An Assessment of the Provision of Refugee Mental Health Services in the London Borough of Camden (–December 2005)
A Report by:
Adrian Jones and John Bristow
Reproduced with permission
Acknowledgments: We would like to express our special thanks to the staff of the St Pancras Refugee Centre for their invaluable input into this report.
We would also like to thank George Binette from the London Borough of Camden and Uta Sievers who until recently worked at the Civis Trust for their assistance and support.
About the authors
Adrian Jones has worked in the public sector for the London Boroughs of Ealing and Newham, Berkshire County Council, and Reading and Slough Borough Councils. He has also worked as a Research Executive for MORI, a Research Fellow at the Centre for Research in Ethnic Relations, University of Warwick, as a part of the housing team at the Centre for Urban and Regional Studies, University of Birmingham and as Principal Researcher for the Council of Ethnic Minority Voluntary Sector Organisations. The co-author of Somalis in Camden: challenges faced by an emerging community he has recently being carrying out extensive research with refugee communities in Manchester.
John Bristow currently works for Trident Housing Association, a Midlands- based specialist care and support provider, as a senior strategic manager helping to develop accommodation, care and support services for a range of vulnerable groups. He has almost 20 years experience of working within the voluntary mental health service sector both at an operational and strategic level, which has included helping Trident to develop and deliver specialist support services to individuals with mental health needs in Birmingham’s Chinese community. He has a particular interest in mental health and cultural issues as well as delivering training on aspects of mental health and recovery models.
Previous surveys of local BME communities (Bangladeshi, 1995/6, Chinese 1998/9 and Somali 2003/4) were generalist in nature and relied on a combination of detailed analyses of Census data and structured one-to-one or household interviews backed up with qualitative work. Given the rather different scope of the current research and the general lack of “hard” statistical data (due, for example, to inadequate ethnic monitoring systems) the following methodology was used:
i) A review of existing literature and resources relating to mental health issues and refugee communities
ii) Examination of the actual level of provision of mental health services currently available in Camden & Islington by both the statutory and voluntary sectors
iii) Examination, where possible (using data from ethnic monitoring systems), of take-up of mental health services by people from refugee communities
iv) A series of semi-structured interviews with key staff in statutory and voluntary organisations and in some of the larger refugee community organisations based in the borough. In total 19 such interviews were carried out, focusing on the key concerns of the study:
- Perceptions of service take-up by refugee groups
- Perceptions of needs/key issues
- Barriers to accessing services - and solutions for reducing them
- Gaps in service provision and actions needed (and who should do what)
Of the 19 interviews, nine were with statutory agencies, and 10 with voluntary agencies/community groups.
The United Nations 1951 Convention gives the following legal definition for “refugee”:
A person who owing to well founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of nationality and is unable, or, owing to such a fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, unwilling to return to it.
An asylum seeker is someone who has applied for asylum and is waiting for a decision to be made by the Home Office.
A person with leave to remain status is someone whose application for asylum has been processed and who has been granted leave to remain in the UK under one of the following types of leave to remain:
Current System (as of August 2005):
From previous system:
Exceptional leave to remain
Indefinite leave to remain
Adults given any of the above are allowed to have recourse to public funds and to seek employment.
Background: Objectives of the Project
Camden has the highest suicide rate in England - between 1997 and 2001 this was, on average, 36 people each year. The report of the London Borough of Camden Suicide Prevention Scrutiny Panel (July 2004) notes with regard to the borough’s refugee population that:
“The Working with Refugees Scrutiny Panel heard that people arriving into this country often have been the victims of violence, rape and torture. Many people develop psychiatric problems arising from trauma, or isolation from their own communities…
Refugee groups suffer additional trauma above that experienced by their black, minority and ethnic counterparts and this may contribute to the high suicide rate”.
This research was carried out in response to the Panel’s identification of further work that needed to be done with certain groups who may be deemed at particular risk of committing suicide but who have not been fully considered to date. These included refugee communities.
During the course of drafting this report details emerged of an initial national “census” conducted on 31 March among patients in psychiatric hospital/mental health wards. The findings of this survey confirm that a disproportionately high number of people from Black African and Caribbean communities face institutionalised treatment (see the section on ‘Service take-up’ for a brief discussion of its headline findings).
The NHS Information and Resource Pack “Meeting the health needs of refugee and asylum seekers in the UK - an information and resource pack for health workers” contains a wealth of information on the mental health issues that may affect members of refugee communities. As the Pack notes:
“Psychological distress is common amongst asylum seekers and refugees. People commonly experience:
• extreme sadness
• anxiety, depression and panic attacks
• problems with memory, concentration, disorientation and
• poor sleep patterns (almost universal).
These may result from:
• the atrocities and multiple losses that people have experienced
• displacement and their current situation in the UK
• social isolation, poverty, hostility, loss of status and racism, which have a compounding negative effect on psychological health
• the uncertainty of a life in limbo and the fear of being sent home
• loss of their friends, family and community, as well as their home, job, culture and country
• mental illness, which may be long-standing, or which may be linked with their experiences.”
The Pack further notes that:
“Expressions of distress and the ways in which people cope differ both between and within cultures, which makes assessment and treatment of psychological health problems of refugees complex …Cultural differences and difficulties with language and communication may increase the possibility of a misdiagnosis of mental illness”.
Nationally, a series of initiatives have been taken to identify and address the mental health needs of refugees and asylum seekers. In Greater Manchester, for example, the Wellbeing project helps isolated asylum seekers and refugees in developing a positive sense of well-being. This project was established because:
“Refugees can be more vulnerable to developing mental health problems, especially anxiety or depression. This is partly because of the kinds of trauma many have experienced in their home country – many refugees have seen the deaths of family and friends, or have lived through civil war, or have been beaten up and tortured for their beliefs and many have feared for their own lives.
However refugees are also vulnerable to developing mental health problems because of the huge challenge of adjusting to a whole new way of life, away from everything that is familiar. Many are here without family or friends and many are fearful for family or friends back home. Refugees have to leave their job back home and can find it very difficult to get employment in the UK. Many refugees and asylum seekers can become incredibly isolated”.
More locally, depression and mental health problems were identified as an important issue in the 2004 report, Somalis in Camden: challenges faced by an emerging community (Khan and Jones, 2004). Problems highlighted with regard to this ethnic group included stress, especially Post-Traumatic Stress Disorder (PTSD), depression, trauma and the psychological side-effects of khat use.
“Mental health: people keep everything inside, cannot communicate, they tried to kill themselves. Suicide is rising in the Somali communities”
(Participant in Somali Health Focus Group)
n.b. with regard to the Somali community in the UK more widely, the 1999
CVS Consultants/Migrant and Refugee Communities Forum report A Shattered World – The mental health needs of refugees and newly arrived communities, has referred to:
“The numbers of young Somali boys and men committing suicide in a most dramatic and gruesome fashion (and who come from a community in which suicide is virtually unknown in the country of origin)”
Beyond the identification of mental health issues, accessing existing mental health services can be a key issue. In many societies mental illness carries significant stigma, which may deter people from accessing services. For example, the report of the 8th National Chinese Mental Health Conference (June 2002) notes that:
“There is a stigmatization of individuals with mental health problems . . . This level of stigmatization was a significant reason why people didn’t seek help.”
The CVS Consultants/Migrant and Refugee Communities Forum report additionally notes that:
“According to the Somali Counselling Service there are many health problems which are traditionally seen in Somali culture as being caused by the will of God, and there is a strong taboo around such problems. Mental illness is one such problem and thus any treatment associated with any aspect of mental health would be seen by many Somalis as particularly offensive, making it very difficult for most Somalis to come forward and seek stress therapy, for example. Other projects, however, felt that . . . religion was less strong for Somali people and that the real issue was a lack of awareness of mental health issues and symptoms and a lack of awareness of the services that are available”.
Regardless of whether the key issue is one of stigma or one of lack of awareness the outcome is evident: lower levels of take-up of the services provided than might otherwise be expected.
