Asylum seeker and refugee mental health

Asylum seekers and refugees often have significant underlying physical and mental health problems, caused by factors arising before, during and after migration. These include experiencing conflict, violence, danger, exploitation and loss, uncertainty around housing, finances and employment during the process of seeking asylum, challenges accessing care, and potential discrimination from healthcare professionals and the local community.

All displaced people experience the loss, in some form, of their social structures, cultural values and community rituals. However, it is important to remember that displaced people have varying countries of origin, cultures, levels of education, knowledge of English and levels of support of available to them.

Among displaced people, children (especially unaccompanied minors and those under 5), women (especially those pregnant and breastfeeding), elderly, disabled and LGBTQ+ people are at particular risk of developing mental illness.

Distress among displaced people is very common, and is not in itself a mental illness though can persist without timely and appropriate support networks. Common mental illnesses in displaced adults include PTSD (31%), depression (31%), anxiety disorders (11%), and psychosis (1.5%). There are also high rates of distress, grief and PTSD in displaced people under the age of 18, especially in the context of war and trauma.

Displaced people may have additional diagnoses, such as alcohol and substance use disorders, or intellectual disabilities, which further increase their care needs. Displaced people will often also have poor physical health with complex pre-existing illnesses, including physical injuries, exposure to communicable diseases, and undiagnosed or poorly treated medical disorders.

Some displaced people will arrive already receiving treatment for mental illness, but most are unlikely to be able to provide medical documents or a clear outline of past treatments. Others can become unwell because of their recent experiences of displacement.

Refugees and asylum seekers are entitled to free NHS healthcare in the UK. Services should aim to make the process of accessing care as simple as possible and work to remove unnecessary barriers.

Services across the UK, even those where there have been fewer displaced people historically, will need to ensure their services can meet the needs of asylum seekers and refugees. Staff should feel confident and skilled to meet needs that they might not have encountered before.

Psychological first aid

Incorporating the principles of psychological first aid includes:

• Practicing good communication – Being calm and understanding, not pressuring individuals into speaking, and remaining aware of your words and body language.
• Preparing to speak to individuals by learning about their situation and experiences, services available to support them and how they can access them.
• Looking, listening and linking – Look to see if the individual and/or their family has any urgent basic needs, might be experiencing further harm, or is having a serious distress reaction. Find out what their needs and concerns are and link them with health, housing, financial and legal services.
• Ending your help appropriately by explaining to the person who will be helping them going forward. If you have linked the person with other services, explain what they can expect.

Trauma-informed practice

Trauma-informed practice aims to recognise the impact of trauma on the emotional, psychological and social wellbeing of people by:

• Acknowledging the links between trauma and mental health
• Adopting a broad definition of trauma responses, while avoiding over medicalisation and inappropriate treatment of understandable distress
• Discussing trauma sensitively, and understanding the risks of re-traumatisation
• Prioritising trustworthiness and transparency
• Approaching care through collaboration and partnership
• Emphasising strength and coping
• Prioritising safety and ensuring a safe and welcoming treatment environment
• Understanding and addressing second-hand trauma experienced by caregivers
• Fostering community and social networks amongst displaced people and with wider society
• Ensuring access to evidence-based care where needed

Cultural competence

Cultural competence means working continuously to understand the cultural context of the people you are supporting or treating to give them the most effective care, by:

• Being aware of cultural differences in the way individuals express distress, seek help and explain illnesses, and a potential lack of comparable terms for English terms for mental health problems such as ‘depression’ ‘anxiety’ or ‘PTSD’.
• Taking into account the importance of social and family environments, past and current adversities, current and future strengths, coping mechanisms, needs and aspirations.
• Not focusing excessively on current symptoms and behaviours
• Where necessary, explaining local healthcare systems and entitlement to care
• Being aware of treatment norms in the country of origin of those who are already being treated

Working with interpreters

When working with interpreters, healthcare professionals should:

• Explain the service they are providing to the displaced person, the aim of the consultation and the expectations they have of the interpreter
• Avoid using family members where possible, especially if they are children or were involved in the experiences being discussed, as this may discourage transparency
• Emphasise confidentiality
• Ensure all information is shared verbatim between clinician, patient and interpreter
• Try to use the same interpreter in subsequent consultations
• Help interpreters understand care and treatment norms in countries of origin and have some familiarity with the terminology used in the country of origin and the host country to ensure accurate two-way communication.

