In the series “The state of migrant women mental health,” we have exposed the barriers that migrant women, particularly asylum seekers and refugees, face in accessing mental health services. While the challenges will be hard to dismantle due to systemic inequality and policies like the Nationality and Borders Bill, it is not enough to simply point out the barriers without reflecting on how to improve these services. In this article, we will explore structural and practical changes that can be made and who needs to be involved in facilitating these changes.
by Rachel Jenkins
Before we look at viable solutions, it is important to remember why the “hostile environment” is mentioned again in this article. In the UK, the government plays an important part in fostering a hostile environment in various ways. First, through policies that undermine people’s human rights, as we can see with the Nationality & Borders, Bill passed in 2022. Siobhán Mullally, the UN Special Rapporteur on Trafficking in Persons, stated that the bill would “seriously undermine the protection of the human rights of trafficked persons, including children; increase risks of exploitation faced by all migrants and asylum seekers; and lead to serious human rights violations”.
The government has also spread misinformation that has been used to dehumanise migrants. This can be seen through the lies that led up to Brexit, in which immigration was used to argue for stricter immigration policies. For example, Michael Gove once stated, “Because we cannot control our borders – and because our deal sadly does nothing to change this fact – public services such as the NHS will face an unquantifiable strain as millions more become EU citizens and have the right to move to the U.K.” The government has repeatedly used immigration to scare people into thinking that institutions such as the NHS were at grave risk without stricter immigration laws. This has further highlighted the already insidious racism and xenophobia within the UK.
The government has repeatedly used immigration to scare people into thinking that institutions such as the NHS were at grave risk without stricter immigration laws.
After over a decade of budget cuts to the NHS, the healthcare sector does not have nearly what it needs to provide vital services. We have seen essential staff training defunded, pay rises for essential workers blocked, community healthcare teams disbanded, and parts of the NHS sold to private companies.
Simply put, there is just not enough money being allotted to services that could otherwise address some of the barriers migrants face because investing in these services does not reflect the interests of a government that spends more time covering up Covid parties than it does consider how migrants feel. Even better for the government if they can ‘justify’ removing some of those migrants seeking asylum and send them off on planes to Rwanda. When it comes to the human rights of migrants, this government’s unwritten policy seems to be ‘out of sight, out of mind.’
So, when it comes to finding community solutions to breaking down barriers to accessing these services, we all have to get a little political. We are going to have to organise as communities and as professionals. Politics are inherently personal. They affect many aspects of our daily lives. People will suffer directly from the UK government’s policies toward migrants. But then, that is the point of creating a hostile environment, isn’t it?
Implementing informed, culturally appropriate, and trauma-informed mental health support
The first change that needs to come from within the healthcare sector and any organisation supporting migrants is an understanding of informed, culturally appropriate, and trauma-informed mental health support. Being informed is important, as so many professionals do not understand the rights and entitlements of migrants, and this is often the first barrier migrants face upon arrival in the UK when attempting to register with a GP.
We will start first with GP registration because if migrants have a negative first encounter attempting to register, their entire experience of the NHS might be one of anxiety and distrust. The British Medical Association has produced a helpful resource guide for healthcare professionals that can be found here. The guide explains that any staff who register patients should be aware that it may be difficult for some migrants, particularly asylum seekers and refugees, to bring identity documents commonly asked for on GP registration forms. Sometimes they may not have documents to produce at all. The BMA guide states, “If a patient cannot provide identity documents, it is not reasonable grounds to refuse to register them.” Yet this refusal to register migrants who do not have documentation happens often, so the need for staff training on the rights and entitlements of migrants is clear.
The first change that needs to come from within the healthcare sector and any organisation supporting migrants is an understanding of informed, culturally appropriate, and trauma-informed mental health support.