Mental Health services provided within Camden
As part of our research we sought to identify the mental health services that were available within Camden. We would not claim that the list of services that we identified is fully comprehensive although we believe it does give a reasonable indication of the services that are currently available. For a far more comprehensive listing of mental health services for asylum seekers and refugees in London, we would recommend the SPaRC/ICAR report (Ward and Palmer, 2005). Service providers identified by that report with a focus specific to Camden were:
NHS trust specialist services
Tavistock Centre provides a range of services including the Peace of Mind project [see below]. Services provided include:
- Family work, parent work, individual or group therapy for children and/or parents
- Consultation with schools and the professional network
- Community-based initiatives including a time limited in-school counselling service for refugee young people in a comprehensive school, a group for refugee children aged between four-six years in a primary school and individual work with refugee children in a range of local primary schools.
- From one to four consultations with a member of the staff of the Trauma Unit
- A specialist group, which meets weekly, for individuals whose fluency in English, is limited. The services are offered by medical and non-medical psychotherapists who give consultation, training and treatment. By and large they work within the framework of psychoanalytic or systemic psychotherapy.
Traumatic Stress Clinic – specialist trauma therapy [see below]
Intercultural Counselling Service – Serves Camden and Islington. Counselling psychologists offering short-term counselling. Services are delivered in five GP practices across Camden and Islington. Counselling can be provided in Turkish or Farsi and an interpreter is used for other languages.
Primary care trust (PCT) services improving healthcare access for refugees and asylum seekers
None were identified in Camden.
Specialist mental health services outside the NHS
Bosnian Resource Information Centre Kosovar Support (BRICKS) – [see below]
St Pancras Refugee Centre (SpaRC) – [see below]
Ethiopian Support Association – [see below]
[Source: Ward and Palmer (2005)]
It is worth pointing out that the SPaRC/ICAR mapping exercise highlighted the comparative lack of mental health services for refugees and asylum seekers in London generally (i.e. not just in Camden):
- o Only five of the 11 Mental Health Trusts provide specialist services that are specifically designed with the needs of refugees and asylum seekers in mind. These services are provided by: Central & North West London; North East London; Barnet, Enfield & Haringey; Tavistock & Portman, and Camden & Islington.
- o Some of the services provided by the other Trusts, such as the Traumatic Stress Service (South West London and St George’s) and the Institute of Psychotrauma (East London and City of London) provide specialist trauma services for refugees and asylum seekers (who make up about 50% of their client group), but they do not have a team or an individual that works specifically with asylum seekers and refugees.
- o Services for refugees and asylum seekers within PCTs are very difficult to locate. The research has shown that equality and diversity managers are often unaware of individuals or departments that have a special responsibility for refugees and asylum seekers. Some commissioning departments also seem to be unaware of services that the PCT funds. It is also very hard to locate individuals, such as health visitors, whose remit is to work with refugees and asylum seekers, but who are not attached to a dedicated asylum seekers team.
- o With the exception of a handful of PCTs, there appears to be a general lack of awareness that refugees and asylum seekers are a group that have distinct needs, which are multiple and complex, and that require specialist knowledge.
- o There are only a small number of ‘specialist’ organisations outside the NHS that provide culturally appropriate services to this group.
As per the SPaRC/ICAR study, we would also wish to point out that a number of the services included in our study were not specific to Camden. The services included in the research are detailed below.
Peace of Mind Somali Children’s Project
Funded by the Children’s Fund, set up in partnership with the Somali Community Centre and based at the Tavistock Clinic, this Camden-specific project focuses on 5-13-year-olds of Somali origin, working with the children, their families and their teachers, and addressing issues of mental well-being.
The name of this service carefully avoids any mention of mental health, as any such mention would dissuade people from using the service owing to the stigma attached to mental illness (see “Factors affecting access to services” below).
Staff work in pairs: a Somali worker and a Children and Mental Health Service (CAMHS) worker.
The Project includes:
- Drop-in sessions
- Parent-School Consultation Service
- Awareness Days for parents
- Parenting training
- Group work with children.
Primary Care Mental Health Workers
Part of a Government initiative based in GP practices, a six-person team of Graduate Workers provides Camden-specific services. Team members are assigned to one of five locations (covering three to five practices), with a sixth (Bengali-speaking) member “floating” around practices with Bangladeshi clientele. One team member is Somali-speaking. While not specifically focused on refugees, it is estimated that 50% or more of the caseload is comprised of refugees and asylum seekers.
Two specific services are provided (for those aged 18+ years):
i) community links – linking clients to community and social groups:
“There’s so much for this client group in Camden that they don’t know about”
ii) Guided self-help.
Traumatic Stress Clinic
The Traumatic Stress Clinic is part of the Camden and Islington NHS Mental Health and Social Care Trust (i.e. it serves both London boroughs). It is a specialised service for adults, young people, children and families. Originally established by the Department of Health, the service offers outpatient treatment for Post-Traumatic Stress Disorder (PTSD – see below). Indeed, the clinic specialises in treating refugees who have suffered /are suffering from PTSD.
Referrals are accepted mainly from secondary care services (e.g. Community Mental Health Teams within the Trust and Psychology services), although there have been some GP referrals and physical health teams have also been known to refer clients for treatment (e.g. neurology). The team specialise in working with refugees and asylum seekers aged 18 and up, but are flexible in accepting those who may be a little younger.
There is a multi-professional approach to providing services, including psychiatrist, clinical psychologist and psychotherapists. Services provided include: specialist psychological interventions, therapy, individual, and group counselling; treatments including Cognitive Behavioural Therapy (CBT); Assessment/Psychiatric Support although this input is reducing due to funding; psycho-education methods to reduce anxiety levels and sleep problems and help individuals to control and manage symptoms; group therapy (e.g. a Women’s group and a group for survivors of torture).
Support/therapy is delivered on a phased intervention. The first phase is about early intervention following assessment, developing safety, trust, establishing therapeutic relationships with clients, assisting them to take control, support and referral with legal status (with legal advice from St Pancras Refugee Centre – see below). The second phase is focused on treatment - individual therapy, group therapy (n.b. these groups can last for up to a year). The team and individuals will see clients for a lot longer to assist in achieving stability - up to two years, particularly for those with multiple traumas (60%) or those who are survivors of torture.
The current waiting list for the clinic is 50+. Individuals can wait for between one-two years for treatment though most are able to be placed/offered support through the phased intervention approach. All clients referred are assessed within a period of two to three months.
The main communities served by the clinic are Kosovans (especially women), as well as clients from North African Communities, Somalia, Afghanistan, Bosnia, Iraq, Iran, and Kurdish and Turkish communities.
Interpretation is provided. Some interpreters go on to become counsellors and volunteers to work at the centre. In terms of language support, Turkish, Albanian, Arabic, Farsi and Kosovan speakers are seen as well served. There are, however, gaps/current difficulties in language provision in terms of: Ibo, Somali, Swahili, Russian and French.
The clinic has undertaken (and continues to undertake) training and awareness sessions for Community Mental Health Teams (CMHTs), and NHS Trust staff regarding refugees and Post-Traumatic Stress Disorder (PTSD – see below), so helping to build up expertise within a range of professionals. The clinic would like to extend this to the primary care system.
Bosnian Resource Information Centre Kosovar Support (BRICKS)
BRICKS provides social and cultural events, physiotherapy, advocacy and advice for anyone from the former Yugoslavia. In addition, BRICKS provides specialist counselling and psychotherapy (cognitive, psychodynamic and existential) to people with Post-Traumatic Stress Disorder (PTSD) and depressive disorder. This service is provided free of charge and is offered in both English and Serbo-Croat (Kosovan/Albanian interpretation is also available).
In order to make people feel more active and valued, and to overcome isolation, the organisation tries to draw on the expertise of community members through talks, art and performance, n.b. the SPaRC/ICAR report (Ward and Palmer, 2005) has noted that:
“Psychosocial support, in the form of practical help and social activities, was seen as the most effective way of reducing isolation and responding to mental health issues”.