It is recommended that professionals receive training on how to work effectively with interpreters.

Working with children

Abuse, neglect, severe stress and other traumatic events increase the risk of physical, mental, emotional, social and relational health problems in children. In 2011, over a billion children and young people under 18 were living in countries affected by war. Attacks on children and families are often part of war strategies and consequently many of them become refugees. Often, children are separated from one or both parents in the process and may be unaccompanied.

Investment in health, wellbeing and sustained recovery from trauma (not only symptom management) is paramount for children. It is important to keep siblings together and with the adults with whom they have become displaced, supporting their social connections, connections to home and routines. Access to play and learning as part of their routine is important and supports their development and recovery.

It is crucial for professionals coming into contact with displaced children to demonstrate a willingness to hear, understand and believe. Signs of stress in children may include regressed behaviour, a loss of skills and expressing physical symptoms in place of communicating psychological distress.

Children should be referred to schools-based, community or specialist children’s services as appropriate and may need multi-agency input. GPs are not advised to prescribe psychotropic medications for children without seeking advice from a specialist.

Children are affected by how their parents or carers are functioning and services can help by supporting the adults with advice and guidance about how to care for them. Where both children and adults in a family are experiencing mental health problems, a co-ordinated family approach should be used, working collaboratively with adult services. Assessing children without their families misses an opportunity to create a safer network around a child, and important information can be lost by not seeing the whole family.

If displaced people are presenting symptoms that are: multiple, disabling, persistent and more prominent or severe than what would be regarded as an ‘appropriate’ response to trauma within their culture, triage should be performed to understand if there is a need to refer into specialist mental health services.

The UN High Commissioner for Refugees proposes an umbrella classification of ‘Emotional Disorders’ (which include depression, anxiety and PTSD) that is characterised by one or more of the following symptoms lasting for at least two weeks:

• Overwhelming sadness/apathy
• Highly distressing symptoms (re-experiencing, avoidance, hyperarousal) related to trauma
• Extreme or uncontrollable anxiety/fear

A sensitive but comprehensive health screening should be performed as soon as possible. This should incorporate physical, mental and social health concerns, health screenings should aim to provide a safe space for disclosures regarding trafficking, modern slavery, sexual exploitation, female genital mutilation (FGM) or previous torture. Identifying individuals still at risk must be prioritised and familiarity and engagement with local safeguarding pathways and practice is crucial.

It is important to encourage the use of both support and therapeutic services (both NHS/social care and third sector) that are available locally, as well as pathways into specialist mental health care. 

• When assessing self-harm and suicide risk:
• Approach assessment non-judgementally
• Where there has been a suicide attempt, assess intent to die (at the time of the attempt and after it)
• Ensure safeguarding
• Identify and address underlying ‘drivers’ to the attempt

Psychosocial interventions and mental health treatment

Health and social care professionals may come into contact with displaced people with mental health needs through a number of avenues. Providing early psychosocial support and care for people who are distressed may help prevent them from developing mental illness, and healthcare professionals should prepare to listen to traumatic experiences with compassion.

Evidence-based approaches reflecting NICE guidelines include:

• Cognitive behavioural therapy (CBT) for depression and anxiety
• Trauma-focused CBT, Narrative Exposure Therapy and EMDR for PTSD
• SSRI antidepressants for both depression and PTSD, or other antidepressants if SSRIs are not appropriate

Local psychological therapy services should consider how counselling and psychotherapy can be adapted to be more accessible, and culturally and developmentally appropriate. Displaced people should receive information about any treatments and their effectiveness.

Specialist care

Individuals who have experienced multiple and/or repeated trauma may often need to be referred for more personally tailored psychotherapy. This should focus initially on stabilisation through understanding and controlling their symptoms, followed by working to process traumatic memories and a final phase of social and psychological integration.

Where there are issues of trust, a loss of ‘agency’, an inability to imagine a personal future, inappropriate risk-taking and where mental distress is expressed in the form of unexplained physical symptoms, people are at greater risk of developing complex PTSD.

Documenting torture and ill-treatment

Healthcare professionals may be asked to document torture and ill-treatment. The Istanbul Protocol Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment provides authoritative guidelines on the documentation of the physical and psychological effects of torture. Where appropriate, health professionals may need to work closely with legal representatives of displaced people.

