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Bridges and Barriers to Mental Health Services for Asylum Seekers and Refugees : 

Bridges and Barriers to Mental Health Services for Asylum Seekers and Refugees The Challenges of Accessing Mental Health Services

The study: 

The study HARP conducted a DH funded study to identify the bridges and barriers into mental health services for asylum seekers and refugees. As part of this study we conducted community consultations with  107 asylum seekers and refugees based in Birmingham and Sheffield. We used semi-structured focus groups over four days, (two women only sessions and two mixed sessions). These groups were sub-divided into fourteen focus groups and the respondents came from Bosnia, Cameroon, Democratic Republic of Congo, Eritrea, Ethiopia, Iran, Iraq, Independent Kurdish areas of Iraq, Lebanon, Liberia, Zimbabwe, Somalia and Sudan.   The researchers provided interpreters, crèche facilities, travel expenses and as well as lunch for the sessions. (Summer 2005)

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1. Perceptions of mental health and mental health problems in countries of origin 2. Coping mechanisms and support pathways in countries of origin. 3. Mental health stressors in the asylum process. 4. Barriers to mental health care 5. Improving mental health services:community perspectives.

1. Perceptions of mental health and mental health problems in countries of origin: 

1. Perceptions of mental health and mental health problems in countries of origin Negative concept All of the participants who took part in the study expressed views indicating that mental health issues were viewed negatively in their country of origin.

Enduring problem: 

Enduring problem For most participants, in their home country, the concept of becoming mentally ill was seen as ‘going mad’ and was identified as an enduring problem from which there is no prospect of recovery.

Stigma in countries of origin: 

Stigma in countries of origin Stigma was accentuated and systems for psychiatric support were generally viewed as custodial in nature and therefore not conducive to care and recovery.

Participant from Cameroon: 

Participant from Cameroon There is a conflict in the term ‘mental health’ – in our society mental has only one meaning and that is a negative one, so if you are talking about mental health, it is a situation where there is no health.’

Participant from Somalia. : 

Participant from Somalia. Where we send people who have mental health problems, we call it in Somali “a jail for mad people”, [it is] not called a hospital.’

Gender issues : Men: 

Gender issues : Men The majority of the male participants in the community consultations felt that men in their country of origin faced specific pressures that did not facilitate the self-acknowledgement of emotional or mental health problems and that early socialisation in most cultures did not encourage men to talk about their problems.

Participant from Ethiopia.: 

Participant from Ethiopia. Men do not openly air their emotional or mental health problems. Once you are known to have had mental health problems, then there is no way back from that. It is difficult to regain your status in society. You will always be viewed as the ‘mental’ person. Men keep it secret.’

Gender issues: men continued: 

Gender issues: men continued A number of male participants also felt that, in circumstances where there is a breakdown of civil order or targeted hostility, a man might be undermining the safety of his family by admitting emotional distress and seeking help. Where social and civil infrastructures had broken down, one’s primary focus was on survival and finding security not on assessing one’s emotional state and mental health.

Gender issues : women: 

Gender issues : women For women, the issue of mental health and emotional support appeared to be more open and many spoke of the value of family networks and how they are supported within their families

Participant from Somalia.: 

Participant from Somalia. For women who are feeling down, the support comes through dancing and singing and getting together. The community support is very strong. If a women is having problems with her husband or through child bearing they may turn to Zar. Here they will be supported by mother. An entranced state induced by dance and ritual allows a person to forget about problems. The dance is addictive and the noise, incense, dancing and singing are all meant to heal. Traditional healers and assistants are leading the Zar. They wear costumes and take on another personality. Men don’t believe in Zar, it is not supported by them in general.’

2. Coping mechanisms and support pathways in countries of origin : 

2. Coping mechanisms and support pathways in countries of origin Most participants identified that interventions that were put in place to support mental health problems were not usually those of a biomedical model, but psychosocial or spiritual in nature and usually community focused.

Participant from Somalia. : 

Participant from Somalia. The community will come together to provide support. If someone is anxious, then they will talk to families and friends to help resolve issues. There will always be someone to give you guidance. If they are down, friends will gather and socialise. No one who is feeling down will be left alone; there will be constant support. People will gather, take it in turns to be with the person who is down, they will sing together, dance together.’

Spiritual support: 

Even though the participants came from different religious and spiritual traditions, all of the focus groups identified spiritual practice as significant in supporting mental distress and consultation with religious or spiritual leaders was widely used as a help-seeking behaviour. Spiritual support

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For more persistent problems, ceremonies come into play – religious ceremonies, or traditional healers. It is about the community coming together to support each other.’ Participant from Somalia. ‘Religion plays a big role. Prayers help you…. here are also rituals, exorcisms, and drumming to help.’ Participant from DRC.