The Fe-So Project
The Fe-So project provides culturally sensitive support to people who have mental health needs from African and Caribbean communities. Services provided at the Fe-So project include support and advice; emotional and psychological support; confidence building, advocacy and recovery work; Food and Mood Group (how different foods can affect mood); cultural discussions group; African Drumming; an Out and About group visiting concerts, theatres, galleries, educational and fun activities; and workshops on ICT, dance therapy, health, arts and crafts and alternative therapies. The project also provides alcohol and drugs advice sessions via New Roots and advice sessions by CHA Social Inclusion Team. Fe-So staff provide keyworking support to members on various services, e.g. benefits, housing etc. Duty staff are also available to members with emergency support issues. Fe-So also provides an outreach service to clients currently in hospital within Camden, e.g. St Luke’s and the Huntley Centre at St Pancras hospital.
The Medical Foundation for the Care of Victims of Torture
Not Camden-specific: it provides a range of services provided including consultation, report writing (medical legal reports to support asylum applications), counselling (with 10 full-time posts, 20 volunteer counsellors and 15 psychotherapists) and capacity building. “Softer” services provided include a befriending scheme and art, writing and gardening groups. The Medical Foundation will provide services in cases where someone:
i) has been detained and tortured
ii) has been affected by detention or torture
iii) is able and willing use the Medical Foundation, and
iv) has no easily accessible alternatives.
St Pancras Refugee Centre (SPaRC)
Not Camden-specific (c. 50% of clients are from Camden). The Centre’s aims are (HCCT, 2003) to:
“Benefit and ensure access to services for refugees and asylum seekers in Camden and Islington improving health care, social inclusion and quality of life. Through a range of services provided by both the project itself and a number of partner agencies, the project impacts on health, housing, benefits, community care, education and employment”.
SPaRC provides an integrated/holistic service (psycho-social support) with a mental health focus. The project’s principal aims are social inclusion, and prevention/reduction of poverty in its client group. This is achieved by providing a comprehensive one-stop service focusing on professional advice, advocacy and casework, social support and outreach. Services provided include:
- Twice weekly drop-in sessions (with interpreters for main community languages)
- Advice, advocacy and casework
- Health education and awareness
- Outreach work (e.g. at TB clinics and Traumatic Stress clinic)
Counselling is provided in non-direct ways such as art workshops, health workshops, and the drop-in sessions.
“I am 20 years old and Congolese. I didn’t have a childhood, like most people my age. I lost all the people and family dear to my heart. I was despairing when I came here. I was living with a friend at first, but had to leave. My second GP sent me to a psychiatrist, who put me on medication and sent me on to a specialist at the Mortimer Clinic for treatment for Post-Traumatic Stress Disorder. She told me about Holy Cross. When I left my friend’s house, I had no papers, no income for six months. I slept on a church floor. The psychiatrist said I needed their help to become stable socially, when she would then be able to treat my PTSD. At the time I was angry with God, blaming him for my bad experiences, jealous of other people my age who had good lives. I hated them. Arriving here really helped. They sorted my benefits out, I have a roof over my head in a hostel, I have a National Insurance number and my psychiatrist can treat me. I’m beginning to see a purpose to my life, my English is improving and I have met others with similar problems. The meals here are very important for everyone and it’s a time when the team are helping others with mental health problems and their benefits. In the outside world, when I tried to cope, with no money and with mental health needs, ordinary people treated me as nothing and I had no self-esteem left. The first GP refused to treat me – I have asthma – because I had no fixed accommodation; they said they couldn’t register me. Although I needed treatment for my asthma, the receptionist blamed me and refused me a service. It’s like I have a family here; I can talk about my problems and get help. I’m attending Kingsway College now for English classes. It means I’m with my own age group, as the classes here are attended by older people mainly. I don’t yet feel 100% safe, but I do have goals now.”
SPaRC service user quoted in “Camden Best Value Review of Mental Health Day Services – Narratives of Stakeholders”
With regard to statutory services there is a clear division between primary and secondary care. In terms of the former, GP services were identified as an area of concern by many interviewees. These were seen as the services that refugees were most likely to be “plugged into”, often as temporary patients. Many GPs were seen as being notoriously bad at using interpreters (it was, however, also pointed out that refugees can be poor at keeping appointments). Primary care providers can find it particularly problematic to meet the needs of refugees because of:
i) the range of problems that they might have, and
ii) the “language problem” slowing things down.
On the other hand, it was stated by a PCT interviewee that specialist services won’t offer people treatment unless their refugee status is certified. Thus, there is a huge group of people experiencing stress who cannot access the services they need.
It was clear from our research that data regarding the take-up of mental health services by refugees is, at best, patchy. For primary services, interviewees in the sector themselves saw service-monitoring data as:
Whilst “Hard” data was generally not available, the more subjective view emerged that the take-up by refugees of primary services around mental health was very high.
With regard to statutory secondary mental health services, however, the picture appeared to be less clear. On the one hand there was a perception that take-up by refugees was much lower (partly because there is reportedly no reason to assume that refugees have higher rates of paranoia, psychosis etc, and partly due to the barriers to service access detailed below). On the other, it was felt that refugees are likely to be more prevalent at the “severe” end of mental health provision and less likely to get treatment at the “soft” end (massage, “buddying”, activities etc), primarily because (for the range of reasons we detail later in this report) they are likely to access services only:
“When they collapse”.
It should be noted, however, that a PCT interviewee felt that generally some 90% of people with mental health problems don’t get referred to specialist services, as they don’t meet the appropriate criteria, and are thus managed in the primary care sector.
It should also be noted that there might potentially be differences in the take-up of mental health services by different communities. For example, service take-up by the Congolese community is perceived (within that community) as being very low given suspicion, lack of trust and lack of understanding of how mental health services operate. It is also seen as shameful not to cope or to be able to deal with one’s problems within one’s immediate family/community (see “Factors affecting access to services” below). Consequently, individuals will seek help through GP practices but will report physical rather than psychological problems. Occasionally individuals will be prescribed anti-depressants by their GP, however, more often than not individuals will turn to community leaders, friends and family to help deal with mental health problems, or seek to resolve them through spiritual intervention i.e. possession by evil spirits dealt with by the church or church leaders.
What is clear, however, is that there appears to be a dearth of ethnic record keeping and monitoring in the statutory sector. To give but one example (and it is not our intention to be overly critical of this particular agency) no ethnic monitoring data was available from the Traumatic Stress Clinic, even though the clinic reportedly keeps records and monitors referrals/caseloads/clients. The current database is limited in terms of the information it holds (see also the Medical Foundation for the Care of Victims of Torture below) and is currently being updated.
On 31 March 2005 “Count Me In: National Mental Health and Ethnicity Census, England and Wales”, the first Census of all mental health inpatients in England and Wales, was carried out. It covered some 34,000 mental health inpatients (99% of the eligible total), using services provided by 102 NHS trusts and 110 independent providers in England and Wales.This was led by the Mental Health Act Commission (MHAC), in collaboration with the National Institute of Mental Health in England (NIMHE) and the Healthcare Commission. The Project Protocol states that:
“All registered providers of mental health inpatient services (NHS and private and voluntary establishments) must complete the Census”
The Project’s aims were:
- To obtain robust baseline numbers of black and ethnic minority inpatients (informal and detained patients) using mental health services on a specified date in 2004-5 and to analyse the information available in a variety of ways as described in the Protocol
- To encourage all mental health providers to have accurate, comprehensive and sustainable ethnic monitoring, and ethnic record keeping procedures in place that will provide the basis for high quality data on the ethnicity of patients in all future data gathering exercises, and
- To investigate the extent to which the providers of mental health care, as perceived by service users and service commissioners, have implemented culturally sensitive, appropriate and responsive services with effective care planning and local evaluation influenced by information on patient ethnicity.
Published in early December 2005 (after the completion of the Camden research) the Count-Me-In census showed that Black African and Caribbean people were three times more likely to be admitted to hospital and up to 44% more likely to be detained under the Mental Health Act, when compared with the general population.
Mental health officials see the census as a significant step forward since it offers for the first time a baseline for ethnicity monitoring at a national level.
