AT A recent international meeting of mental-health professionals, a therapist working with refugees arriving in Germany revealed that almost two-thirds were suffering with some form of mental condition. Post-traumatic stress disorder (PTSD) alone accounted for up to 40 per cent of the cases — ten times the level in the general population. Half the refugee children have significant mental-health problems, including anxiety, depression, phobias, panic attacks, sleep disorders, and self-harming behaviour.
The reasons are obvious: apart from all the physical privations of the tortuous journey to Europe, of the more than one million who have already reached Germany, almost three-quarters had witnessed violence, half had actually experienced it, and two-fifths had themselves been tortured.
Besides the 126,000 refugees already living in the UK, Britain has agreed to take 20,000 Syrians over the next five years under its Vulnerable Persons Resettlement Programme, although only about 1000 have arrived so far. The Government has also recently agreed to the additional admission of an unspecified number of unaccompanied children.
Refugee support groups are warning that greater efforts are needed to attend to the mental health of these groups, especially if the political climate changes and more migrants are allowed into Britain. Alongside this, the Government has acknowledged complaints that general mental-health provision in the NHS lags well behind physical services, and work is needed to meet demands for parity of esteem.
MARCEL VIGE, the head of the Equality Improvement Team at the mental-health charity MIND said: “It is a desperate situation, partly because of the scale and the potential numbers coming,” said Marcel Vige, the head of the Equality Improvement Team at the mental health charity MIND. “There is quite a big problem around mental-health support in detention centres. It is often the last thing that is on anybody’s mind, because generally it is a warehousing process.
“We are in an era of cuts. We are starting from a low point. Where there are major policy announcements, resources will follow, but generally it is just more of a shifting around of services. We have been trying to urge commissioners into prioritising services for refugees when they commission mental-health services. The wider primary-care type of support isn’t really well-equipped to deal with the mental-health challenges that refugees bring.”
He also highlighted problems with health entitlement. While emergency treatment is available for all, less urgent care may not be so readily funded. “The rules around what people are, and are not, entitled to can be interpreted quite differently in different services and authorities,” he said. The thought of having to pay for healthcare is off-putting for many who may desperately need it.
MIND is working with the NHS to configure services for refugees. In March, they jointly launched commissioning guidance for dealing with vulnerable adult migrants. “A lot is showcasing good practice and informing people about health entitlement,” Mr Vige said. “It’s also about outreach work within communities which can be quite self-contained. Services don’t have experience of engaging with them; so there can be hidden pockets of need, and a fear of authority, because of where they come from.”
DAVE SMITH is the founder of the Boaz Trust, which accommodates around 70 mostly failed asylum-seekers in Manchester. He describes mental-health services across the board as “very patchy”. “People’s mental health is a significant issue,” he said. “It’s often the compounding of things: they escape the trauma back home and come to the UK, believing we are a welcoming and fair country. But when they get here the treatment they get from the Home Office belies that. They get the sense that no one believes them, which is worse for some than what they have been through in their own country.
“Suicide is not uncommon, certainly among those in detention. Detainees regularly self-harm. People go in healthy and come out ill. They think ‘Why am I here? I have not done anything wrong. I am not a criminal.’ That can’t be good for your mental health. Changing the system is the bottom line in preventing this. But people do need specialist counselling: there needs to be more of that.”
SUSAN MUNROE, chief executive of Freedom from Torture, believes that the provision of mental-health services is inadequate. “It’s not up to scratch for the indigenous population, let alone capable of dealing with any influx of refugees,” she said. “There is no reason why it shouldn’t get better, but it needs some financial investment, and at the moment we are not seeing much will to actually achieve that.”
Her organisation provides therapy for some of the most disturbed refugees and asylum-seekers. It takes about 1500 cases a year, 40 per cent of which are referred by the NHS. The average length of treatment is 34 months.
“Our biggest challenge is that we are only able to see one out of three referrals because of our resources, but we have a ten-year plan to grow by 150 per cent the number of clients we are able to support. We are the only UK organisation dedicated solely to supporting survivors of torture. If we don’t support them, there is nowhere else they can go, because the NHS can’t or won’t support them. They will end up being admitted as an emergency in-patient.
