highlights #2.5

Mental Health Problems Associated with Asylum Procedures of Refugees in European Countries

Gail Womersley
University of Neuchâtel

Laure Kloetzer
University of Neuchâtel

Betty Goguikian Ratcliff
University of Geneva

Events that took place before migration have an influence on the mental health of asylum seekers and refugees. But research findings show that the majority of stress factors are directly related to post-migration living conditions and restrictions. Prolonged legal insecurity, the obligation to move from one center to another, and isolation among other factors contribute to the deterioration of refugees’ mental health. Implications reach far beyond the individual: it is a question of social and economic significance for Switzerland as well.

The World Health Organization defines mental health as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.” An epidemiological study conducted among asylum seekers in Switzerland found that 13.7% suffered mental health disorders.(1) Among a clinical sample of asylum seekers in the canton of Zurich for example, researchers noted a prevalence rate of depression of 33% and Posttraumatic Stress Disorder (PTSD) of 24%(2), a prevalence similarly noted in the canton of Geneva(3) and Vaud(4). Therefore, the mental health of this sizable population is a public health priority relevant not only for the individuals concerned and their communities but also for Switzerland.

What factors contribute to such high prevalence of mental health disorders? This high rate is not only linked to events experienced in asylum seekers’ countries of origin. The literature also highlights the post-migration period as being critical to the mental health of refugee populations. In a multi-agency guide on the mental health of refugee populations released in 2015, UN agencies and other international humanitarian organizations have highlighted that potentially traumatic events from the past are not the only, or even most important, source of psychological distress but that the majority of mental health problems are directly related to current stress factors.(5) Other studies show that post-migration factors such as unemployment, an insecure residency status, fear of repatriation, insufficient proficiency in a host language, social discrimination, and difficulties with integration are similarly significantly correlated with mental health problems.(6) Those living in institutional accommodation or with restricted economic opportunities are particularly affected.

“Potentially traumatic events from the past are not the only, or even most important, source of psychological distress. The majority of mental health problems are directly related to post-migration factors.”

Asylum Seekers and Recognized Refugees: Two Distinct Phases with Different Stress Factors

The third author identified the period before and after being granted asylum as being two distinct periods in the psychological lives of migrants.(7) Both involve substantial psychological stress, but for different reasons.

Stresses identified during the asylum-seeking phase include:

– Delays in the processing of asylum application

– Fear of repatriation

– Exclusion from the labor market

– Forced dependence on social welfare

– Loneliness, boredom

– Discrimination, marginalization

– Poor housing conditions

– Prolonged uncertainty, insecurity, lack of control

“A long asylum procedure is associated with psychiatric disorders: forced idleness and fear of being forced out of the country constitute significant stress factors.”

Indeed, a long asylum procedure can be associated with psychiatric disorders.(8) In particular, an insecure residency status is a significant stress: lack of control over one’s future and one’s ability to integrate, social isolation, the continued fear associated with the risk of not being granted asylum and being forced out of the country are all factors mediating psychic suffering which might turn into mental distress. This is further worsened by conditions wherein individuals may be forced into a rhythm of perpetual displacement by being moved from one center to another, experiencing delayed asylum procedures and poor living conditions in reception centers – often poorly accessible by public transport to main economic and social hubs. Left with a life in limbo, activities of social integration and personal development are hindered under such conditions.

Obtaining refugee status (both subsidiary protection and full refugee status) may indeed alleviate some of the stress factors specifically related to the period of requesting asylum. However, after months or years of suspended lives, this is a period where refugees are required to quickly adjust and integrate into their new environment especially by becoming financially independent. Refugees now need to fully participate in a new cultural environment and locally reconstruct their lives, all the while maintaining their cultural identity – in other words, without losing their connection to their cultural heritage or the sense of who they are and where they have come from. During this phase, a new set of stressors may be encountered. Those in the Swiss context include:

– Difficult access to employment and training, non recognition of former diploma and careers

– Poor language proficiency

– Financial and housing difficulties

– Lack of family, social and shared cultural resources

“Difficulties in finding employment, social isolation, and differences between expectations and encountered reality may produce a vicious cycle affecting mental health.”

