Feature

The need for understanding

Mental health services may feel overwhelmed by the needs of refugees and asylum seekers – but there are opportunities to develop a more holistic approach to care, argues Charles Watters

Over the past decade, issues relating to asylum seekers and refugees have received persistent and widespread coverage media. Successive Conservative governments introduced legislation to stem a rising tide of asylum applications and presented the majority of asylum seekers as ‘bogus’.

Labour’s approach (embodied in the Immigration and Asylum Act 1999) is characterised by two fundamental aims; first, to restrict access to the UK for those not already here and, second, to deal swiftly with the applications of those who do reach the UK.

Measures in the first category include, for example, the introduction of visa restrictions on countries sending refugees and new penalties for those who transport asylum seekers into the UK. In the second category there are measures for streamlining the application and appeals procedures. The government wants initial decisions within two months and final decisions in four months. But there are currently over 80,000 applications outstanding so it is hard to see how this can be achieved in the near future.

The government has also announced new social care arrangements, including measures to disperse asylum seekers from areas where they are most highly concentrated, specifically London and the south east of England, and to continue with vouchers rather than cash payments as the chief means by which refugees obtain basic necessities.

Those claiming asylum will either have to survive on their own resources, for example through the help of friends or relatives, or accept a support package that includes accommodation on a ‘no choice’ basis in one of nine ‘cluster areas’ outside the south east of England. Payments, largely as vouchers, of up to 70 per cent of income support will be made to individual asylum seekers.

While asylum seekers have very restricted access to housing and benefits they are fully entitled to healthcare. Meeting their healthcare needs, however, is far from straightforward.

Asylum seekers and refugees come from a wide variety of countries and may come from minority groups within those countries. In 1999, for example, the main nationalities applying for asylum were from the former Yugoslavia, Somalia, Sri Lanka, Afghanistan, the former USSR and Turkey. Substantial numbers were from minority groups, for example Kurds from Turkey and Tamils from Sri Lanka. This varies from year to year in response to factors such as war, natural disasters and the persecution of particular minority groups.

This diversity presents a major challenge for services. How can a mental health or social care provider provide a culturally appropriate service in this context? Where such services have been developed they have been confined to major cities with high concentrations of refugees. Examples include the One Stop Service in Brixton run by the Refugee Council, and the Medical Foundation for the Care of Victims of Torture and the Evelyn Oldfield Unit based in London.

There are a number of services that have been developed by refugee groups themselves to offer support to people from similar backgrounds. Again these are almost exclusively based in large urban areas. Asylum seekers and refugees naturally gravitate towards areas where there are established communities with the same cultural backgrounds. But Labour’s policy of dispersal means that asylum seekers are being sent to areas where there are no established communities with the same cultural backgrounds. The government has suggested that dispersal should be to areas where there is a ‘multi-ethnic population or infrastructure able to assist asylum seekers’ (Asylum Seekers Support, Home Office 1999). But the fact that there is a multi-ethnic population in an area does not necessarily mean that it will have the sort of culturally specific support networks that asylum seekers and refugees need. For many groups of asylum seekers there are no appropriate support networks outside large cities. For some, London is the only place in the UK with communities of people from comparable backgrounds.

Studies of the mental health of refugees often divide their experience into three episodes. First, there are the traumatic conditions refugees may have experienced in their home countries, including war, famine or persecution. Much clinical work and research has focused on the impact of such events on mental health, particularly the development of post-traumatic stress disorder. Second, there is flight from the home country; this can be as hazardous and stressful as the problems the refugees were seeking to escape. Refugees may have had to pay criminals large amounts of money to be transported across borders and have lived under constant threat of discovery and consequent torture or incarceration. During the journey refugees may be subjected to physical or sexual abuse or deprivation. Third, refugees’ problems do not end when they reach their destination. If discovered they may be sent back to their home country immediately or to an intermediate country.

Sometimes refugees face detention in camps or prisons where there has been well-documented decline in refugees’ mental health, including feelings of hopelessness and despair. The UK’s approach towards detention has been described in a recent Minority Rights Group report as the worst in Europe. Detention centres are normally run by private contractors who buy in professional health and social care services. The knowledge and training of workers in such centres may be minimal. So what are the key issues surrounding the mental health of refugees?

