It is likely that those planning, managing or commissioning mental health services will be able to create changes that make them more effective for people seeking asylum. There are some recurrent themes in publications about what changes are needed. However, priorities are different in different situations and from different perspectives. One approach to choosing how to use limited resources is to consider what guiding principles are most important. We consider the implications of adopting each of six principles: anti-racist and anti-discriminatory practice; ‘first do no harm’; a human rights approach; evidence-based care; using public health principles; working with organisational values. An alternative approach to deciding on what actions to prioritise is to identify specific goals. We discuss what might be done towards the following nine goals: involving people seeking asylum; improving interpreting; removing barriers to access; using training, supervision and support to enable staff to provide good care; working with community groups and other agencies; working to guidelines, standards or checklists; creating alternative services; prevention; making a difference quickly.

Specific diagnoses have specific implications, and this chapter examines these. Prevalence of specific conditions is difficult to establish, but some broad findings are reviewed. Specific diagnoses are then considered in turn, looking at their conceptual basis and potential misunderstandings, diagnostic criteria and the difficulty of categorising symptoms, and the implications of making, or not making, each. For each diagnosis the authors consider how culturally normal reactions may wrongly be labelled as ‘symptoms’ but equally how problems may be wrongly ascribed to ‘culturally normal’ experience. Some diagnoses may be overlooked, especially if difficulties are ascribed to cultural factors – substance abuse, traumatic brain injury, intellectual disability and neuroatypicality.

Situations where there is no diagnosis, or changing and overlapping diagnoses are reviewed. Fabrication is considered, and the value and hazards of raising the possibility in an assessment.

People seeking asylum have particular needs that affect what kind of interventions will help, and how they should be offered.

The chapter first considers unmet physical health needs and the interconnectedness of physical and mental health. The role of medication for mental health difficulties is then reviewed, with detailed attention to the choice of medication, and to the practical and psychological context of prescribing.

The authors consider when formal psychological therapy may be helpful, looking at the factors common to all therapies, and at the specific options available. NET, EMDR, trauma focussed CBT and expressive, creative and body-based therapies are reviewed, together with a discussion of other forms of therapy.

Interventions for post-migration difficulties may be both the most acceptable and the most effective. The range of these interventions is considered, including the provision of medical evidence in an asylum claim. Risk management is reviewed, with attention to safety planning, minimising the harms of immigration detention, managing the threat of removal, and preventing destitution.

Work with people seeking asylum brings unfamiliar experiences, challenges, rewards, and dilemmas. Resonances for the therapist and sharing the client’s pain and hopelessness can be distressing. Power, powerlessness and privilege are common themes. Facing the limits of our own compassion, and of what it is possible to do, can be hard. How can we ‘do differently’ and what new skills are needed? The work can be isolating, and exhaustion, burn out, vicarious traumatisation and other existential reactions can arise. Clinicians face many dilemmas, such as over boundaries, neutrality and self-disclosure, overt political action, and how to deal with different perspectives in the same organisation. What helps clinicians do well is a focus on reflection, and accessing supervision and other reflective spaces, such as Balint groups or solidarity teams. Pitfalls of not attending to our own responses are highlighted, as is the need to protect reflective spaces. Remote meetings make access easier for both training and peer support. Meetings in non-clinical settings with people who have sought asylum can also be enlightening.

People in the asylum system who might benefit from mental health care frequently find it very difficult to access this.

Some do not seek help, perhaps because they do not expect mental health services to be helpful or because of fear, stigma, or wanting to avoid the processes of help-seeking. Those who do seek help encounter multiple challenges including language barriers, the limitations of health care provision within the asylum system, difficulties negotiating primary care, NHS charges, practical difficulties in getting to a first appointment, and service eligibility criteria. People may face barriers linked to their age, gender, sexuality, or being destitute.

The chapter offers a typology of obstacles to reaching effective mental health care as a step towards considering how these may be addressed. This considers the context (resource limitations /ambivalence about providing equal care) and the sources of specific obstacles, including ‘hostile’ asylum policies. Recurring themes include the need for accessible information, friendly compassionate staff, cultural competence, access to qualified interpreters, appropriately trained staff, and a willingness to be flexible.

A formulation is an attempt to understand an individual’s predicament. In contrast, a psychiatric diagnosis is a way of categorising difficulties. Making a formulation or diagnosis is not a straightforward task, especially given differences of culture and power. It is helpful to think of both as constructed narratives.

With people seeking asylum, both present specific benefits, disadvantages and challenges. They can powerfully affect the person themselves, determine what help is offered and influence third parties, such as asylum decision-makers. A helpful approach to formulation and diagnosis depends on the therapeutic relationship and the clinician’s skill in working with differences in culture and power. Clinicians need to bear in mind how formulations and diagnoses depend on the quality of assessment and the cultural context in which they are embedded.

Formulations for people seeking asylum need to pay particular attention to culture, family, and physical health, and to the impact of the asylum process, of being a refugee, and of discrimination. Diagnoses should be made only after discussing formulation and considering the potential additional impacts of a diagnosis.

The chapter considers essential components of any effective treatment or intervention, and the need to adapt standard approaches for people seeking asylum, how this may be done, and the limitations of the ‘evidence base’. Barriers to accessing intervention are discussed, and the need for services that address the complexities of interpretation and cultural differences.

Therapeutic relationships are reviewed, and collaborative work is emphasised.

Therapeutic organisation is also important: early intervention, a conducive setting, continuity of care, and minimising pitfalls of onward referral. Mental and physical health care should be integrated as far as possible, with attention to communication with other professionals and feedback to the client. Consideration is given to how to identify starting points for an intervention. Interventions for specific groups are reviewed, including gender and sexuality, and related to torture, trafficking and sexual violence. Work in inpatient settings and immigration removal centres is considered. Remote working is reviewed, as is the possible therapeutic role of medicolegal assessment. Ways of ending treatment constructively are discussed.