Important stress factors are the difficulty in finding employment, deskilling(9) and social isolation. Another factor is the substantial differences between the pre-migration expectations (of the individual as well as their family) and encountered reality on the labor market upon arrival. They are likely to produce feelings of discouragement, injustice, self-depreciation, social and occupational worthlessness, and lack of satisfaction, also worsened by the negative feelings felt during the asylum procedure. Refugees risk being trapped in a vicious cycle where these difficulties affect mental health, which in turn affects ones’ capacity for social integration and accessing the labor market.

Effects of Post-Migration Factors on Mental Health: A Tale of Two Migrants in Athens

In order to examine the complex interplay of factors between mental health and integration trajectories, we introduce an ongoing research project in Athens, Greece. The study’s main question is: What are the effects of the asylum procedure on asylum seekers’ mental health and capacity for integration into European societies? The answer in a word, paramount.

> Data and methods / The Migration and Mental Health Database

Let’s consider two participants in our research, Dilraj and Jules, whom we met during our fieldwork in Athens. Both are victims of torture because of political activism in their countries of origin. Both recently arrived in Europe to seek asylum. Both arrived alone. Both have been diagnosed as suffering from post-traumatic stress disorder. We followed them over a period of 9 months, which included conducting multiple interviews with themselves as well as their doctors and psychologists.

Dilraj

Dilraj is a 30-year-old Indian asylum seeker referred to a center for victims of torture in June 2016, where his treating doctor describes “a clear case of post-traumatic stress disorder.” We first interviewed him in August 2016. A few weeks thereafter, he was given an appointment for his asylum interview. However, the administrator in charge was not present on the day (for reasons unclear to Dilraj and his lawyer). His status as an asylum seeker was renewed and he was given a new date for his interview in December. During this period, he was living alone in a 30 meter-squared hotel room in an old building recently repurposed to house asylum seekers:

“I don’t even know any Sikh community here. (…) When I am staying at a hotel, whenever somebody is knocking at the door, I feel scared, I never go out.”

Dilraj described feeling a sense of social isolation. He was scared to leave his home as he didn’t know many other members of the Sikh community with whom he could have contact. This made it difficult for him to feel socially integrated into his new environment. He therefore kept to himself, remaining alone. Towards the end of 2016, his psychological condition deteriorated. Due to personal financial reasons, he was forced to move out of his small hotel room. Put into shared accommodation, he accused his Pakistani roommate of spying on him. Psychotic symptoms started to emerge, including auditory hallucinations (hearing voices) and paranoia (a feeling that other people want to hurt him). Many of the voices that he heard were those of authority figures, including officials in Greece. He was hospitalized as a result. His psychologist stated:

“One voice said: ‘You will be homeless you will be homeless.’ And there is a possibility to be homeless. Or another voice said: ‘They will not believe you, they will send you back to India.’ What he hears is normal, it’s his fear. (…) Yesterday we talked about the possibility now to communicate with his lawyer in order to see if it’s possible to make his [asylum] interview sooner.”

What is interesting to note is her understanding of his mental health deteriorating because of his current reality: “because he has not passed his interview” (meaning that he has not yet been officially recognized as a refugee in Greece) and because of the real risk of him being homeless. She therefore highlighted the fact that the current situation was having an impact on his mental health. The voices that he heard were in his mind, yet based on fears related to his real-life situation. He seemed to be as scared of the Greek authorities as he was of the people who tortured him in his country of origin. He was unsure of whether or not asylum would be granted to him, and this made him even more afraid. His doctor similarly noted the potentially harmful effect of the delayed asylum procedure on his mental health:

“It’s not a good time for him generally, because first he found himself living in an apartment with Pakistanis. They could speak the [same] language [as him]; he got afraid. They were drinking, smoking and things like that; he got very scared. That was when things really got bad. (…) Another very stressing thing for him is that his interview got postponed until August. That made him really angry and frustrated. All these things add up.”

Already fearful and suspicious of others, he was particularly affected by living with people who spoke the same language as him but were not Sikh. He was also scared and frustrated by having to wait for the asylum decision. The delayed asylum trial and poor living conditions had a detrimental impact on his mental health.