• Post-traumatic stress disorder Traumatic experiences and the shattering of values and beliefs regarding self, world and future can lead to severe psychological and psychiatric problems. The most commonly diagnosed severe psychological problem for refugees is post-traumatic stress disorder, which is a prolonged reaction to intense stressors such as war or persecution. It has been criticised for inadequately describing the experience of refugees, and for consigning trauma to the past, implying that it was something experienced pre-flight or during flight and not in the country of resettlement.
• Distress and mental illness It is essential to distinguish between distress and clinically defined mental illness. Mental health professionals must be very careful to avoid labelling the distress of dislocation as mental illness. It may not always be helpful to refugees to have their distress articulated through conventional Western definitions of psychological ill-health. Refugees suffer language and communication difficulties and a lack of understanding of the culture, religious beliefs and attitudes of the host country, and resultant misunderstandings can lead to a misdiagnosis of mental illness.
• Refugee women Refugee women are often isolated at home with young children in inadequate housing and with little money. They are likely to have received less education than men and are less likely to have opportunities to learn English, restricting their movement and potential for employment. Many refugee women with children may be alone in the UK because their partners have been killed, detained or have stayed behind to fight. Women may have experienced rape in their country of origin and in the process of flight.
• Children Refugee children may have witnessed death and destruction during civil war or political repression. Many experience constant nightmares, depression, anxiety and at times violent behaviour, easily provoked by friends unaware of their inner feelings. In parts of the UK, refugee children face difficulty finding a place at school. Many are lonely and do not interact with their schoolmates.
• Social support Refugees may be extremely isolated. Often families and friends have been left behind, causing a high level of anxiety about their well-being. Studies of refugees’ mental health needs confirm the importance of social support.

Recent research evidence suggests that the best mental health outcomes are achieved when, in addition to refugees having close links with people from their own country of origin, they also have good ongoing links with the host community.

• Socio-economic factors The relationship between social deprivation and mental health has been widely demonstrated. Recent debate about the provision of benefits to asylum seekers has highlighted the destitution faced by many.

Against this background the challenge facing mental health services can appear overwhelming. Refugees’ needs challenge the very basis of professionals’ attitudes to mental health work. But effective steps can be taken to address the mental health needs of refugees, even if a paradigm shift in professional thinking is necessary.

Three useful ideas when considering services for refugees are refugees as a resource, consultation and integration.

Refugees or asylum seekers are rarely talked about except in terms of being a ‘problem’ or a ‘drain on limited resources’. Little attention is given to the fact that refugees have often displayed incredible resilience to make the journeys they make and to cope with new and alien cultures. A high proportion of refugees are well-educated and have made significant contributions to their home countries before their flight.

Seeing refugees as a resource, rather than as a problem, opens the possibility of drawing on refugees’ experience and expertise in designing and implementing services. This is inextricably linked to consultation. Imaginative programmes have already been established in the UK to train refugees as counsellors, and to establish groups of refugee advisors for service development and research projects. The advantages of this approach are numerous: not only does it empower refugees, it also offers a way of addressing some of the complexities arising from the sheer diversity of refugee groups.

This approach also has potential benefits for training mental health professionals. A recent survey indicated that mental health professionals throughout Europe felt that training in this area was very poor. Refugees could be a valuable resource for the design of appropriate training courses and for direct training. For example, the University of Kent is offering an MA on migration, mental health and social care and a central component is working with refugees in developing mental health and social care services.

Central to establishing appropriate services is a willingness to integrate mental health and social care into a holistic approach. Refugees rarely view their problems as about mental health. When questioned most talk in terms of basic needs such as housing, employment, education and being able to re-establish links with family members.

If professionals concentrate too much on perceived mental health problems they risk alienating refugee clients who may regard mental illness as highly stigmatising. It is widely accepted that trust is central to the development of an effective therapeutic relationship and this can often only be achieved if mental health professionals initially engage in helping refugees to address pressing practical problems.

At the time of writing there are new opportunities for developing an integrated approach to mental health and social care. The Camelot Foundation is funding a three-year project in partnership with the Refugee Council and the Medical Foundation for the Care of Victims of Torture. The project is being evaluated by the University of Kent and will provide an opportunity to examine the potential for developing integrated care. But the challenge of responding to refugees’ mental health needs can only fully be met by services prioritising this work and working in creative and collaborative ways with local refugee communities.