In a joint foreword to the report of this census, Healthcare Commission Chairman Sir Ian Kennedy and Mental Health Act Commission Chairman Professor Kamlesh Patel say: "Ethnic monitoring has been mandatory in publicly-funded mental health services since 1995. That it has not been done well shows a lack of understanding of the value of having such data for planning services that are culturally sensitive."
In addition to information on ethnicity (using the Mental Health Minimum Dataset classifications plus an additional code for Welsh), the census dataset includes a category “Patient known to staff as Asylum Seeker” (“Is the patient known to staff as an asylum seeker?). Whilst the usefulness of this category is open to debate (Will staff necessarily know that someone is an asylum seeker? What about someone who already has refugee status? Isn’t the category “asylum seeker” too broad? etc). It should, at the very least, provide some very basic information. During the course of our research, however, we were unable to obtain any hard information from the “Count Me In” Census, regarding refugees and asylum seekers.
While information on service take-up (either by ethnicity or by asylum seekers/refugees) in the statutory sector was generally conspicuous only by its absence, in the voluntary sector a number (but not all) of the agencies we interviewed kept far more detailed records (although it should be pointed out that this might be due to funding requirements). Details from the voluntary sector agencies are given below:
While no “hard” data was available, the organisation was reportedly working at capacity (80 people per year):
“But there’s much more people who use it.”
It was reportedly hard to get people to consider psychotherapy at first (due to an attitude of “I’m not mad, I don’t need it”), but people had been encouraged to come forward. Cognitive psychotherapy was felt to work particularly well with refugees as it reinforced a positive attitude.
The Medical Foundation for the Care of Victims of Torture
Only estimated data was available – this would suggest that there are between 2,000 and 2,500 open cases at any one time and in the region of 2,500 new referrals each year. More accurate data was not available because:
i) Volunteers see filling in forms as unnecessarily bureaucratic
ii) The database is inadequate
It was perceived that there has been a major shift in the client countries of service users in the last five years. Prior to this service usage used to be 50% Middle Eastern and Asian, 40% African and 10% European. Now at least 50% of service users are African.
F- So Project:
Details of service take-up for the third quarter of 2004-2005 are given in the table below. “MHG” refers to Mental Health Grant. Figures will include people who are not refugees (as the service is for people from African, Caribbean and Asian communities who have mental health needs).
No. of service users aged <65
No. of service users aged > 65
Women from BME communities with Mental Health problems
Men from BME communities with Mental Health problems
Total no. of service users
Sixty-eight of the service users described themselves as “Black African”; no specific data on individual refugee/asylum seeker communities was, however, available.
The St Pancras Refugee Centre (SPaRC)
The Centre keeps extremely detailed records of service usage. In 2004 SPaRC saw a total of 410 clients for advice appointments, which resulted in 1,047 appointments. Clients can access support and advice from the project by using the appointment system or by attending one of the drop-in sessions that are held on Wednesday or Friday afternoons. The number of times that a client attends the project for assistance depends upon the nature of the issue and can range from a one-off contact to a series of contacts over many months.
The table below shows the nationalities that comprise the client group. Nationalities are displayed when four or more clients from that country have attended the project.
Source: SPaRC, 2005
More than half of the clients that are seen by the project are from Africa. Somalis make up the biggest nationality group. Somalia, Eritrea, the Democratic Republic of Congo, Iran and Afghanistan are all countries that are currently producing a lot of asylum seekers (see Home Office (2005)). However, the project sees very few clients from other countries, such as Sudan and China, which are also significant countries of origin for local asylum seekers. This is probably due to the fact that SPaRC covers a limited area of London and, in general, there is a tendency for ethnic groups to form communities in specific areas rather than disperse throughout the city. Camden is a key focus for Somalis, others from the Horn of Africa, Iraqis and Iranians. More recently, the borough has attracted large numbers of people fleeing war and disruption in the Democratic Republic of the Congo and neighbouring states (as reflected in the table above).
More than two-fifths of the project’s clients have been granted indefinite leave to remain as refugees (42%), and a further 35% are asylum seekers.
Source: SPaRC, 2005
A majority of the project’s clients are female and between the ages of 31 and 60:
Source: SPaRC, 2005
Source: SPaRC, 2005
In addition to the above, in the first three quarters of 2004/5 the project has undertaken comprehensive casework with 181 Camden residents from 27 different nationalities speaking 22 different languages. Throughout the whole year 410 individuals benefited from advice and intensive casework, of whom 333 were new to the service.
While it is clear that a number of voluntary sector agencies are collecting quite detailed records in terms of the ethnicity/country of origin of those using their services, there is still a problem regarding the interpretation of that data. Internal month by month, year by year trends can be identified but there remains the problems of there being no external “baseline” against which service take-up can be compared. This is due to the lack of accurate data on specific refugee communities:
- The ethnicity categories used in the 2001 Census were very broad – for example, according to the Census 5.96% of Camden’s population in April 2001 described themselves as being of “Black and Black British: African” origin, with no sub-division of this category being available
- Following on from the above, the Somalis in Camden: challenges faced by an emerging community report (Khan and Jones, 2004) noted that:
“While several researchers have cast doubt on the accuracy of Census figures [e.g. Jones, 1998], there are, at least, some hard figures available. This has not been the case with Somali community due to the…absence of a separate “Somali” category”
This clearly holds for other refugee communities as well.
There was no Census question specifically about refugee status.
Country of origin data was collected as part of the Census – figures for Camden’s population by country of origin are as follows:
Country of Origin Number
Other South and East African 2,631
(includes Ethiopian and Eritrean)
All Central and West African 3,457
(includes DRC 333
and Sierra Leone) 313
Former Yugoslavia 1,872
(includes Kosovan) 968
(Source: National Statistics, Census 2001)
* while this figure refers to Albanians from Albania (i.e. it does not include ethnic Albanians from the former Yugoslavia) it does seem questionably low.
A number of important caveats must, however, be attached to these figures:
i) these figures do not include other members of the household or those born in this country
ii) refugee community sizes are likely to have changed since the Census was carried out in April 2001. Consequently, the data for some countries will have limited validity/relevance.
In conclusion, however, accurate baseline data regarding refugee communities in Camden will be of little use in terms of providing a comparator for service take-up data if there is no monitoring of the take-up of services in terms of ethnicity/country of origin in the first place.
Factors affecting access to services
Barriers to access by refugees of primary and secondary health services have been widely identified. A study for the Home Office (Carey-Wood, 1997), for example, noted that:
“Though registration with General Practitioners amongst refugees is high … several factors lead to under-use of primary and secondary health services. These include lack of spoken English (or adequate interpreting services); lack of awareness or sympathy towards the refugee experience on the part of health professionals; and lack of knowledge on the part of refugees about their rights to health care. Another factor is the psychological or stress-related nature of many health problems suffered by refugees, which are particularly difficult to explain in a foreign language”.
With regard specifically to access to mental health services, while those we interviewed during the course of our research generally felt that many refugees do, quite understandably, have mental health issues they also identified a number of clear potential barriers to the take-up of mental health services by refugees.
While some of the obstacles to take-up were specific to refugee groups, several, particularly attitudinal ones, are hardly peculiar to refugee communities, though they are quite probably more prevalent than in the white British or BME population generally.
The key barriers identified by those interviewed were those of language (as per the Home Office study cited above with regard to health services generally) and the lack of culturally appropriate provision, with interpretation (or rather the lack of it) being clearly seen as the main barrier to service access. With regard to language issues a number of problems were identified:
- Word for word translations can often be misleading, failing to get the true message across
- There is not enough “same language” counselling
- There is a need to ensure that, where it is available, interpretation is accurate
- Lack of interpreters (e.g. at GPs’ surgeries) makes it difficult for refugees to access services and discourages them from coming back.
- GPs will often rely on friends/family of a refugee to interpret rather than arranging a later meeting with the refugee – the risk with this is the interpretation may not be accurate and/or the client may be unwilling to give all the details
- Medical staff either don’t know how to access interpreters or feel uncomfortable accessing them. GPs were seen as reluctant to exceed their funding for interpretation and yet, from the point of view of a non-English speaker:
“If we don’t have an interpreter we struggle.”
