Simple and humane

Two thirds of refugees worldwide come from just five countries: Syria, Afghanistan, South Sudan, Myanmar and Somalia. Our collective responsibility in the UK is now more important than ever, with the humanitarian catastrophe in Syria resulting in the largest refugee crisis since the second world war.

Asylum seekers and refugees are much more likely to experience poor mental health than the wider population. It is estimated that more than 20 per cent suffer from anxiety, depression or post traumatic stress disorder (PTSD), with the figures for refugee children higher still. The factors known to increase the risk of mental health disorders in this population have been described as the ‘triple trauma of the refugee’:

• The trauma in the country of origin – people seeking asylum in the UK are usually fleeing a trauma so severe that they are forced to leave their home, their livelihood, community and often their loved ones. Many of the patients we care for have witnessed devastating violence either towards them or their family or friends.
• The trauma during travel – many refugees will have made perilous journeys to reach the UK, often travelling with false or no documentation and in constant fear of what will happen to them.
• The trauma of resettlement and integration – as clinicians we frequently observe that the mental health of refugees and asylum seekers can worsen after reaching the UK.

This final trauma of resettlement and integration is important to consider in detail, as this is an area where we can make positive changes in the UK. In our GP surgeries we hear so many personal stories of anxiety and depression associated with the exceedingly complex and laborious asylum process. Our patients going though the system often feel they are living in limbo, that their lives are on hold whilst they wait for an outcome, often for years. During this time they are unable to work and so miss out on the meaning and purpose provided by employment as well as being unable to provide for their families. Many of the people we support have been separated from their spouses, children and other loved ones and have constant fear about those missing or left behind.

Finances are often exceedingly precarious and perversely, the situation is frequently at its most difficult when an asylum claim is accepted and the newly qualified refugee then has just 28 days to find new accommodation, work or to claim benefits.  We find that without support, this period can often result in homelessness and destitution. For those less fortunate, who receive a final rejection of their asylum claim, their long held concerns about detention, deportation or destitution can become a stark reality.

Many of our patients are housed in poor or unsuitable accommodation, it would be a unusual day for either myself or my GP colleagues to not be shown an image on a patient’s phone of a damp, leaking wall or hear about difficulties with landlords. In addition to these hardships our refugee and asylum seeking patients often face negative attitudes, prejudice and discrimination, all of which further hinder efforts to adapt to life in the UK and add to the heavy toll on their psychological wellbeing.

A significant body of research over the past decade points to simple, humane measures which could reduce the trauma of resettlement and integration. For example, a recent Danish study showed that secure employment was particularly associated with improvements in PTSD. Other studies have suggested that refugees with access to housing have better mental health outcomes than those without.

Having social support can be a stronger predictor of wellbeing than previous trauma. Indeed, the World Health Organisation (WHO) advise that enabling refugees to achieve social integration in host countries can be seen as the most influential prevention strategy for mental disorders on a public health level.

There is good evidence that a lengthy asylum seeking process,  such as that in the UK, has a negative impact on mental health and that a majority of people who develop acute stress reactions or PTSD will improve when they feel they are in safe conditions. We also know that families that are not reunified may be at greater risk of prolonged mental health problems. Sadly a safe, smooth, short asylum process and efficient reunification of families feels a long way off in the UK.

There is considerable confusion about entitlement to healthcare for refugees and asylum seekers in the UK. We need improved clarity of information and education for both patients and health care professionals on entitlements to care, as well as sufficient mental health services to meet the needs of this group. Studies have shown that interventions to facilitate access to and engagement with care, including good quality interpretation services, can reduce deterioration in existing mental health problems and improve outcomes.

Despite all the challenges they face, many refugees do adapt incredibly well to life in the UK, including some of the most resilient and resourceful people I have been fortunate enough to know. My hope is that we can learn from experience and research to enable us live up to our humanitarian responsibilities and care for the mental health and wellbeing of those seeking refuge from war, violence and persecution.

This article is part of the series ‘Fabian perspectives on mental health’, organised by the Fabian health and social care interest group. To find out more contact: healthgroup@fabians.org.uk

Image credit: Ani Bashar/Flickr