The case of Susan - Essay Example

The case of Susan Introduction: The patient in question was a Turkish lady d Susan, who came to England as a refugee with her husband and three children, now aged 9,6 and 4 respectively. She found herself alone after her husband committed suicide a year ago. Thereafter she moved in with a friend in Kent where there is Kurdish community from her village in Turkey. She began to develop mental problems such as panic attacks and was treated with anti depressants as a temporary patient. Two months later, she was treated again after overdosing herself on tablets. A few weeks later, her friend communicated her inability to continue to accommodate her and she is now living in a lodge with her children while the local council is arranging housing for her. Her children do not go to school and she has been referred to the mental health trust, where I have been one of the persons assigned to perform a mental health evaluation with the help of an interpreter. Legal aspects to be considered in Susan’s case: As a refugee, Susan does not yet have the legal status necessary for employment. The curtailment of the right to freedom of movement and employment places her in a legally indeterminate state, ridden with anxiety, especially since legalizing residence has been refused arbitrarily in some cases (Amnesty International, 2004). Since 2003, with the introduction of Section 55 of the Nationality, Immigration and Asylum Act 2002, many claims of refugees for asylum have been rejected under this provision, on the grounds of delay in filing their claim for asylum, thereby leaving them destitute (Williams, 2004). Although Susan, being a refugee as defined in the 1951 UN refugee convention, may be entitled to remain in the UK for a provisional, limited five year period; however permanent residence is not guaranteed since it is to be evaluated on a case by case basis (House of Commons, 2005). These changes have been implemented as of 30th August, 2005 and have proved to be detrimental to the mental health of refugees, since they generate high levels of anxiety with placement remaining indefinite. According to the Medical Foundation for the Care of Victims of Torture (2003), there is a high level of risk of suicidal tendencies among refugees. There have been five Directives introduced in Europe, including the Reception Directive which ensures that refugees receive necessary health care, especially emergency treatment (Anonymous, 2005). However, with the increasing strain placed on the health care system in the UK and the perceived abuse of the system by refugees, new proposals introduced by the Government are regulating the provision of free secondary health care services and withdrawing it for those refugees whose asylum bid has failed (Hargeraves et al, 2005). Only infectious diseases are still freely treated. Further legislative moves have also begun to restrict welfare benefits for refugees and asylum seekers which could pose further risks to the health and psychological wellbeing of refugees by forcing them to live in poor conditions (Tribe, 2005). All of these aspects would also apply in the case of Susan. However, I have found some difficulties in my efforts to discover how well informed Susan is about her legal status and the status of her application for permanent residence. The reason is that I have to work through an interpreter and find it difficult to discuss such sensitive issues that involve issues of confidentiality and legality. Therefore, it is difficult for me to assess the extent to which Susan’s indeterminate legal status may be impacting negatively on her mental health, especially since her husband is also dead and her friend has now denied her shelter as well. Social Aspects: In Susan’s case, it appears likely that her mental condition and panic attacks may be closely related to delayed bereavement for her husband and the resulting anxieties (Burnett and Peel, 2001), especially since she has three children to support. Social isolation is also likely in her case, especially since her friend is no longer able to support her at her residence. Research has also shown that to a large extent, it is the stressors in the environment that may be responsible for psychiatric and psychological disorders in refugees (Vega et al, 1987) and since Susan has been persistently experiencing attacks of depression, there is a strong indication that her mental state is being severely affected by the trauma in her life in the past year. Bach et al (1982) have highlighted the proclivity of refugees to experience mental problems because of the problems they may have experienced in their home country and the tortuous conditions that they may have run away from. It appears that Susan is suppressing memories that may be causing her pain, however it has been difficult thus far to get her to speak about them and relive her mind of the anxiety and pain that she may have experienced. The pain of her husband’s death may also be festering in her mind, however the intensely personal nature of the problem seems to make it difficult for Susan to communicate these problems, even to the interpreter who is also from her own country. Issues of trust appear to play a significant role in Susan’s case, and it is possible that her already shaky trust in a new land and people may have been further eroded by the rejection of her friend who had supported her for so many months. As Meucke (1992) has stated, refugees have often faced fear and oppression, lies and deception from those they trust in their home land. They may have learnt to lie and hide their true feelings and views, for fear of being exploited or persecuted on account of those