“We are trying to work with GPs and bring these matters up all over in various forums. Their vision is that these people are transient and they can’t be bothered to offer a humane service. Practices, mainly single-handed, south of the Borough are the worst. Group Practices further north in Camden are much better. We are working to offer interpreting services and have made successful links with TB services to do so, at no cost”
Manager of the Refugee and Asylum Seekers Service, quoted in “Camden Best Value Review of Mental Health Day Services – Narratives of Stakeholders”
A number of examples of good practice in terms of the provision of community languages were identified. The St Pancras Refugee Centre, for example, has a core group of eight interpreters covering key refugee community languages. In addition, it has links with other “occasional” interpreters who can cover other languages.
With regard to mental health services generally, the following barriers to access were identified:
- The lack of recognition/awareness amongst some refugee communities of the complex nature of mental health. For example, several interviewees referred to the Somali view of mental health as consisting of “sane” or “mad” with nothing in between, or as one interviewee put it:
“You’re mad or you’re not”.
Similarly, in the Congolese community, mental health/illness is not recognised or accepted; it is a taboo area and can bring shame on families and individuals.
- Following from the above, the stigmatisation of mental ill-health in some communities:
“Somalis have no culture of accessing mental health services due to the stigma”.
This can have a major impact on service take-up. For example, we were told that many Somalis with mental health problems would not access mental health services, or even inform others that they feel distressed, due to the stigma attached. Consequently, they will only use mainstream mental health services if they have been referred to them by a GP and then only when their problems have reached a critical stage. It was clear from our research that this is not restricted to the Somali community alone.
- As well as stigma within a community, individual communities can themselves be stigmatised by other communities. For example, the Roma community, which is very closed, experiences a lot of stigma. It is reportedly traditionally self-reliant, so finding it difficult to accept/access services.
- Mental health can have moral and spiritual dimensions, and mental ill health can reflect badly on a person’s entire family. With regard to the Somali community, the view was expressed that mental health problems are seen as:
“An act of God, therefore you don’t touch it”.
- There can be pressure to conform to societal/traditional ways of coping (e.g. maintaining confidentiality within the community/resolving issues by traditional methods such as family intervention, herbal remedies and medicines or through spiritual intervention).
- For the Kosovan community there are clear gender differences. Men traditionally are stoical and feel they need to be strong and are in denial of their experiences. Consequently, they present with physical symptoms and would much rather have/be prescribed medication as opposed to talking therapies. For Kosovan women, the Traumatic Stress Clinic has seen a high incidence of trauma caused through rape and torture, leading to stigma within the community or fear that the community will find out and they will be isolated/ostracised.
- Fear of being labelled as “mad”:
“A genuine fear that they’re going to be sectioned, institutionalised”
As a result of this mental health problems were often hidden within the family
- Fear that, if you are still seeking asylum, the “authorities” will use the existence of mental health problems as an excuse to repatriate you
- Problems of motivation (linked to mental health problems)
“They think they can sort it out themselves”
- The clash between youth and traditional cultures, with youth having little or no respect for the traditional culture. For example, in the case of the Congolese community part of the traditional “respect” culture is confidentiality within the family or immediate community in order to resolve problems without getting professionals/social services, etc involved. Mental health issues are therefore somewhat hidden and individuals who suffer are taken care of within their own community. In the Congolese community individuals tend to be ostracised within their community if they bring in professional services. Those with mental health needs tend to be supported by community leaders and the church.
- Differing definitions of “mental illness” between cultures. Indeed, the SPaRC/ICAR report (Ward and Palmer 2005) notes that:
“Refugees and asylum seekers often see the Western mental health model as an alien concept and psychiatric treatments are generally unfamiliar to them. Many do not understand the treatments administered.”
- No experience of mental health services in country of origin.
With regard specifically to statutory services the barriers identified included:
- Lack of knowledge of services available or knowledge of where to go to access them. For example, documentation in the appropriate community languages (to enable individuals to know who to contact and how) is not adequate.
- Lack of awareness on the part of refugees that GPs can deal with mental health issues as well as physical problems
- Unfamiliarity with the appointment system. The failure of clients to keep appointments may, however, be due to their unwillingness to travel owing to fearfulness/flashbacks.
- Length of waiting lists (e.g. for the Traumatic Stress Clinic).
- Fear of accessing “mainstream” providers e.g. one interviewee referred to the “institutional” physical nature of many sites of service provision and the fear that that might engender (especially among former victims of torture).
- Linked to the above, the view was expressed that refugees have such a negative experience simply registering with GPs and getting past the receptionist that they are reluctant to come back. Consequently, GPs only tend to see them when they have reached a crisis situation.
- If they are not registered with a GP then they cannot get referred to specialist services.
- Whilst some GPs were seen as forward thinking, others were felt not to be interested in addressing refugee mental health issues, seeing refugees as “trouble”.
- Given that GPs may be seen as “overwhelmed” and thus not able to give individuals enough time, combined with the wide range of problems that refugees might be facing (and the language problem/ lack of interpretation) there is a danger that GPs may miss mental health problems (or may fear “opening up a can of worms”), with the result that the patient is not referred to the specialist service/s they may need. This is of key importance given that it was stated that:
“GPs are the gateway to people accessing services”.
- Parallel to the above, given the range of problems they are faced with there is a danger that refugees themselves may ignore health problems until they become critical:
“When you’ve got a million problems health is the lowest priority.”
- Fear of Western medicine making refugees reluctant to access mainstream services. For example, we were told that some Somalis fear that if you ingest some medicines (or have an injection) it will take your personality away, leaving you in a virtual zombie state.
- Fear of what will happen to your children if you admit to having mental health problems – the persistent fear in the Somali community, for example, that Social Services are there to take your children away from you.
Voluntary sector service providers, or more exactly those with specific links into refugee communities, can have distinct advantages in terms of accessing members of refugee communities, in providing culturally appropriate services and providing services in the appropriate community language:
“We’re culturally sensitive…we work within the community”
Without such cultural sensitivity one voluntary sector interviewee stated that:
“It’s not really a profound dialogue”.
On a similar note, the Medical Foundation for the Care of Victims of Torture felt that one factor behind the high level of take-up of their services by refugees was that they are seen as a “Human Rights” organisation, rather than specifically as a provider of mental health services.
The key role played by refugee community organisations (RCOs) was highlighted by several interviewees. Alternatively, the view was also expressed that the most seriously distressed members of refugee communities are also those least likely to engage with RCOs. Generally, however, it was felt refugees were more likely to accept treatment (or at the very least information regarding potential treatments) from people who shared their culture and language.
Key mental health issues for refugee communities in Camden
It would, of course, be erroneous to assume that just because someone is a refugee then s/he must have mental health problems. The East Midlands Consortium for Asylum Seekers Support have noted in a briefing paper (Read et al 2002) that:
“There is a dichotomy of opinion about the level of psychiatric morbidity and the mental health needs of this population. One view is that all asylum seekers (and refugees) will have severe mental health problems arising from their experiences, which require specialist help, the other is that the morbidity in this group is no higher than the indigenous or general population. In reality there is a continuum of needs, for example there are those who would have suffered from mental health problems regardless of their ‘location’ to some who will undoubtedly experience problems as a result of the experience of transition, change, the asylum seeking process, loss of status etc. At the other end of the spectrum there are those who experience severe mental health problems e.g. psychosis or difficulties resulting from torture and other persecution, or from the experiences of their flight from their homeland. Some will fall between these two extremes”
Many of those we interviewed, however, felt that refugees were more likely than the “indigenous” population to have mental health problems.
