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When assessing people from very different backgrounds who have had complicated and challenging life experiences, mental health professionals need to be wary of jumping to wrong conclusions.
With people seeking asylum, interpreting appearance, behaviour and non-verbal communication is likely to be harder than usual. Narrative style and autobiographical memory are subject to diverse influences that include attachment security and autobiographical competence, emotional distress, external prompts and context, social identity, and culture. Major adversity and PTSD can result in complex difficulties in giving clear consistent accounts. Neurodevelopmental diversity and intellectual disabilities present specific challenges. People seeking asylum also face some narrative dilemmas particular to their situation.
The outcome of an asylum claim often hinges on judgements about a person’s credibility. While determining credibility is the responsibility of the Home Office and courts, mental health professionals can contribute to good decision-making by offering clinical explanations for features of a person’s account or behaviour that have been used to cast doubt on their credibility.
The Ukrainian refugee crisis highlights the many issues associated with trauma, distress, mental and physical health, culturally competent assessments, and meaningful support and interventions. This crisis requires international support and a global response, as hosting countries have specific competencies and capacities. The authors hope that the groundswell of international concern over the crisis in Ukraine will lead not only to a comprehensive response to the needs of refugees from that country but also to a recognition of the needs of other asylum seekers and refugees and to our collective moral obligation to address those needs equitably.
Convincing international evidence demonstrates that immigration detention adversely affects mental health. During the COVID-19 outbreak, additional concerns were raised about the safety and appropriateness of immigration detention. Consequently, several hundred migrants were released en masse from UK immigration detention centres, and few new detentions took place. Over 70% fewer migrants were held in detention centres in June 2020 compared with December 2019. This large ‘natural experiment’ has demonstrated that detaining fewer migrants is possible and it provides an opportunity to review the necessity for large-scale detention for the purpose of immigration control, as well as its impact on health inequalities. Additionally, given that detainee release arrangements had already been considered unsafe prior to the pandemic, clinicians and service providers should take into consideration that many of those released may not be receiving adequate post-release continuity of care.
Human trafficking is a grave human rights violation and a major public health concern. Survivors present with high rates of mental health problems including post-traumatic stress disorder (PTSD). Studies of effective treatments for PTSD in survivors of human trafficking are lacking. Narrative exposure therapy (NET) is an effective PTSD treatment for multiple, prolonged and complex trauma, but its efficacy has not been rigorously tested in survivors of human trafficking.
To test the feasibility and acceptability of a randomised controlled trial (RCT) offering NET as a treatment for PTSD in trafficking survivors with a history of multiple traumatic events, as well as providing preliminary evidence regarding its efficacy (trial registration: ISRCTN95136302).
A single-blind RCT compared NET with a wait-list control in survivors of trafficking with PTSD (n = 25). In the NET arm of the study, participants attended a mean of 17 sessions.
NET was well tolerated by participants. There were significant reductions in PTSD, depression and anxiety symptoms post-treatment in the NET group but no significant change in the wait-list group.
The results indicate that NET is a promising and acceptable treatment for trafficking survivors. Psychological therapy in an RCT design can be safely delivered to this vulnerable group, although modifications are required to ensure their holistic needs are properly addressed.
Refugees and asylum seekers often report having experienced numerous complex traumas. It is important to understand the prevalence of complex post-traumatic stress disorder (CPTSD), which can follow complex traumas.
This systematic review aims to summarise the available literature reporting the prevalence in refugees and asylum seekers of three operationalised definitions of CPTSD: the ICD-11 diagnostic criteria, the ICD-10 criteria (for enduring personality change after catastrophic experience) and the DSM-IV criteria (for disorders of extreme stress not otherwise specified).
Six electronic databases were searched for studies reporting the prevalence of CPTSD in adult refugee and/or asylum-seeking samples. Owing to heterogeneity between the studies, a narrative synthesis approach was used to summarise studies. Methodological quality was assessed using the Joanna Briggs Critical Appraisal Checklist for Prevalence Studies. This systematic review has been registered with PROSPERO (registration number CRD42020188422, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=188422).
Systematic searches identified 15 eligible studies, with 10 examining treatment-seeking samples and five using population samples. CPTSD prevalence in treatment-seeking samples was between 16 and 38%. Prevalence in population samples ranged from 2.2 to 9.3% in four studies, with the fifth reporting a much higher estimate (50.9%).
This review highlights both the high prevalence of CPTSD in treatment samples and the lack of research aiming to establish prevalence of CPTSD in refugee and asylum-seeking populations. Understanding the prevalence of these disabling disorders has implications for policy and healthcare services for the appropriate promotion, planning and provision of suitable treatment and interventions for this highly traumatised population.
Asylum-seekers experience high levels of traumatic events pre-, post- and during migration. Poly-traumatisation is associated with complex post-traumatic stress disorder (CPTSD), which has not yet been extensively explored in this population. CPTSD is a prevalent and highly disabling disorder in the present population requiring culturally sensitive diagnostic and treatment approaches. In this service evaluation, we evidence the high prevalence of CPTSD in an asylum-seeking sample and its association with greater distress compared with PTSD. We outline the treatment needs of asylum seekers with CPTSD.