Support is available to health professionals who are interacting with distressing content at work. You can find out more about this in the further information section of this resource.

Displaced people experience a number of unique barriers to accessing treatment:

Systemic barriers

• Lack of awareness from healthcare professionals of the entitlement of displaced people to care, the possibility of complex health needs, and of cultural differences.
• A lack of specialist services, making it difficult to quickly refer on those who need a higher level of care.
• A potential lack of affordable interpreting services and a disinclination to use them
• A need for documentation of past or ongoing health problems that might be unavailable to displaced people
• Frequently changing accommodation causing disruption to healthcare provision
• Conscious or unconscious discrimination from healthcare professionals.
• Digital poverty leading to challenges in accessing care, and online consultations acting as a barrier to clear communication.
• An already overloaded system and substantial backlog potentially causing delays to care.
  

Individual barriers

• Lack of familiarity with a new country’s services, rights and culture, and rules around confidentiality
• Language barriers and literacy issues that make it difficult to find out relevant information or travel to appointments easily
• Cultural differences in understanding of physical and mental health issues
• Fear of disclosing information due to risk of deportation, imprisonment, or traffickers
• Disclosure causing re traumatisation, flashbacks and dissociation
• Trauma causing challenges with memory and communication.
• Lack of trust of authority figures that may include medical professionals
• Loss of ‘agency’ and autonomy through experiences of displacement
• Health needs such as intellectual disability, learning difficulties, impact of physical injuries and pre-existing health conditions being challenging to identify and increasing the complexity of diagnosis and treatment

• Safeguarding issues can be complex and are often inextricably linked to health needs.
• Displaced adults and children may be at high-risk of abuse, neglect, exploitation, trafficking and modern slavery before and after migration.
• Ensure you have contact details for your local Safeguarding Professionals who are vital source of advice and support for any concerns. Safeguarding referrals must follow your usual local processes irrespective of immigration status. The NHS has a Safeguarding app available for Apple and Android devices.

Information for healthcare professionals

• Seeking Asylum and Mental Health: A Practical Guide for Professionals, Cambridge University Press – This book provides practical guidance for professionals and services working with refugees and people seeking asylum in mental health, social care, legal, government. managerial and commissioning roles.
• Primary Care Mental Health, Cambridge University Press – Information and advice for primary care clinicians and specialist mental health professionals liaising with primary care. See chapter 22.
• Handbook of Refugee Health, For Healthcare Professionals and Humanitarians Providing Care to Forced Migrants, CRC Press – This book looks at the rights of refugees and provides a framework to identify and approach health needs. See section 10.
• Oxford Textbook of Migrant Psychiatry, International Organisation for Migration - A reference resource covering the mental health of migrants, refugees and asylum seekers.
• Refugee mental health and wellbeing portal, University of East London – This portal aims to provide information, resources and practical tools on refugee mental health and wellbeing.
• The Trauma-Informed Code of Conduct, Helen Bamber Foundation – A resource for all Professionals working with Survivors of Human Trafficking and Slavery.
• National Referral Mechanisms: Joining efforts to protect the rights of trafficked persons, Office for Democratic Institutions and Human Rights – Guidance on the identification and management of victims of modern slavery and human trafficking.
• Mental Health and Psychosocial Support for Refugees, Asylum Seekers and Migrants on the Move in Europe: a multi-agency guidance note, World Health Organisation – Advice on protecting and supporting the mental health and psychosocial wellbeing of refugees, asylum seekers and migrants in Europe.
• Mental health: migrant health guide, gov.uk - Advice and guidance on the health needs of migrant patients for healthcare practitioners. Further specific guidance includes:
  • Human trafficking
  • Female genital mutilation (FGM)
  • Vulnerable migrants
• Care of unaccompanied migrant children and child victims of modern slavery, gov.uk – Statutory guidance for looking after children and professionals who support unaccompanied migrant children.
• BMA refugee and asylum seeker health resource, British Medical Association – This guidance is for doctors who may be uncertain about the specific health needs and care entitlement of patients who are refugees and asylum seekers.
• All Our Health: Vulnerabilities and trauma-informed practice, eLearning for healthcare – A bite-sized session to give health and care professionals an overview of vulnerabilities (registration needed).
• Maternal Health: exploring the lived experiences of pregnant women seeking asylum, Maternity Action – A project exploring the lived experiences of pregnant women receiving asylum support.
• National Referral Mechanism, Every Child Protected Against Trafficking – A process set up by the Government to identify and support victims of trafficking in the UK.
• Modern slavery and exploitation helpline – A helpline for potential victims, businesses, the public and statutory agencies such as the NHS and police.

