Psychosocial care of immigrants in the Czech Republic as a country in transition

Summary

The Czech Republic is a country in transition, and its historical sociopolitical isolationism lingers to this day, with restrictive attitudes towards immigrants. International collaborations among transcultural psychiatrists and non-governmental organisations (NGOs) could help increase awareness of the service needs of immigrants and improve access to mental healthcare. A lack of state and academic interest persists despite the increasing importance of the issue. These neglected problems burden NGOs that have limited financial and staffing resources. Legislation on the humanitarian needs of immigrants must enhance the efforts of NGOs, and psychiatrists may serve as liaisons to effect the necessary change.

The immigration crisis, in parallel with political and social discourse, is catalysing awareness of the need for national policies that support integration. Over the past three decades, the Czech Republic, traditionally homogeneous and isolated in its totalitarian past, has become both a place of transit and a destination country for legal immigration.¹ According to the Czech Statistical Office there were 564 345 legal foreign residents in the Czech Republic on 31 December 2018. Recent immigrants presently account for 5.1% of the total population of 10.7 million inhabitants. In 2017 this number was 4.8%, up from 4.5% in 2016. Residents from Ukraine are the largest group of legal immigrants (131 302), followed by residents of Slovakia (116 817). There are also Asian immigrant communities in the Czech Republic, the largest being the Vietnamese (61 097), followed by Mongolians (9075) and Chinese (7485).² The number of applicants for international protection was 1702 in 2018 (only 42 were granted asylum) and 1450 in 2017 (only 29 successful applicants). Most applicants for international protection in 2018 were from Ukraine (418), Georgia (170), Cuba (154), Armenia (117) and Vietnam (100). The number of illegal immigrants in the country, mostly from war-torn countries, is estimated to be several thousand.³ The Czech Republic is among the few EU countries that rejected the most recent United Nations migration treaty, a non-binding pact aimed to better organise the flow of international refugees and promote integration and self-reliance.

The immigrant experience in the Czech Republic

Societal attitudes

Despite legislative changes after accession to the EU, the attitude towards immigrants in the Czech Republic remains restrictive. Critical psychosocial assistance is largely the responsibility of under-financed non-governmental organisations (NGOs) and volunteers.⁴ The media greatly influences public opinion about immigrants and refugees in Czech society. Selective reporting of facts about immigrants highlights a narrative of crime, burden to others and dangerousness, contributing to xenophobia and negatively affecting the process of integration.⁵ Psychosocial stressors that refugees face include pre-migration factors such as persecution, torture and war trauma; migration factors such as separation, physical danger and unsatisfactory living conditions; and post-migration factors, including uncertainty, detention and xenophobic prejudices in the host country. These psychosocial factors are associated with morbidity and ill health. A country-specific Czech study on immigration and its impact on mental and physical health supports the general assertion that psychosocial stressors erode the health of immigrants.⁶

The state's integration policy

The government body responsible for integration policy in the Czech Republic is the Ministry of the Interior. It assigns tasks and responsibilities to other bodies, such as ministries, regions, municipalities and the newly established Centres for the Support of the Integration of Foreigners. None of these provides comprehensive psychosocial care at present. The updated national legislation on integration also fails to address long-range impact factors, such as the question of immigrants' inclusion into the public health insurance system, nostrification of international university diplomas and degrees, and political participation by immigrants.⁷ This level of neglect may compound unemployment risk, social distress, lack of adequate access to healthcare and consequent psychological distress.

Healthcare professionals’ attitudes and training

Healthcare professionals may be ill equipped to work with immigrants and refugees owing to insufficient awareness of similarities and differences, resulting in cultural misalignment, language and non-verbal communication barriers, and a rudimentary understanding of how cultural background and belief systems influence mental health. Examples of nuanced areas that merit training and heightened attunement include concepts of trust, authority, dignity, self-image, gender roles, role of family and society-specific taboos. Of importance are also immigrants’ unrealistic expectations associated with the host country, disappointment and working through frustration after confronting reality.

There is an obvious need for a comprehensive system of psychosocial care, cultural competence and willingness to understand the complex problems of new fellow Czech citizens. Mental health clinicians recognise the importance of establishing a trusting therapeutic alliance to ensure treatment adherence and achieve better clinical outcomes. Stigma and discrimination of vulnerable immigrants unnecessarily adds to suffering, alienation and psychological distress. Alcohol and other substance use disorders and psychotic episodes are highly prevalent among immigrants admitted to Czech psychiatric hospitals.⁸ Traumatic and stress-related disorders are probably underdiagnosed in these cohorts as well. At present, NGOs provide almost all of the psychosocial support for immigrants in the Czech Republic. Psychiatrists are usually involved only as volunteers. NGOs provide supportive psychotherapy, social services, law counselling and specially designed programmes for children and adolescents and seniors. Multicultural support groups, festivals and ethnocatering services serve the purpose of networking and enhance support. Cultural awareness programmes designed for the general public may support ease of integration through education. These could include open discussion workshops, targeted talks and cultural exhibitions. Ethnocultural pedagogical seminars for clinicians and volunteers could maximise effectiveness of clinical services.

A call to the state and psychiatry

Despite a large influx and pressing needs, the psychosocial care of immigrants and refugees in the Czech Republic is still underdeveloped and overlooked by academics and mental health specialists.

The Czech Republic could rise to the challenge and serve as an example of a post-totalitarian country in transition striving to renounce isolationist attitudes, combat xenophobia and welcome diversity through legislation and clinical services that target fluid immigration, integration and humanitarian asylum for neighbours in need.

Czech psychiatrists face the challenge of establishing more facilities that provide psychosocial support for immigrants and refugees. They could do this by encouraging academic interest and international collaborations in the fields of traumatology and transcultural psychiatry. Collaborating with the media may neutralise sensationalist reporting. Sharing research findings that highlight the mental health needs of immigrants could lead to protective legislation that avoids stigmatisation, respects cultural diversity and promotes generative integration.