We want to celebrate the resilience of refugees. We therefore dedicate this chapter to all those who came to the UK seeking protection and have made a life in the UK against the odds. Past mental health work has been disproportionately focused on post-traumatic stress disorder (PTSD) as a diagnosis. This imbalance has improved in more recent years. Refugees are now known to have a higher rate and wider range of mental health problems as well as psychosocial stress. Refugees need their basic needs met as well as addressing mental health problems. Interventions that have helped have been social such as access to employment, combating discrimination and fostering inclusiveness. Resolving asylum uncertainty has been central to a reduction in mental health distress. The importance of the culture of the refugee cannot be underestimated in assessing and managing their health needs. One difficulty has been refugees’ access to mental health services. Mainstreaming was the main approach, but some specialist services enhanced access during this time. Some specialist services developed within the voluntary sector.
The majority of requests for reports in immigration and asylum cases arise in the asylum context. However, issues of mental health will frequently come up in human rights applications and may give rise to similar requests. Here, we provide an outline of the asylum legal process, identifying the relevance of expert psychiatric reports within that process and the duties of the psychiatric expert, and providing guidance on the conduct of such assessments and the preparation of reports.
Mental illness is common among forced migrant populations, and ongoing mental illness can hinder refugees’ ability to negotiate the asylum process. This editorial rehearses the challenges of undertaking research among forced migrant populations, exploring how they could be addressed in future research, and outlines differences between forced migrant groups. It points to the growing body of evidence that can be called on in advocating for systemic change in government policy and mental health services, with significant support for a sensitive and objective inquisitorial approach to gathering evidence in support of asylum claims.
Asylum seekers are required to narrate past experiences to the UK Home Office, doctors, lawyers and psychologists as part of their claims for international protection. The Home Office often cites perceived inconsistencies in asylum interviews as grounds for refusal of their claims. A number of processes affect asylum seekers' abilities to narrate past experiences fully to the professionals interviewing them. The dilemmas around disclosure that asylum seekers face have received little attention to date. This work aims to explore the perspectives of UK-based medico-legal report-writing doctors, lawyers and psychologists whose work involves eliciting narratives from asylum seekers on the processes that affect asylum seekers' abilities to disclose sensitive personal information in interview settings. Eighteen professionals participated in semi-structured interviews in individual or focus group settings to discuss, from their perspectives of extensive collective professional experience, the narrative dilemmas experienced by asylum seekers with whom they have worked.
Professionals identified a number of processes that made disclosure of personal information difficult for asylum seekers. These included asylum seekers' lack of trust towards the professionals conducting the interview, unclear ideas around pertinence of information for interviewers, feelings of fear, shame and guilt related to suspicions around collusions between UK and their country-of-origin's authorities, sexual trauma and, occasionally, their own involvement or collusion in crimes against others.
Recommendations are made on how to improve the interview environment to encourage disclosure. These have important implications for future research and policy initiatives.
Post-traumatic stress disorder (PTSD) is a potentially chronic and disabling disorder affecting a significant minority of people exposed to trauma. Various psychological treatments have been shown to be effective, but their relative effects are not well established.
We undertook a systematic review and network meta-analyses of psychological interventions for adults with PTSD. Outcomes included PTSD symptom change scores post-treatment and at 1–4-month follow-up, and remission post-treatment.
We included 90 trials, 6560 individuals and 22 interventions. Evidence was of moderate-to-low quality. Eye movement desensitisation and reprocessing (EMDR) [standardised mean difference (SMD) −2.07; 95% credible interval (CrI) −2.70 to −1.44], combined somatic/cognitive therapies (SMD −1.69; 95% CrI −2.66 to −0.73), trauma-focused cognitive behavioural therapy (TF-CBT) (SMD −1.46; 95% CrI −1.87 to −1.05) and self-help with support (SMD −1.46; 95% CrI −2.33 to −0.59) appeared to be most effective at reducing PTSD symptoms post-treatment v. waitlist, followed by non-TF-CBT, TF-CBT combined with a selective serotonin reuptake inhibitor (SSRI), SSRIs, self-help without support and counselling. EMDR and TF-CBT showed sustained effects at 1–4-month follow-up. EMDR, TF-CBT, self-help with support and counselling improved remission rates post-treatment. Results for other interventions were either inconclusive or based on limited evidence.
EMDR and TF-CBT appear to be most effective at reducing symptoms and improving remission rates in adults with PTSD. They are also effective at sustaining symptom improvements beyond treatment endpoint. Further research needs to explore the long-term comparative effectiveness of psychological therapies for adults with PTSD and also the impact of severity and complexity of PTSD on treatment outcomes.
Identifying the causes of psychiatric and physical symptoms in asylum seekers, refugees and other migrants and making definitive diagnoses can be challenging. Ethical and legal challenges in the UK include the likely deterrent effects of upfront charging for National Health Service (NHS) services. This paper focuses on the fictitious case of an asylum seeker presenting to a mental health service in England, highlighting some of the difficulties in assessing and treating this patient group and providing advice to clinicians on clinical and practical management. Current NHS entitlements for migrants are summarised and a list is presented in the online supplement of non-governmental organisations that can provide further support.
The world has the largest number of refugees and asylum seekers living outside their country of origin due to wars, political upheavals, violence and various other causes than there have been at any time since World War II. This crisis has an impact on all services in countries that are hosting refugees. Most research has focused on the needs of younger refugees and women and has neglected to study older individuals and their particular vulnerabilities.