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

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

• The Challenges of Accessing Mental Health
  Services

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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 servicescommunity
perspectives.
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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.

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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.

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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.

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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.
  

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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.
  

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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.

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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.
  
  

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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,
  ones primary focus was on survival and finding
  security not on assessing ones emotional state
  and mental health.

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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

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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
  dont believe in Zar, it is not supported by them
  in general.
  

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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.

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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.

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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.

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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.
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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

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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.

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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

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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.

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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.

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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.

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4. Barriers to mental health care

• Is there a mental health problem?
• Acknowledging you need help
• Practical issues
• Health workers attitudes

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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.

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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).

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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.

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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 dont 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.

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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.

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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.

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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.

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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

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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

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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.

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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.

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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.
  

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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).

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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

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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
  

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5. Improving mental health servicescommunity
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, womens
  groups, mens groups, could raise awareness of
  mental health issues

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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.

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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.

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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 childrens befriending project in
  Birmingham)

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Improving mental health services

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

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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.
  

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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.

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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)

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For more information

• www.harpweb.org.uk
• (including access to free multilingual
  appointment card)