Migration is a universal phenomenon; individuals and groups have always moved and will always continue to move. The past decade has seen a rise in migration to an all-time high of nearly 70 million. There has, in particular, been a very substantial increase in migration related to conflict. In parallel with this, there has been a rise in media and political interest in migration and in the variety of political and moral responses in ‘host’ countries.
In recent decades there have been many studies looking at migrant mental health. Migrants not only have higher rates of post-traumatic stress disorder – (this is hardly surprising) – but also of depression, of anxiety disorders and of psychotic conditions such as schizophrenia. We also know that there are several factors that migrants experience before leaving their home country (such as war, torture and exploitation including human trafficking and other forms of modern slavery) and during their journey (such as hazardous journeys, physical and sexual abuse and further exploitation) which are likely to increase their risk of developing mental health problems.
As mental health professionals in host countries, we’re limited in what we can do to mitigate these pre- and peri-migration risks. This is why we are particularly concerned with the aspects of migration that adversely affect a person’s mental health which can be prevented or at least alleviated after they have ‘arrived’.
Once an individual arrives in the UK there are a considerable number of factors which may cause or aggravate mental health problems – which are under our control. If addressed, these factors can have a significant positive impact in the short and long term, thereby making it more likely that an individual will be able to thrive in the UK and less likely that they will require mental health services in the longer term.
There are four factors worth highlighting: the nature and complexity of the asylum process; the widespread use of administrative detention within that process, the barriers migrants face in accessing healthcare, and the risk of destitution arising from inadequate provision of basic needs.
The legal process for those claiming asylum is lengthy and difficult for UK based clinicians to understand – let alone the migrants who have to engage with the system. Migrants with pre-existing mental health problems often have great difficulty in describing their traumatic past experiences as they are required to do within the asylum process. During this time they receive limited subsistence and become deskilled because they are not allowed to work. Reductions in the provision of legal aid has significantly aggravated an already hugely difficult process. In our experience the asylum claiming process can have a significant adverse impact on an individual’s mental health.
Studies from across the world have proven that immigration detention adversely affects an individual’s mental health, both worsening pre-existing conditions and leading to new mental health disorders. In the UK immigration detention is widely used and (unlike all other European countries) is without time limit. The process for identifying vulnerable individuals and for enabling their asylum claims without recourse to detention is in our view flawed, and the provision of mental health care in immigration detention centres remain inadequate.
Migrants face multiple practical barriers to accessing healthcare including language difficulties and the mistaken idea (held both by many migrants and by many health practitioners) that they are not entitled to care. This is particularly problematic for those with mental health disorders who face (or fear) additional stigma and may not recognise their difficulties as a health problem that could improve with appropriate, specialised care. This is only aggravated by ‘hostile environment’ policies which actively exclude migrants from NHS care, blocking them from accessing (already inadequate) mental health services.
Lastly, vulnerable individuals who have experienced a traumatic migration process (sometimes via forced migration/trafficking) face ever more obstacles in accessing basic needs such as shelter and food. If these basic needs are not met then their mental health disorders worsen and become increasingly difficult to treat. These problems may continue even after migrants are granted protection and leave to remain, at which time, rather than being welcomed, they often face a further traumatic transition from asylum support into mainstream accommodation, benefits and work in which their vulnerability remains inadequately recognised.
We can, and must, do better. There are a number of basic solutions which, if implemented, could allow us to build a humane system which prioritises the needs of migrants who are already in a difficult situation. They would reduce the mental health burden and distress suffered by many. The asylum process needs to be adequately resourced and fair – inquisitorial rather than adversarial. The decision about whether an individual needs protection should be independent from the Home Office – treated as a public health issue and not one of political point scoring. We need to urgently consider ending the use of immigration detention, or at the least restricting its use to ‘exceptional circumstances’ and introducing strict time limits – of days, not months.
Active efforts should be made to address barriers to accessing healthcare for vulnerable migrants. These should include appropriate training for staff and specific programmes to identify and act on vulnerability (including mental health problems) where these are identified. There should also be a clear distinction between immigration officials and healthcare workers – we should be able to focus on patients, not acting as de-facto border guards.
Better recognition of vulnerability factors, and a determination to minimise the aggravating effects of post-migration experiences would go a long way towards improving mental health outcomes.
Dr Hugh Grant-Peterkin MRCPsych and Prof Cornelius Katona FRCPsych are both consultant psychiatrists working with migrants. This article represents their personal views, nor those of their organisations or The Royal Society of Medicine. They will be participating in the discussion ‘Migrant mental health: rights, access and advocacy‘ at The Royal Society of Medicine on Saturday 23 June.