Spiritual support continued: 

Spiritual support continued A number of participants expressed concerns that in their countries of origin, manifestations of psychosis were sometimes understood to be spiritual in origin, thereby delaying interactions with medical services that may be of benefit.

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Only a few of the participants, namely those from Bosnia and Iraq, made reference to the medical profession as a primary support for mental health problems in their country of origin.

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The individual will be well cared for by the family, or if no family, by the wider community, but no intervention will be sought. Hospitalisation is viewed more as incarceration. The environment is not one of care and support but more one of restraint. Hospitals are not always accessible, they are too far away. Help from doctors is expensive. Ethiopian Participant.

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3. Mental health stressors in the asylum process

Mental health stressors in the asylum process: 

Mental health stressors in the asylum process All of the health professionals and refugee organisations interviewed stated that the one thing which would promote good mental health for asylum seekers and refugees would be changes to the asylum process and to NASS policy.

Mental health stressors in the asylum process: 

Mental health stressors in the asylum process In the community consultations people identified Arrival, detention and uncertainty Practical issues, e.g. housing, lack of employment Living in a climate of prejudice Family dislocation and reunion Domestic violence Living in the shadow of deportation

Domestic violence: 

Domestic violence Many women and some men reported that domestic violence was extremely common. They suggested that the husbands are seen to have lost their status and role in life and consequently often acted out their authority within the home through violence. Some male participants acknowledged that it was very difficult not being able to provide for and protect their family.

Domestic violence: 

Domestic violence When questioned further, the women disclosed that domestic violence is never reported to the police. This was due to fear that it may impact on their asylum claim and fear of the repercussions for their husbands. Many women stated they did not know that anyone could help them.

Domestic violence: 

Domestic violence Many of the men in the consultations identified that the asylum process did undermine their manhood and that it was difficult to ask for help, especially with emotional or mental health problems. Most of the men expressed concern that they were often excluded from support mechanisms and projects and they felt that most agencies gave help and support to women and children. Acknowledging the mental health needs of asylum seeking and refugee men is clearly important, on an individual level and also in terms of the family well being.

4. Barriers to mental health care: 

4. Barriers to mental health care Is there a mental health problem? Acknowledging you need help Practical issues Health workers attitudes

Is there a mental health problem?: 

Is there a mental health problem? Because asylum seekers and new refugees face a plethora of practical, legal and emotional problems, sometimes it can be difficult to assess if a person is in need of practical and social support, or is in need of mental health support. A holistic approach ensures that all aspects of psycho-social care are addressed.

Is there a mental health problem?: 

Is there a mental health problem? Asylum seekers, refugees, community leaders and practitioners all expressed concerns about the over-medicalisation of asylum seeker experience and and recognised how this can create a tension for some health practitioners who are often reluctant to respond medically, to what they see as a social problem (e.g. depression caused by isolation, lack of information and poverty).

Acknowledging you might need help and knowing where to get it : 

Acknowledging you might need help and knowing where to get it A number of participants remarked that people within their communities believed that the diagnosis of a mental health problem would increase the chances of their asylum applications being turned down. Or, if they are mothers, that it would lead to their children being taken away.

 Somali asylum seeking woman: Birmingham: 

Somali asylum seeking woman: Birmingham ‘You know, it is difficult to know when you should ask for help and when you should leave it. This man I know, he stays in his room all day, he has started not to get out of bed and sometimes he does not wash or eat. He does not talk. You know, I don’t know if we should get help and will he still trust me if I bring someone in to the house. The man… (long pause) he is my brother.’

Acknowledging you might need help: 

Acknowledging you might need help A number of participants identified feelings of guilt emanated from the fact that family members were left behind and maybe lost or continuing to face conflict or civil disorder, or the social and economic hardships. Thus there was a sense of obligation to those left in the country of origin to ‘succeed and to support those left behind’, rather than to admit to their own mental distress.

Somali Community Leader.: 

Somali Community Leader. Refugees try very hard to hide their mental health issues. They cannot show their vulnerability to the community. If they admit to distress, everyone will say, ‘stop winging, we are all in the same boat’. All these points affect people. So mental health problems are nearly always only identified once they have reached crisis point.’

Finding a service: 

Finding a service Most participants commented on the ‘invisibility’ of mental health services; most participants did not know that there were specialist mental health care workers or therapy available and several participants did not know they could discuss these issues with their GPs.