“One of the challenges for us is that the National Institute for Health and Care Excellence guidelines say there is no point in beginning therapy with PTSD while people have an unstable life. That would mean many of our clients wouldn’t be able to get access to therapy for 12 years or so, because of the asylum appeals process. Fortunately, the guidelines are up for renewal, and we are working on providing evidence that can help change that.”
She is concerned over the way the Syrian relocation plan is operating. “It is supposed to identify the most vulnerable, but, because of the huge numbers in the camps, the UNHCR doesn’t have time to identify the most vulnerable. Survivors of torture find it very difficult to disclose they have been tortured, and when applying for refugee status they feel a great sense of shame about what has happened to them. They don’t want to talk about it, particularly when it’s sexual torture. They also fear they will be perceived as being a bad person, in some way justifying their torture, and they think they won’t be accepted on any relocation programme.”
ONE of the charity’s clients, Ehsan, 46, had a good life in Afghanistan, with a wife and children. He was a community volunteer, teaching women to read, but his life changed when a new government came to power. He was arrested and held for 20 days in a filthy cell. Twice a day he was taken away for torture: his body was beaten and salt was poured in his wounds.
He managed to escape to the UK, but his ordeal continued when he learned two of his sons had been killed by his torturers. He is overwhelmed with grief and anxiety, and he is unable to work while his asylum claim is assessed; so he is even more isolated.
He was referred to Freedom from Torture for individual counselling. He also joined its Natural Growth Project, which offers the therapeutic benefits of gardening with others. “My life is so stressful and worrying,” he said, “but here I can feel confident, safe, and happy. Talking with other torture survivors who will listen and help — it’s a great comfort to me and gives me hope for the future.”
Another participant in the gardening project is Zariya, 34, from Ivory Coast. She was in her twenties when she lost her father, sister, and brother amid the chaos of war and political repression. Because of her involvement in a community self-help group, she was beaten and tortured so severely that she miscarried. “Without the project, there would be no life for me. I still have bad thoughts and nightmares, but being in the garden gives me a chance to forget about my past life,” she says.
PROFESSOR Cornelius Katona, the Royal College of Psychiatrists’ lead on refugee and asylum mental health, believes that the NHS will cope adequately with the numbers currently being admitted, but, “if one puts a nought or two on the figures, then we would have to have a completely different plan. And, as far as I know, there is no such plan.The big political unknown is whether that will change, given the pressures being put on the UK to take a bigger share.”
The Professor, who is also the medical director at the London-based human-rights group the Helen Bamber Foundation, says: “If we took a share comparable to Germany, then we would be in a completely different position. We would be talking about at least 100,000, and possibly several hundred thousand, of which perhaps one in five, or even more, would have serious mental-health problems. That would have a very substantial impact on local and national services, and the voluntary services.”
Many of the services for asylum-seekers and refugees are “postcode-lottery distributed”, he said. “However, the best of them are very good. There is good practice to learn from, and there are skills that are reasonably easy to identify which could be disseminated further. We have had waves of people who have been ill-treated coming to the UK for years; we have a lot of experience in working with refugees from Nazi Germany, people from Uganda, Vietnamese boat people.”
He also believes that the problem should be tackled on a pan-European basis. “At the moment, I would certainly look for good practice to Germany, because they are the country most like us which is doing this work at a volume far greater than we might ever have to do. We could also look to the Lebanon, Turkey, and Jordan.
“It is also important not to make things worse. There is a lot of evidence that prolonged asylum processes and things associated with that — detention and destitution — make people, if they already have mental-health problems, deteriorate. And it’s more likely to make people who don’t have mental-health problems develop them. It is important to identify problems early and to make specialist support accessible and culturally competent, because there are linguistic and cultural barriers.
“While it costs money to set up early and preventative strategies, it also costs money not to. The cost to the health service, the welfare state, and the community as a whole may be very much greater than that of prevention, early intervention, and active integration. There is potential for a lot of people to get a lot worse if preventive measures are not taken, and if the asylum journey is not made less daunting.”
Refugee Week is 20-26 June. www.refugeeweek.org.uk