Once a person has registered with a GP, their next point of contact is a GP, midwife, or nurse. Again, due to a lack of training around entitlements, there is often a lot of confusion around whether patients are chargeable. This further adds to the anxiety and distrust migrants have in accessing healthcare services. The BMA states that its “member survey found that 55% of doctors who work with refugees and asylum seekers were frequently or sometimes uncertain about their entitlement to care”. This leads to vulnerable people being incorrectly charged and forces healthcare professionals to make decisions with serious implications for people who may be facing difficulties around their immigration status and may fall in and out of being chargeable. Training is essential here to solve this problem, but so is getting actively involved in campaigning for policy change. Currently, the BMA has called for an end to NHS charges for migrants, especially for up-front medical care, which has resulted in people having to go without proper care due to their immigration status.
There is also a lack of training around trauma and the symptoms and conditions trauma can cause, which makes it extremely hard for clients to access specialist trauma support. Piyal Sen warns that a “lack of knowledge could lead to some patients receiving inappropriate psychiatric diagnoses, and normal human responses to extremely traumatic life events could be inappropriately pathologized.”
Let’s say a client presents to their GP and says they hear voices. During the 10-minute consultation, they start yelling, their eyes seem glazed, and they do not seem to be ‘present’. There may be a rush to diagnose this client with conditions such as psychosis or schizophrenia without considering important background information that might be crucial to understanding the client’s needs. For example, what if the client has a high ACE score and has experienced significant childhood trauma? In this case, the symptoms the client is experiencing, such as hearing voices and not seeming ‘present’, could much more likely indicate dissociation due to trauma or PTSD than psychosis or schizophrenia. Still, this route is much less likely to be explored. In this case, that could mean that the client is pushed down a psychiatric route instead of a trauma route, and it will take even longer to get them the support they need.
There is also a lack of training around trauma and the symptoms and conditions trauma can cause, which makes it extremely hard for clients to access specialist trauma support
If you are a team member of a GP surgery who agrees these solutions could be implemented – start implementing them tomorrow. If you cannot implement them, raise the issues with governing bodies so they cannot be ignored. Make your surgery a safe space for migrants – put up stickers that say, “everyone is welcome”, and make sure all your staff are knowledgeable and welcoming to everyone who tries to register. Use interpreters, always, but make sure they are appropriate first. Go out of your way to offer a safe space to migrants seeking care, as your surgery is the first experience of the UK healthcare system people will encounter. Doctors of the World offer interested GP surgeries to join the Safe Surgeries Initiative, which helps GPs tackle the barriers that prevent migrants from accessing healthcare. Further resources and information on training can be found on their website.
The kind of support we are offering matters
The next point of contact for migrants seeking mental health support after registration and speaking with a GP is with either a statutory counselling service, a CMHT, or another mental health professional. Many mental health professionals do not understand the varied and differing needs of migrant groups and how different people can express and process their mental health or trauma. Providing culturally appropriate support means acknowledging that the systems and methods we use in the UK to talk about mental health are not the same everywhere in the world. Often, intake sessions for counselling or mental health support are based on language that could be very inappropriate for some people. Piyal Sen, Medical Director and Consultant Forensic Psychiatrist at Elysium Healthcare and Chair of the Special Committee on Human Rights at the Royal College of Psychiatrists, states, “Mental health workers need to understand that ‘talking therapies that have been developed in high-income countries are primarily ego-based and require detached introspection. Such introspection could be unfamiliar to a socio-centric individual, who might respond better to a treatment focused on functional recovery.” Providing appropriate mental health support must be person-centred and tailored to the individual as a ‘whole’ person, which means identifying the language and type of support they need.
Providing culturally appropriate support means acknowledging that the systems and methods we use in the UK to talk about mental health are not the same everywhere in the world.
We as professionals must also challenge ourselves to be more comfortable asking questions to ensure we are using helpful language. One is no less an experienced professional if they ask, “do you feel comfortable with using the term mental health, or is there another term you’d feel more comfortable using as we discuss how to get support for your depression?” Asking questions is a positive aspect of any helping relationship and should be encouraged in reflective peer or clinical supervision.