Resources for patients and carers

• Translated health information for patients, Doctors of the World – Resources in a broad range of languages that explain how the NHS works, Covid-19 vaccine information, the right to care, wellbeing guidance, information for young people and more.
• Caring for children through conflict and displacement, UNODC – A resource for parents and carers looking after children who have experienced conflict and displacement. This resource and a resource on caring in a crisis situation is available in different languages on the UNODC website.

Support for professionals

• Support available for our NHS people, NHS England – Resources and information to support the health and wellbeing of NHS staff.
• Self-Help Plus (SH+): a group-based stress management course for adults, World Health Organisation - A course for groups, delivered by supervised, non-specialist facilitators who have completed a short training. Suitable for adults who experience stress, and shown to reduce psychological distress and prevent the onset of mental disorders.

References

• Drury  J, Williams R. Children and young people who are refugees, internally displaced persons or survivors of war, mass violence and terrorism. Current Opinion in Psychiatry 2012; 24(4):277-284.
• Hunt, J., Witkin, R. and Katona, C. (2020). Identifying human trafficking in adults. BMJ, p.m4683.
• Hunt, J., Unigwe, S. (2019) Quick Guide to Modern Slavery and Human Trafficking. Helen Bamber Foundation. [online] Available online.
• Kang, C., Tomkow, L. and Farrington, R. (2019). Access to primary health care for asylum seekers and refugees: a qualitative study of service user experiences in the UK. British Journal of General Practice, [online] 69(685), pp.e537–e545. Available online.
• Sweeney, A., Clement, S., Filson, B. and Kennedy, A. eds., (2016). Trauma-informed mental healthcare in the UK: what is it and how can we further its development? Available online.  [Accessed 10 Mar. 2022].
• The Slavery and Trafficking Survivor Care Standards. (2018). Available online.
• Uphoff, E., Robertson, L., Cabieses, B., Villalón, F. J., Purgato, M., Churchill, R., & Barbui, C. (2020). An overview of systematic reviews on mental health promotion, prevention, and treatment of common mental disorders for refugees, asylum seekers, and internally displaced persons. Cochrane Database of Systematic Reviews, (9).
• von Werthern, M., Robjant, K., Chui, Z., Schon, R., Ottisova, L., Mason, C. and Katona, C. (2018). The impact of immigration detention on mental health: a systematic review. BMC Psychiatry, 18(1). Available online.
• Williams R. The psychosocial consequences for children of mass violence, terrorism and disasters. International Review of Psychiatry 2007; 19(3):263-277.
• Wood, L.C.N. (2020). Child modern slavery, trafficking and health: a practical review of factors contributing to children’s vulnerability and the potential impacts of severe exploitation on health. BMJ Paediatrics Open, 4(1), p.e000327. Available online.  [Accessed 10 Mar. 2022].
• York, N. (2004). OFFICE OF THE UNITED NATIONS HIGH COMMISSIONER FOR HUMAN RIGHTS Geneva PROFESSIONAL TRAINING SERIES No. 8/Rev.1 UNITED NATIONS Istanbul Protocol Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. [online] Available online.

Expert authors

• Professor Linda Gask, Emerita Professor of Primary Care Psychiatry, University of Manchester and Royal College of Psychiatrists Presidential Lead for Primary Care
• Professor Neil Greenberg, Professor of Defence Mental Health, King’s College London and Royal College of Psychiatrists Lead on Trauma and the Military
• Professor Cornelius Katona, Medical and Research Director, Helen Bamber Foundation, Hon Professor, Division of Psychiatry, UCL and Royal College of Psychiatrists Lead on Refugee and Asylum Mental Health
• Professor Richard Williams, Professor Emeritus of Mental Health Strategy, University of South Wales, and Royal College of Psychiatrists Presidential Lead on COVID-19, Emergency Preparedness and Mental Health