views and vulnerabilities. I have found this to be a huge problem in Susan’s case and it appears that her trust has taken a beating, so that she is not comfortable confiding in anyone. Added to the trauma that she has already experienced while fleeing her country, the loss of her husband and the support of her friend have further reduced her willingness to trust and share her fears and worries, and health problems so that they can be effectively treated. I have also found the inability to communicate in Susan’s language a big barrier, since language is so intimately associated with cultural norms. A study by Shah and Priestly (2001) revealed the lack of cultural sensitivity of health care services, especially where the needs of Muslim and Asian patients was concerned. This has been a difficult issue to deal with, since Susan’s inability to communicate freely could be linked to inadvertent cultural insensitivity of the team that is treating her. Ethical issues: One of the most difficult issues in dealing with Susan has been the question of ethics and confidentiality of her health issues. Since our team is working through interpreters, there is a great deal of uncertainty about how exactly to ensure that confidential medical information pertaining to Susan’s condition is not made available to other parties through the involvement of the interpreter. Since the interpreters are not professional health providers, it is difficult for them to conceive of the legal and ethical implications of patient-provider confidentiality. Although every effort has been made to ensure that interpreters are made to understand the ethical issues involved, there is still uncertainty attached to this aspect. Moreover, it has also been difficult to secure the services of the same interpreter each time while dealing with Susan, and this has only compounded the problems. The difficulties and limitations associated with using such ad hoc interpreters have also been highlighted by Putsch (1985:3344-48). Article 8 of the European Convention of Human Rights also mandates the protection of the privacy of individuals, and this places a legal and ethical duty upon interpreters never to disclose confidential health information. However, under the ad hoc circumstances we are working with, no such guarantees can be ensured. Moreover, the question of mental health care involves complex decisions about health care where Susan’s individual autonomy is involved (Austen et al, 2005), therefore the difficulties in communication have proved to be a very thorny problem. The element of trust is vital in the relationship between a health care provider and a patient and obtaining informed consent for treatment is a vital aspect.(Putsch, 1985). Conclusion: On an overall basis, I would rate the linguistic problem as being the greatest difficulty in treating this patient. If I had been conversant with her language and cultural norms, I feel it would have been far easier for her to build trust enough to communicate her problems freely. Moreover, it appears that in Susan’s case, there is also a great load of trauma that she is carrying in her mind, through a series of tragic events, including the suicide of her husband and what she may perceive as the betrayal of her friend through her failure to support her. Moreover, using interpreters on an ad hoc basis and having to communicate through them is the most difficult aspect of all because it does not provide for that one on one contact which can be so informative for a health care provider. This is not a problem I would face with a family that knows English, since it would be easier to slowly build the levels of trust necessary for the patient to discuss her problems for effective treatment dispersal. References: * Amnesty International, 2004. “Get it Right: How Home Office Decision Making Fails Refugees”. London: Amnesty International. * Anonymous, 2005. “Refugee health: Questions for a new Commissioner.” The Lancet, 365 (9467): 1281. * Austen, Garwood-Gowers, Tingle, John and Wheat, Kay, 2005. “Ethical Practice: Contemporary issues in health care law and ethics.” Elsevier. * Bach, Robert L, Bach, Jennifer B and Triplett, Timothy, 1982. “The ‘flotilla’ entrants: Latest and most controversial.” Cuban Studies, 11: 29-48 * Burnett A and Peel M, 2001. “Asylum seekers and refugees in Britain: health needs of asylum seekers and refugees”. British Medical Journal , 322:544-547 * Hargreaves, Sally, Holmes, Alison and Friedland, Jon S, 2005. “Charging failed asylum seekers for health care in the UK.” The Lancet, 365 (9461):732-33 * House of Commons Hansard (2005) “Written Ministerial Statement for 19 July 2005”. Immigration. Column 67WS. London: TSO. * London Assembly and Mayor of London, 2003. “Access to primary care: A joint London Assembly and Mayor of London Scrutiny Report.” London: Greater London Authority. * Medical Foundation for the Care of Victims of Torture (2003). “Suicide in Asylum seekers and Refugees”. London: Medical Foundation for the Care of Victims of Torture. * Putsch, RW, 1985. “Cross cultural communication: the special case of interpreters in health care.” Journal of the American Medical Association, 254: 3344-3348 * Shah, Sonali and Priestly, Mark, 2001. “Better services: Better Health: the healthcare experiences of black and minority ethnic disabled people” [online] available at: http://www.leeds.ac.uk/disability-studies/projects/healthcare/LIPfinalreport.pdf * Tribe, Rachel, 2005. “The mental health needs of refugees and asylum seekers.” The Mental Health review, 10(4):8-16 * Williams, Lucy, 2004. “Refugees and asylum seekers as a group at risk of adult abuse.” The Journal of Adult Protection, 6(4): 4-16 Read More