The “Asylum Seekers and Refugees in Camden” health needs assessment (Arora et al, 2003) identified mental health as one of the key issues with regard to healthcare services for refugees, stating that:
“Mental health including post-traumatic stress, anxiety and/or depression”
were specific areas which health care services need to address. The SPaRC/ICAR report (Ward and Palmer, 2005) similarly notes that:
It has been acknowledged that refugees and asylum seekers are a particularly vulnerable group and are especially vulnerable to psychiatric disorders, including depression . . .and post-traumatic stress disorder. Research has shown that traumatic events, such as imprisonment; severe bearing; lack of shelter, food or water and torture, are associated with a high prevalence of mental health issues such as; anxiety; concentration problems; sadness; nightmares; recurrent memories of past events
Indeed, it has been pointed out (Mahmoud and Gray, 1999) that:
“Given the level of stress and distress suffered by refugees and asylum seekers, it is perhaps surprising that overt mental health problems are not more common. This in itself can be seen as testament to the resilience of refugees – the ability of the vast majority to function well despite major losses and stresses. The fact is that the refugee dilemma is not primarily a mental health one, but one of social and cultural displacement which may have mental health implications”
Our research identified a wide range of often inter-linked problems that can impact upon the mental health of refugees. One interviewee listed them as:
“War trauma…loss of family…loss of community…dislocation adjusting to a new life…[and following these the need for] rehabilitation after trauma”
Other factors influencing mental health identified during the research were:
- experiencing violence
- being victims of abuse
- witnessing atrocities.
These factors often did not occur in isolation and thus many refugees may have suffered from multiple traumatic experiences.
In the UK there were additional factors including:
- lack of opportunity
- poor diet or inability to access culturally specific food
- misuse of drugs and alcohol as a means of controlling voices/hallucinations
- denial of benefits
- poor (often temporary) accommodation
- stress caused by awaiting outcome of asylum process
- fear of being sent back to country of origin
- social isolation, where individuals have not been able to link in with their own community support networks,
- lack of understanding by service providers of cultural needs, timely interpretation and language support (and not just when in crisis)
- family separation
- high unemployment
- lack of social status
- poor access to GP services.
Many of the problems identified as a result of these factors (see below) are not, however, specific to refugees. As the Civis Trust has noted (Civis Trust, 2004a):
“Most of the mental health conditions experienced by refugees are extremely commonplace in the general population as well, (e.g. depression)”
As the Civis Trust additionally point out, however:
“In the field of refugees and mental health there is one key syndrome – Post-Traumatic Stress Disorder (PTSD) – that is regularly referred to by different practitioners”
Originally classified in 1980 after the Vietnam War, PTSD (a successor to descriptions such as “shell shock”) can arise from a variety of specific events or a pattern of long-term exposure to extreme stress. The criteria for a diagnosis of PTSD (Summerfield, 1996) can be divided into three groups:
- tendency to re-experience aspects of the original events (in sleep or during the day)
- avoidance of reminders of the events (or diminished interest in things generally), and
- increased nervous system arousal (manifesting as sleep problems, irritability, poor concentration, excessive watchfulness, jumpiness etc)
The diagnostic criteria for PTSD contain symptoms that may be non-specific and associated with other diagnoses, for example, major depressive disorder (MDD) and generalised anxiety disorder (GAD).
Refugees do not, however, automatically experience PTSD. Indeed, the term “trauma” is often used colloquially (“shocking”, “deeply upsetting”) rather than medically. The Traumatic Stress Clinic have noted (Civis Trust, 2004a) that:
- In their experience the refugee experience was not automatically traumatic in the medical sense and…only a minority of refugees in the UK would experience PTSD
- This applied to survivors of torture as well
- Some people clearly did have these symptoms and…by recognising them and working with them, the practitioner was better equipped to help the user.
It should be emphasised that PTSD does not manifest itself in everybody in the same way. The Civis Trust (Civis Trust, 2004b) have noted that:
“Refugees vary in their reaction to trauma. PTSD symptoms in refugees differ depending on their culture and background and on the intensity, repetition, and period of exposure to the trauma”.
Our research clearly identified trauma (however defined) as a key issue. St Pancras Refugee Centre, (HCCT, 2003), for example, estimate that:
“A substantial proportion (over 30%) of the refugees and asylum seekers we have worked with to date [n.b. SPaRC was launched in January 2002] have had significant mental health issues though this often does not emerge until the client has been using the service for some time and trust has been established”.
(Most of these clients were not accessing existing mainstream services, for one or more of the range of reasons given above). In addition a further 30%-35% were felt to have less substantial mental health problems, with a further 10% being “borderline”. Particular issues they identified were trauma and khat-related issues (see below).
While a number of drug and alcohol-related problems were identified during the research (e.g. among young people in the Congolese community), the use of khat, identified most especially with Somali and Ethiopian refugees, emerged as an important issue in terms of its potential effect on mental health and well-being.
Somali interviewees highlighted the effects of chewing khat on both the chewer and his (because khat users are mainly male) family and the impact of the changing nature of Somali families (with the father losing his traditional role and with it his feelings of status and power, leading to distress and loss of sense of worth). The 2004 report on Somalis in Camden (Khan and Jones, 2004), found that khat abuse has become an issue of increasing importance for many Somali people in Camden. Indeed, more than a third (34%) of those responding to the survey that formed part of that research identified it as the single biggest problem presently confronting the Somali community. The report further noted that stress (due to related experiences as asylum seekers) was leading people to “self-medicate”.
The long-term effects of khat chewing on health are under-researched, but it can apparently contribute to:
- Psychological problems e.g. depression
- Insomnia and associated paranoia
- Suicidal tendencies.
A recent report for the Home Office (Patel et al, 2005) notes that:
“It is not clear whether khat use causes mental health problems where they did not exist before, or whether it exacerbates already existing problems. Bhui et al., (2003) found suicidal thinking to be more common among Somalis who were using khat in the UK. Furthermore, khat use – as well as other variables – was a ‘risk factor’ for psychiatric symptoms”
A further factor impacting on the overall mental health of the Somali community is family breakdown. While we have already mentioned the loss of status experienced by many males, the increase in the number of female-headed families has reportedly seen a growth in depression amongst Somali women (who are often left alone with the children in an alien environment and can find it very hard to cope, especially on low incomes).
With regard to all refugee communities, key mental health issues identified through the interviews were:
- Depression and psychosis – these should be dealt with by specialist services (such as the Community Mental Health Team) but there was a perception that there was a “huge number of people” struggling with these problems, who might not meet the necessary criteria and would thus be unable to access specialist services.
- Pressure on the newly arrived asylum seekers and refugees due to their being in an alien culture and an associated inability to cope and manage within this new culture
- Anxiety and stress
- Somatic pain problems
- Panic attacks
- Lack of concentration
- Feelings of guilt (at having survived whilst others did not)
- Feelings of isolation (especially if the refugee is a member of a numerically small community):
“Isolation is a huge problem”
- Feelings of hopelessness (sometimes leading to borderline suicidal depression)
- Feelings of loss
- Feelings of worthlessness.
As mentioned in the introduction to this report, the London Borough of Camden Suicide Prevention Scrutiny Panel (July 2004) highlighted the high suicide rates reportedly found in some refugee communities, identifying isolation as a potential cause. This link became apparent from the interviews carried out for the current research. For example, there are very few specific Ethiopian mental health projects, which may exacerbate isolation and reportedly a disproportionately high suicide rate (although not specifically in Camden). Additionally, the feeling of hopelessness associated with refused asylum applications was perceived as linked to high suicide rates – this was seen as a growing problem.
A view expressed by many of those interviewed was that mental health problems amongst refugees may not be immediately evident, they may become manifest later on. With regard to the Bosnian community, for example, the view was expressed that they become settled:
“And then PTSD sets in”.
Self-questioning as to one’s worth and the purpose of one’s life can emerge after the process of applying for asylum has been successfully navigated:
“They feel so burnt out by the process, both physically and mentally”.
Once people are settled and their children are in school they can experience deep loneliness:
“Emptiness comes to their hearts”
For victims of torture, there is a clear issue of when exactly will someone who has been tortured declare this fact. An interviewee from the Medical Foundation for the Care of Victims of Torture pointed out that many people don’t disclose that they have been tortured until:
“Years and years later, if at all”
This links in with the point made earlier that, given the range of problems that confront them, health is the least of a refugee’s worries, until the other problems (housing, education, employment/benefits etc) are apparently resolved, when mental health issues can come to the fore. It is only when mental health problems become critical that refugees will eventually start appearing on the health service radar. Accordingly, a clear need was identified for early interventions (often of a “soft service” kind), once problems initially start to appear, rather than waiting until they become critical. Again, this would require a holistic approach in order to identify those in need without raising fears of stigmatisation or institutionalisation.