The kind of support we are offering matters, too. Offering traditional talk therapy, even after you know that the client has disclosed that they are in initial accommodation and seeking asylum and very much in crisis for practical items and focused on preparing for their substantive interview, should be an indication that talk therapy is not going to be helpful to that client now. This is where statutory mental health services could work in partnership with the mental health support offered within the voluntary sector, which supports migrants. We need streamlined referral pathways between the statutory and voluntary sectors so that where there is a service one is unable to provide, there is a way for the client to access that support from the other side. For example, one of the most important services to offer migrants is psychoeducational workshops and psychosocial peer opportunities, which may be more desirable or needed than psychotherapy or counselling.
Offering a service where you can teach clients about their symptoms and teach them individual coping strategies places the clients at the centre of their mental health journey and gives them agency. This is where knowing what is culturally relevant merges with mental health support. Many clients who have not engaged with counselling services have found statutory mental health to be re-traumatising, have loved engaging with psychoeducational support, and have found real improvement in their mental health while engaging with activities such as arts & crafts, self-esteem activities, “worries” discussions, drumming or music as a coping strategy, or walking groups that build confidence and enable migrants to feel more “at home” in new cities.
In the case of asylum seekers, this means being careful what support is offered while they are living in initial accommodation centres.
Another trauma-informed change to make is when to offer support. Sometimes professionals across all sectors want to provide mental health support too early, when people are not ready, and we must become more confident saying no when a referral seems inappropriate whilst also offering an alternative that is suitable. It is best practice to not offer therapeutic intervention before clients know where they will be. In the case of asylum seekers, this means being careful what support is offered while they are living in initial accommodation centres. We may think we are helpful, but allowing people to open up about their mental health when we know they may not still be living here three months from now can do more harm than good. There is nothing wrong with saying this is not the time for 1:1 sessions if we offer a solution that does not leave them without support – for example, attending a psychoeducational group or a drop-in where they can access peer support or practical support. Again, this is where we as mental health professionals could work better together in partnership and refer to each other’s services when we know ours are not the most appropriate. Much more could be done to strengthen the relationship between statutory services and the voluntary sector, which we will return to later in this series.
Thrive LDN has produced a guide for professionals and volunteers supporting Afghan refugees’ mental health and well-being, which can be applied more broadly to trauma-informed practice. Their guide states that a trauma-informed workforce should “Support the recovery by providing the person with a different experience of relationships. Promote safety over threats, choice over control, collaboration over coercion, and trust over betrayal. Reverse the association between trauma and relationships. Minimise the barriers to receiving care and support. Minimises potential triggers that will harm the individual.” All mental health professionals should follow these guidelines at the centre of our work, especially if we support migrants. Providing that to a client is not enough to simply be knowledgeable about mental health. We also need to be aware of local migrant groups and support organisations and where to go to ask for help with legal support, benefits, education, housing, and healthcare. It is our duty as professionals to provide support to change our services for our clients, not the other way around.
It is our duty as professionals to provide support to change our services for our clients, not the other way around.
If you are a mental health professional, do not assume that a client is too focused on the Home Office to be able to speak about their mental health. Instead, adapt how you are helping that client so that it meets their needs. Do not expect or ask people to talk about their trauma before a) they express an interest in disclosing information relating to their trauma and b) unless you know you will be able to provide support long enough to work with them on how to manage and process this trauma.
Offer mental health services that provide psychoeducation, access to skills and training, activities-based wellness, and opportunities for peer support. Reach out to voluntary organisations that may have more experience and knowledge of what different migrant groups might be dealing with. Make your practice trauma-informed and do everything in your power to advocate for your client as they navigate a hostile system designed to make them unwell.
In Part II of “Improving health services in a hostile climate: how to introduce informed, culturally aware, and trauma-informed care into the support of migrant women.”, we will focus on how to ensure the organisations we work within are trauma-informed and why is so crucial to providing appropriate support to migrant women.
