in those details and being able to tell them back in the same way, you know, 5 or 10 years later, every time you tell the story, you may tell it a little bit differently depending on the setting, how stressed you are, who's listening, what the information is going to be used for, and and so on. So Doctor Pain had already mentioned something about reliability, and that piece is is very important that people can still have been through lots of difficulties, even if they may not remember exactly specific details. And avoidance is also a big part of coping with trauma. And many people may want to push away or not go to certain places from their past because it's just too too difficult and brings up too much emotion for them. And so they may robotically talk their way through their narrative without showing any emotion, which is also not what you want at the hearing when you're talking about these kinds of things. And on the opposite side, you don't want somebody to be so flooded with with feelings that they can't tell their story at all. So I think the more times people practice and have a bit of exposure, not in the way of exposure therapy, but in the way of just being able to tell their story from beginning to end and kind of get through it and kind of be able to go on from there is is kind of helpful in preparing people for their hearing.
Dr Claire Pain: [00:37:58] I think that the actual experience of interviewing a patient and and doing the report or working with them is an opportunity to coach the patient. Insofar as I find myself saying, "you're doing a very nice job with me, you're so respectful, you have great eye contact. If you can just focus on the question I ask you because it's like practice for the judge. I know you want to tell your story, which is great. You can tell me anything, but right now, practice". So you kind of work with a patient and let them know, the judge may ask you about your assault, they may ask you, "do you feel able to say it?" Because if you don't just say, I'm so sorry, I can't. It's like coaching people to be not advocates for themselves but feel empowered to not let the hearing get away on them. That they can pause, have a sip of water and focus on the questions. But knowing what's in store is enormously helpful.
Sarah Hanafi: [00:39:05] Sounds like a lot of that anticipatory guidance can really be a huge support to patients as they prepare for undergoing this process.
Dr Lisa Andermann: [00:39:14] There are opportunities to visit the hearing venue when when we're not in Covid and hearings are taking place in real time and a lot of claimants don't know about that. So there are community agencies that will take you for a tour and you get to see the room while it's empty and figure out where you're going to sit and where the judge sits. And that can be very helpful in reducing some people's anxiety.
Wiem Sieffien: [00:39:37] Thank you so much. These were very great tips. And I think for me as a medical student, I learned a lot during this time. I think, although I thought I prepared for the episode, but I learned so much from all the experts. And I want to thank you all. I think just to kind of just summarise or to wrap up, what are some take home messages or final words that you want to make sure our audience leave this episode with.
Norma Hannant: [00:40:02] For me as a social worker, when I started working at New Beginnings, I assumed that a big portion of my job was going to be involving processing people's traumas, and I was nicely surprised to learn that that was actually something that people really didn't feel that they needed at the beginning of their process of settling into a new country. Right. That might be something that they're interested in doing years from now, but there's also different forms of doing it and the having connection to their communities, finding spiritual and religious communities that they're connected with, being able to find housing, getting a good lawyer, going to ESL classes. Those are the things that, for me, I really learned in terms of being able to help them to reduce the distress of all of these huge shifts coming to a new country.
Dr Lisa Andermann: [00:41:04] I would add that this work is very, very rewarding. It might sound challenging, it might sound intimidating writing reports for lawyers, but refugees are an amazing population to to work with. We learn new things every day about every corner of the world and people's resilience and what's important to them and what keeps them going. It's just very rewarding. And when people come back with good news that they've passed their hearing or you're able to do an assessment and write a letter that prevents somebody from being deported and they're allowed to stay after ten years of limbo, you know, nothing beats that.
Dr Claire Pain: [00:41:44] Yeah, I agree. I think I actually think this is advice for all of us with patients, but in particular with refugees. It's like they're, as Lisa said, they're ordinary people, they're ordinary folk caught up in bad situations who've managed to flee for their lives successfully to find safety in Canada and then cross the next hurdle, which is to be accepted here. So I think that one of the reasons I love working with refugees is I'm a learner. Like, how did you do that? Well, what was the worst thing about? How did you overcome it? Where did you find support or guidance? You know, it's like I will never, thank God, have to do what they've done. So I'm in this wonderful situation where I can actually respectfully understand more from someone who has first-hand experience about resilience, about and it helps me understand what about human beings we need to focus on and support.
Sarah Hanafi: [00:42:48] Thank you all so much. We're very privileged to have had your time for you to be able to share this this expertise with our audience. So once again, we wanted to thank Norma Hannant, Dr. Lisa Andermann and Dr. Claire Pain. You've been wonderful and we're really excited to share this episode with our audience. We also want to thank you all for listening to PsychEd. Feel free to contact us on Twitter @Psychedpodcast or check us out on psychedpodcast.org. We love hearing from you and your feedback and your questions are vital to the podcast. Take care.
Sarah Hanafi: [00:43:23] PsychEd is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced by Wiem Sieffien, Randy Wang and Dr. Sarah Hanafi. The episode was hosted by Wiem Sieffien, Randy Wang and Dr. Sarah Hanafi. Audio Editing by Randy Wang. Our theme song is Working Solutions by Olive Musique. A special thanks to the incredible guests Dr. Lisa Andermann, Dr. Claire Pain and Norma Hammant for serving as our experts for this episode. You can contact us at psychedpodcast@gmail.com or visit us at Psychedpodcast.org. Thank you so much for listening.
Wiem Sieffien: [00:44:19] I was always interested in immigrant and refugee mental health, and I had the opportunity to take the Immigrant and Refugee Mental Health Project's online course, which is a free self-directed training course that is offered by the Centre for Addiction and Mental Health. It was a great learning experience. It provided me with a comprehensive overview of immigrant and refugee mental health, some of the key principles, and I learned a lot about the influence of cultural on mental health and mental illness. I also learned some great tools and resources to help me in my clinical training, which I really found helpful during my clerkship. I would highly recommend this course and the link will be posted in the show notes, so I recommend checking it out.