Addressing gaps in service provision
Those participating in the research identified a number of gaps in service provision that need to be filled in order to meet the mental health needs of refugees in Camden.
At the most basic level, in the early stage it was felt that what is most needed is:
“support and a friendly ear”
Indeed a guide produced by the Medical Foundation (Burnett, A., 2002) states that:
“For many people supportive listening, reducing their isolation and dependence, having suitable accommodation, and being busy with education or work can do much to relieve feelings of sadness and anxiety”
Overall some interviewees felt that the whole issue of refugee mental health needs to be “mainstreamed” – that is, those in decision-making positions need to be aware of the issues around refugee mental health, to promote the importance of addressing these issues and to treat refugee mental health as part and parcel of their work. Others, however, felt that integration into mainstream services would not work and that separate, culturally appropriate services were needed.
It should be stressed that this is not a Camden-specific problem. A briefing paper produced by EMCASS (Read et al, 2002) for example, stated that:
“Whilst many Health Authorities, Social Services Departments and Health Trusts have taken important initiatives to address general health and social care needs, the mental health care needs of this client population have not been addressed in any systematic, cost effective way”
A number of issues of general applicability were identified by those we interviewed during the course of our research in Camden. These included:
- The unmet needs of those who do not yet have leave to remain/refugee status, and thus do not qualify for specialist treatment
- The need for earlier interventions before symptoms become severe
- Poor or inadequate access to language support to assist in mental health assessments and other services. There is a need for more available and accessible language/interpretation services that have an understanding of mental health needs - individuals are often unable to explain themselves to professionals. Interpretation was identified as a key issue by all interviewees
- A lack of specialist services e.g. trans-cultural counselling/ the need for access to services for those with post-traumatic stress disorder
- A lack of understanding by professionals regarding cultural needs and norms e.g. use of drugs, and
- A lack of culturally specific provision e.g. psychotherapy.
With regard to the statutory sector generally, there was felt to be a lack of culturally appropriate services. Where such services were provided (e.g. by BRICKS), it was generally the voluntary sector that was providing them.
With regard to primary care services, there were felt to be gaps with regard to:
- health assessments
- interpretation - there is reportedly no system in place for accessing interpreters when needed
- accessing services (as detailed above)
- same language counselling (since counselling through an interpreter is not adequate). It was felt that refugee communities are overcoming previous doubts about the worth of counselling, especially where counsellors are seen as professional and therefore as respecting confidentiality
- cultural awareness on the part of staff, and
- awareness of the specific needs of refugee communities.
More specifically, refugees were not included in the new GP contract with regard to “enhanced services”, although this does include homeless people (which may include a number of refugees). As a solution to this it was suggested that “enhanced services” could be expanded to cover refugees.
In addition to the above, the need for individual advocates (“interpreters plus”) for refugees was highlighted – this is a particular issue given that mental health needs need to be addressed holistically and thus involve a range of different agencies (health services, social services, solicitor etc).
With regard to the secondary mental health sector, there was felt to be not enough provision. Further, there was a gap regarding the needs of people who would be unwilling to consider using something as (Western) culturally specific as counselling.
While the Traumatic Stress Clinic offers psychiatric support through a consultant psychiatrist, prescribed medication etc (as part of the multi- disciplinary approach), this service is shrinking through lack of funding. There is thus a potential gap in current service provision for those with psychiatric symptoms, such as psychosis, which can overlap with symptoms of PTSD.
Further problems identified by the Traumatic Stress Clinic included:
- Waiting Lists for assessment/treatment being too long, resulting in morale issues as well as delays in interventions
- A block on primary care referrals to the clinic
- The problem of medium and longer term funding of the clinic in relation to NHS pressures to achieve outcomes using short-term models of treatment
- Increasing case loads limiting effectiveness of service
- The clinic is primarily a service for adults aged 18 upward, thus more recognition is needed of the impact on and needs of refugee families and younger adults
- The interpretation service that is currently used is NHS in-house, raising problems of what happens if the budget is overspent.
For voluntary sector organisations the key issue identified was (lack of) funding (although the Traumatic Stress Clinic drew attention to the general under-funding of services and the need to find sources of funding other than the trust). Without adequate funding they cannot provide the range of services that the statutory sector is currently failing to provide. Issues such as the cost of interpretation also arise. At present Refugee Community Organisations (RCOs) were seen as heavily relied upon. These organisations were, however, felt to lack both resources and specific mental health expertise.
Refugees do not form a homogeneous group. For specific refugee communities a number of gaps were identified (although the gaps may be of more general applicability). At times, the potential alternatives will pose challenges to conventional western approaches to the treatment of mental health issues. The gaps included:
- For Somalis, projects similar to the Peace of Mind project, but for age ranges other than 5-13 year olds. Previous research (e.g. Fazel and Stein, 2003) has highlighted the high incidence of psychological disturbance (three times the national average) among refugee children. Research in Camden (Ali and Jones, 2000) has highlighted the under-performance of Somali pupils and the sometimes “aggressive” nature of Somali boys. Needs identified by the “Peace of Mind” project include:For Albanian speakers, the need for linguistically-matched psychotherapy
- Support for mothers who are depressed and single parents
- Support for fathers who are unemployed and experience loss of identity, status and self-esteem
- Support for children who experienced civil war and have emotional, social and behavioural difficulties
- For the Congolese, the need among service providers for increased understanding and use of the traditional methods of healing employed with individuals who have mental health problems e.g. family intervention and support, use of traditional medicines.
A number of potential actions were identified by interviewees, which might go some way towards filling the gaps in service provision identified. These included:
- Implementing better systems to monitor service take-up(to include ethnicity and country of origin)
- Training of mental health professionals in the issues that are commonly faced by individuals in the various refugee communities and how these manifest themselves in mental health needs
- Raising awareness of refugee mental health and cultural issues among GPs, community nurses and other health professionals
- Better communication and integration between statutory and voluntary sector agencies working with refugees and asylum seekers. Also closer working and collaboration with NASS
- Greater provision of services that are culturally specific e.g. Black and Asian Psychotherapy services
- Greater use of and access to complimentary physical therapies e.g. massage, relaxation, meditation etc
- Greater use of psychiatry-diagnostic opinions/psychiatric reports
- Some clients are not ready for treatment because of the asylum process, which causes increased anxiety, suicidal behaviour, and depression. There is thus a need for clients to have supported counselling rather than automatic referral to the Traumatic Stress Clinic.
Translation and Interpretation:
- Ensuring that same-language counselling (rather than counselling via an interpreter) is available
- Reviewing languages currently available through interpretation services and comparing this with the languages actually spoken in the borough
- Training for family members with regard to interpretation
- Recruiting interpreters who are based at specific sites (such as the Traumatic Stress Clinic), providing training in mental health and so providing continuity of personnel, trust, relationships, safety
- Mental Health awareness training for individuals and agencies offering language and translation support
- Improvement in literature/printed documents and their availability in more community languages. More information about what services are available to individuals within the refugee and asylum seeker community and how these can be readily accessed
Involving refugee communities
- Training for community members to be counsellors
- Use of psychology assistants from the communities served
- Capacity building of RCOs to help them to deliver culturally appropriate services
- Mental health awareness training for refugee communities to assist in recognising the symptoms of mental ill health
- Use of the skills and experience within the refugee communities e.g. Community development workers who are able to develop trust and value culture and traditional methods of supporting people
- Including service users from refugee communities in service planning
- More support, recognition and advice for carers and families of refugees e.g. support groups, advice and guidance, information about accessing services.
Practical advice and support could also be provided to assist treatment or while clients are awaiting treatment, e.g. befriending, childcare costs, arrangements, assistance with travel to appointments, assistance with other tasks, shopping, accommodation, benefits, practical support that can lessen/reduce symptoms of stress and anxiety experienced and often enables clients to engage better with treatment, therapy.
