Disability and forced migration

Forced migration and disability often are ignored in the research literature. In spite of the equalities legislation for the rights of disabled people, often the responses to disabled migrants are not helpful. In theory, the UK’s National Health Service is founded on the basic principle of universalism. The theoretical hegemonic commitment to universal human rights has often been most overtly broken in relation to migrant rights. In contrast to official condemnation of racism and disablism, successive governments of different political persuasions have continued to, and indeed competed to, prove their hostility towards migrants, whether they are disabled or not. The British asylum system itself is disabling by design. Some people are disabled on arrival in the UK; others become disabled later on. Disabled asylum seekers often describe the system as psychological torture. Therefore, ongoing mental distress can create difficulties in further adjustment, thus compounding problems. Using case histories, this chapter illustrates some of the difficulties faced by migrants with disabilities. A fundamental systemic change is needed to address the injustice encountered by disabled asylum seekers.

High-skilled migration and mental health

High-skilled migrants are more likely to migrate for professional or educational reasons. There is a difference between the high-skilled migrants and labour in that the former may well be responding to pull factors, whereas the latter may be responding to push factors related to migration. These migrants are also more likely to belong to permanent migration category. High-skilled migrants are those with a university degree or extensive/equivalent experience in a chosen field. They are largely likely to migrate from low- to middle-income countries to high-income countries. The immigration rates show that these migrants are likely to be self-selected; have skills that are in demand and globally transferable. In the post-migration phase they may experience mental ill health, especially if they do not feel valued; feel overqualified for the jobs they are doing; and if they experience a discrepancy between aspirations and achievement. Their clinical needs may well differ from those of migrant labour.

Refugee and asylum seekers’ experiences

This chapter reviews the socio-political environment and legal factors that provide the context and influence the lived experience of many refugees and asylum seekers. These factors are considered in relation to flight, arrival, and settlement in a new country. How these contextual factors may impact upon refugees and asylum seekers, their sense of identity, and mental health will be reviewed. The chapter reflects upon the possible challenges faced by many refugees and asylum seekers, as well as arguing that the strengths, resilience, and coping strategies that many asylum seekers and refugees exhibit need to be adequately considered by clinicians, if a meaningful service is to be provided. The importance of clinicians being culturally curious and listening to service users’ meaning-making is vital. An overview of some other issues that clinicians may need to consider is provided. The chapter contains a number of case studies to illustrate the related issues.

Ethics and migrant psychiatry

Ethical practice of medicine in general and psychiatry in particular form an integral part of medical professionalism in order to ensure that patients not only get the best treatments for their needs but also that these are delivered in an ethical framework. For centuries, doctors and psychiatrists have continued to rely on the four principles of autonomy, beneficence, non-maleficence and justice as critical components of decision-making in treating their patients. As the concepts of health have changed the basic principles remain the same. This “four principles” approach has much to offer medical professionals when they are faced with ethical dilemmas in clinical and non-clinical practice. In this chapter, we outline the basis of these principles and consider the key strengths while using this theory. For psychiatrists there is a major imperative as their actions can deprive patients of their liberty. The “four principles” should be considered when making ethical decisions, and in conjunction with professional judgement and wider ethical frameworks.

Psychotherapy and refugees

This chapter explores effective psychotherapeutic interventions for treating post-traumatic stress disorder in adult vulnerable migrants, including cognitive behavioural therapy (CBT), eye movement desensitization and reprocessing, and narrative exposure therapy. An overview of the evidence for these treatments is discussed, as well as how these can be implemented effectively for vulnerable migrants who face ongoing instability and uncertainty, as well as multiple barriers to accessing appropriate treatment. The additional needs of vulnerable migrants are therefore also highlighted. The chapter proposes that to assist individuals effectively in recovering from their traumatic experiences, support must be offered to address these needs, alongside any psychological treatment. A service case example is presented to highlight how an integrated model of care can most effectively meet the needs of vulnerable migrants.

The new face of exploited children in Europe

Children and young people are often trafficked for financial gains as a consequence of trafficking for physical and sexual abuse. The number of such refugees and asylum seekers is almost impossible to determine accurately. Children can be used to smuggle drugs across countries. Although small networks for local crime built around drug dealing, cigarette sales, or the resale of stolen goods use children and young people, there are also highly evolved and structured organizations specializing in drug and sexual trafficking. These challenges require new and different ways of approaching them so that mental health and well-being of children and young people can be maintained. Furthermore, it will be helpful to change the terms of child protection, strengthening structures of support, creating community and street teams with appropriate linguistic competencies, better links between countries of origin and European countries, and better cooperation between police, justice, social workers, and non-governmental organizations. Better approaches are indicated.

Prejudice, ethnic discrimination, and double jeopardy in migrants

Prejudice is a universal phenomenon and all human beings carry at least one prejudice in them, whether this is against individuals with mental illness or migrants. Often potential factors can also cause prejudice. In many clinical settings, migrants with mental illness can face double jeopardy, leading to facing further discriminations at a number of levels. Individuals with mental illness in many countries do not have the right to vote, marry, make a will or inherit property, or the right to employment. Migrants in many countries do not have full rights as citizens. Double or triple jeopardy means that migrants with mental healthcare needs often fail to get their needs met at a number of levels. Prejudice and discrimination are learned behaviours, whereas stigma is often a negative attitude. Racism is a form of discrimination, but it takes the form of xenoracism if the migrant is white, although shared whiteness does not exclude the possibility of racism.

Suicide among refugees

Suicide is a global public health problem, with the majority of suicides occurring in low- and middle-income countries. The UNHCR reported that in 2017 there were 25.4 million refugees, with the majority (85%) being hosted by developing countries, which have limited infrastructure, healthcare systems, and are often politically and economically unstable. A review of suicidal behaviour among refugees reveals a prevalence of 3.4–40%. Female sex, higher education and socio-economic status, exposure to trauma, presence of psychological disorders, long stay in detention centres, and rejection of asylum status are associated with increased suicidal risk. Globally, data for rates of suicide among refugee groups are not available and any interventions to reduce suicide among refugees have received scant attention. A theoretical model for understanding suicide risk in refugees is proposed in this chapter and the possible interventions discussed.

Working with interpreters

Psychiatrists will come into contact with service users who do not use English or the language of the country to which they have migrated. The professional responsibilities of all mental health professionals carry an obligation to serve all members of our communities equitably and impartially; this will include people who have migrated and are not fluent in the language of their chosen country of migration. Working with interpreters and cultural brokers can be an enriching and informative experience for psychiatrists, which can lead to the development of new knowledge. This is in addition to the challenging of what may be taken-for-granted knowledge, as well as the development of additional skills and ways of thinking about mental health. Interpreters and cultural brokers can, in addition to translating the language, explain relevant cultural factors, which are important to the clinical work and the meaning-making of service users and gain additional perspectives.

Separate or integrated services?

In this chapter, we discuss the pros and cons of separate versus integrated services for immigrants and refugees. Our discussion is based on experiences from three high-income countries: Germany, Norway, and Sweden. All three, regardless of general public insurance systems covering healthcare costs, have barriers to mental health care for migrants and refugees. Additionally, their mental health care systems are unaccustomed to responding to cultural variety in patients’ expression of distress, explanatory models of illness, consequences of pre-migratory difficulties, and post-migratory adversities. Attention to post-traumatic stress and social determinants of mental health is also restricted. To bridge barriers and improve access to mental health care for immigrants and refugees, we will comment on the importance of adapting care, training of professionals, and outreach programmes. Also emphasized is the value of culturally sensitive mental health-promoting strategies to improve mental health literacy and reduce stigma among immigrants and refugees.