Practical issues: financial restraints: 

Practical issues: financial restraints ‘My client had to walk more than four miles for an appointment and she had not had anything to eat, as she had no money.’ Counsellor: Sheffield

Practical issues continued: 

Practical issues continued Often people fail to turn up for appointment because they do not have the money for the bus fare to attend on the other side of the town. There just seems no way of finding the money for them. Some of the churches and mosques help and sometimes I give them my own money.‘ CPN: Birmingham

Practical issues: effective communication: 

Practical issues: effective communication Participants identified that letters confirming appointments are sent out in English and if the letter is not responded to, then the appointment is cancelled.

Lack of understanding of the system: 

Lack of understanding of the system Participants remarked that DNA (did not attend) rates to therapy and counselling sessions maybe due to a lack of understanding of what was going to happen, how the system worked and what was expected of them.

Trust and understanding: 

Trust and understanding An element of trust, understanding and positive expectations is a fundamental aspect of any therapeutic service. However, nine of the fourteen groups consulted raised the issue of a lack of trust as a major barrier to asking for mental health support. This was, on the whole, attributed to a widespread perception that GPs could not dedicate enough time to develop a relationship of trust, which might prompt individuals to consult on mental health problems.

Trust and understanding: 

Trust and understanding One participant was scared to tell his GP anything in case it was passed on to other agencies such as the Home Office. No one had ever explained doctor-patient confidentiality to this asylum seeker. He expressed concerns about how his personal information might be used and who had access to such information (this asylum seekers had lived in the UK for six years).

Trust and understanding: 

Trust and understanding Establishing a relationship of trust was further complicated in some cases by the presence of an interpreter. Participants raised concerns about confidentiality and the fear of the exposure of mental health problems to the wider community as a result of the use of interpreters. All groups consulted about mental health care services in the UK felt that many interpreters did not have sufficient training in mental health issues

Trust and understanding: 

Trust and understanding One Bosnian participant said she felt embarrassed telling the doctor what had happened through an interpreter: ‘She [the interpreter] just looked at me like she did not believe me. What happened is bad enough, I did not need someone else judging me’

5. Improving mental health services:community perspectives: 

5. Improving mental health services:community perspectives . Mental health care services need to acknowledge the oral tradition (role of word of mouth) in the spread of information across refugee communities. Bicultural / bilingual workers based within refugee community organisations who attend social networks, women’s groups, men’s groups, could raise awareness of mental health issues

Improving mental Health services: 

Improving mental Health services Many participants expressed the need for GPs and other mental health practitioners to work with their communities in a pro-active manner and they felt that outreach workers should help to develop community activities.

Improving mental health services: 

Improving mental health services Participants identified that there is a need to make mental health services more accessible in places that do not stigmatise people such as social groups and that there is a need for statutory services to create a sense of belonging by automatically offering interpreters in medical settings and not waiting for patients, or carers to request them.

Improving mental health services: 

Improving mental health services Mentoring or befriending projects promoted trust and understanding as well as addressing mental health problems in the wider context of social exclusion (e.g. the Northern Refugee Council befriending projects in Sheffield and the BUMP unaccompanied children’s befriending project in Birmingham)

Improving mental health services: 

Improving mental health services All participants identified the urgent need to address practical problems as a way of relieving stress and improving life quality.

Somali community leader, Sheffield. : 

Somali community leader, Sheffield. Home becomes the symbol of the whole cycle. Home is the beginning and the end and the new beginning. When you leave your homeland, when you are forced to flee, your home is the last thing that you have. You may have lost your job, your schools, everything, but the home is the last thing that you have. The day you are driven out of your home that is the day that you become an asylum seeker. When in your country of settlement you get your home – well that is the sign of the new beginning. So it is so important to get that bit right.’

Improving mental health services: 

Improving mental health services A number of community leaders experienced a lack of meaningful collaboration between mental health care services and RCOs. They generally considered consultations with them to be tokenistic rather than empowering; community organisation complained that they are often only consulted at times of crises.

Improving mental health services: 

Improving mental health services There is a need to recognised and involve RCOs into the planning, commissioning and delivery of mental health promotion and care to create a more appropriate service. [This approach echoes NIMHE Inside Outside: Improving Mental Health Services for Black and Minority Ethnic Communities in England (2003) and the DH   Delivering race equality in mental health care (2005)

For more information: 

For more information www.harpweb.org.uk (including access to free multilingual appointment card)