In addressing the question of who should be meeting the needs identified by the research participants advocated a more integrated, holistic response to the mental health needs of refugees. In order to provide this holistic response, it was felt that only the voluntary sector could make itself sufficiently “user-friendly” and was capable of working adequately on a cross-sector basis in the early stages. For statutory agencies there was perceived as a problem of compartmentalisation, with barriers to cross-organisational/multi-agency work being problematic. At the same time, however, it was recognised that the statutory sector has a key role to play, not least in funding the provision of appropriate services.
SPaRC Case Study
Mr M was referred to the Project by the Traumatic Stress Clinic. He resides in Camden. He is a torture survivor and subsequently has many psychiatric disorders including post-traumatic stress disorder and major depressive disorder with psychotic features. His psychiatrist reports that his mental state is extremely fragile.
When Mr M first came to the Project his asylum application had been refused and his solicitor had made an appeal and was waiting to see if this would be accepted. Mr M was receiving £39 a week from the National Asylum Support Service (NASS) and was sleeping in a basement below a shop, which has no kitchen or bathroom.
We advised Mr M that he is entitled to accommodation from NASS. However, NASS policy is to disperse people out of London except in very exceptional circumstances. We obtained strong medical evidence from Mr M’s psychiatrist, stating that if he were transferred out of London it would be very likely to destabilise his mental state and cause a total psychiatric breakdown, and submitted this to NASS. We contacted NASS three weeks later, to check the progress of the application, and were told that Mr M’s appeal had been dismissed and his entitlement to NASS support ceased two weeks previously. Mr M came into the Project and we made a successful referral to a solicitor who specialises in complex asylum and mental health cases.
We made a referral to Mr M’s Community Mental Health Team (Social Services) requesting a community care assessment and accommodation and subsistence support under the National Assistance Act 1948. After the council’s legal team became involved, Social Services agreed to provide accommodation and subsistence to Mr M. He now receives £35 a week and has his own studio flat with a garden, which he is very happy with.
We also applied for a Prisoner of Conscience grant for Mr M, and he was awarded £250, as well as referring him to a furniture project so he could purchase cheap furniture items for his flat.
Mr M attends the drop-in sessions two-three times a month, as he is not usually well enough to attend more often and cannot always stay for too long due to his anxiety and other mental health issues. He has also attended some of our ESOL classes but has also found it difficult to concentrate during the classes.
The need for a holistic approach to mental health (as highlighted earlier in this report) cannot be over-emphasised. Mental health does not exist in isolation. Indeed, social problems (lack of benefits, threat of dispersal, breakdown in relationship with NASS and/or lawyer) can have a major impact. For example, interviewees highlighted the link between poor housing and depression, anxiety and demotivation.
Recent research by Shelter (Shelter, 2004) has highlighted the link between living in temporary accommodation and health problems. Shelter’s research found that:
“More than half of people in the survey stated that they were depressed. This figure was even higher (64%) for people living in workless households. The case histories show how depression impacts on people’s levels of motivation; in some cases people found it difficult to perform even basic tasks, such as cooking”.
Consequently, any approach to meeting the mental health needs of refugees in Camden, needs to root itself in an understanding of the refugee experience (in the country of origin, in transit and in the UK) in its entirety. Dealing with manifestations of mental ill health at their most extreme is not enough. Action needs to be taken to address the inter-related factors that lie at the root of mental health problems.
In summary, an investment in low-level, often labour-intensive interventions may be seen as costly but could pay benefits in reducing the necessity of treating refugees for more serious psychiatric disorders at a later stage. The development of more joined-up services, with greater levels of cultural sensitivity and appropriate translation and interpreting provision, needs to be seen as part and parcel of the development of effective strategies for refugee integration.
BME – Black and Minority Ethnic
BRICKS - Bosnian Resource Information Centre Kosovar Support
CAMHS - Child and Adolescent Mental Health Service
CBT - Cognitive Behavioural Therapy
CMHT - Community Mental Health Team
EMCASS - East Midlands Consortium for Asylum Seekers Support
GAD - Generalised Anxiety Disorder
GP – General Practitioner
ICAR - Information Centre about Asylum and Refugees in the UK
MDD – Major Depressive Disorder
MHAC - Mental Health Act Commission
NASS – National Asylum Support Service
NHS – National Health Service
NIMHE - National Institute of Mental Health in England
PCT – Primary Care Trust
PTSD - Post-Traumatic Stress Disorder
RCO - Refugee Community Organisation
SPaRC - St Pancras Refugee Centre
Ali, E. and Jones, C. (2000), Meeting The Educational Needs Of Somali Pupils In Camden Schools - A report to Camden LEA, Institute of Education, London University
Arora, S., Bichbiche, K., Alaa, M. and Adshead, F. (2003), Asylum Seekers and Refugees in Camden: A Health Needs Assessment, Public Health Directorate, Camden Primary Care Trust
Bhui, K., Adbi, A., Abdi, M., Pereira, S. and Dualeh, M. (2003) Traumatic events, migration characteristics and psychiatric symptoms among Somali refugees: Preliminary communication. Social Psychiatry and Psychiatric Epidemiology, 38 (1), 35-43.
Burnett, A. (2002), Guide to Health Workers Providing Care for Asylum Seekers and Refugees, Medical Foundation for the Care of Victims of Torture
Burnett, A. and Fassil, Y. (2002), Meeting the health needs of refugee and asylum seekers in the UK: An information and resource pack for health workers, Department of Health
Carey-Wood, J. (1997), Meeting refugees’ needs in Britain: the role of
Refugee-specific initiatives, Home Office
The Civis Trust (2004a), Refugees and Mental Health: A good practice guide for primary care workers, The Civis Trust
The Civis Trust (2004b), Refugees and Mental Health: A good practice guide for refugee community organisations, The Civis Trust
CVS Consultants and Migrant and Refugee Communities Forum (1999), A Shattered World: The mental health needs of refugees and newly arrived communities, CVS Consultants
Fazel, M. and Stein, A. (2003), Comparative study of the mental health needs of refugee children, British Medical Journal, No. 327, 19 July 2003
Holy Cross Centre Trust (2003), Holy Cross Centre Trust: Finding new ways to support socially excluded people – Report 2001-2003, Holy Cross Centre Trust
Home Office (2005), Asylum statistics: 4th quarter 2004 United Kingdom, London
Jones, A. (1998), The Invisible Minority: The Housing Needs of Chinese Older People in England, School of Public Policy, University of Birmingham
Khan, S. and Jones, A. (2004), Somalis in Camden: challenges faced by an emerging community, London Borough of Camden
London Borough of Camden (2004), The report of the Suicide Prevention Scrutiny Panel, London Borough of Camden
London Borough of Camden (2004), Camden Best Value Review of Mental Health Day Services – Narratives of Stakeholders, London Borough of Camden
Mahmoud, A. and Gray, P. (1999), Mental Health Care for Refugees and Asylum Seekers – A guide for Advisory Workers, Mental Health Foundation
Mental Health Act Commission et al (2005), Count Me In: National Mental Health and Ethnicity Census, England and Wales – Full Project Protocol,
Mental Health Act Commission
Pagoda of Hundred Harmony et al (2002), 8th National Chinese Mental Health Conference, Pagoda of Hundred harmony Chinese Community Centre
Patel, S.L., Wright, S. and Gammampila, A. (2005), Khat use among Somalis in four English cities, Home Office Online Report 47/05
Read, S., Regel, S., and Williams, S. (2002), The Mental Health Care Needs of Asylum Seekers – Briefing paper, East Midlands Consortium for Asylum Seekers Support Regional Health Group
Shelter (2004), Sick and tired: The impact of temporary accommodation on the health of homeless families, Shelter
Summerfield, D. (1996), The Impact of War and Atrocity on Civilian Populations: Basic principles for NGO interventions and a critique of psychosocial trauma projects, Relief and Rehabilitation Network, Overseas Development Institute
Ward, K. and Palmer, D. (2005), Mapping the provision of mental health services for asylum seekers and refugees in London: a report, Information Centre about Asylum and Refugees in the UK and St Pancras Refugee Centre