Jules 

Jules is a 40-year-old Congolese man who, like Dilraj, sought asylum after being tortured in his country of origin. Upon arriving in Athens, he was able to find accommodation in shared state-sponsored housing with other Congolese men – which he described as being a significant resource:

“Here, we live in community. (…) I live thanks to people I know who are helping me.”

The fact that the state sponsored his housing reduced his personal financial stress. He felt socially connected to others who were “helping” him, which contributed to improving his mental health condition.

He explicitly linked an improvement in his mental health to his current social and economic reality, including free access to public transport and healthcare:

“I can travel all around Athens. The pain diminishes. (…) They give free medical care also. (…) Here, they don’t know me and I’ a black man, but nevertheless they give me free treatment.”

What helped to improve his mental health was the lack of discrimination he perceived, his access to free health care and the fact that he was able to travel freely without fear of being arrested. His primary concerns were to be granted asylum and freedom of movement:

“My wish, in order to be able to be calm, is to have the documents already. If they grant me asylum, it will be better. (…) When you know that you are here to stay, you can quickly find work, you can do something. You can have money, but if you have documents and can travel freely with your ideas, that would be better [than just having money]. You can survive.”

For Jules, being active and able to move around in the city enabled him to be actively engaged in constructing a new life for himself in his new environment. He also spoke about the impact of the asylum decision on his life, saying the sooner he receives a decision from the asylum court “the better.” This is because knowing that he was there to stay would allow him to integrate into his new environment.

Implications for the Swiss Context

As recently noted by Alexander Betts and Paul Collier(10), it’s not just fleeing conflict that makes victims out of refugees, it’s also denying them the means to become autonomous and productive. The results of our research indicate that asylum seekers and refugees are actively and continually engaged in their own development. However, delaying and restricting opportunities to move, to access the labor market, to integrate and create new lives has a substantial impact on the mental health of the research participants. This in turn may influence their capacity for social and professional integration.

Policies should consider the alleviation of stress factors relating specifically to the situation of the individuals, notably their legal status. Shortening procedures may help (see article by Hainmueller et al. in this issue), but so does allowing asylum seekers to participate in the social life of their host communities during these procedures. Further improvements could include, for example, avoiding displacement of asylum seekers from center to center, which create disruptions in social integration (especially for families with school-aged children) and locating reception centers within easy access to economic and social hubs. Finally, refugees tasked with integrating into the host society should be supported with policies and initiatives aimed at creating opportunities for social adaption and enhancing economic autonomy (see article by Stefanie Kurt in this issue). For example, learning a local language makes more sense if the courses are connected to opportunities for professional integration – beyond just needing to be understood and orient oneself in Switzerland.

“Integration policies should take into consideration the personal, social and cultural needs of asylum seekers and refugees to overcome psychological stress and improve their mental health.”

In all cases, ensuring a sufficient number of trained interpreters available, as well as access to culturally sensitive quality health care, including mental health care, is crucial. Mental health, and personal, social, and cultural resources, do have a mediatizing effect on the stressors identified above and may go a long way in assisting migrants with the reconstruction of their lives – in turn benefitting Switzerland both socially and economically.

—

(1) Bischoff et al. 2009

(2) Maier et al. 2010

(3) Premand et al. 2013

(4) Faucherre et al. 2009

(5) IASC 2007

(6) Goguikian Ratcliff 2016

(7) Abbott 2016; Jurado et al. 2017

(8) Laban et al. 2004

(9) Goguikian Ratcliff et al. 2014

(10) Betts and Collier 2017

References

Abbott, Alison. “The Mental-Health Crisis among Migrants.” Nature 538, no. 7624 (2016): 158-60.

Betts, Alexander, and Paul Collier. Refuge: Transforming a Broken Refugee System. London: Allen Lane, 2017.

Bischoff, Alexander, Martin Schneider, Kris Denhaerynck, and Edouard Battegay. “Health and Ill Health of Asylum Seekers in Switzerland: An Epidemiological Study.” European Journal of Public Health 19, no. 1 (2009): 59-64.

Faucherre, Florence, Olga Weber, Doug Reeves, and Patrice Guex. “Action Research and Clinical Governance: The Example of the Project ‘Psychiatry and Migrants’ at the Vaudois University Medical Center.” Revue médicale suisse 5, no. 217 (2009): 1826-30.

Goguikian Ratcliff, Betty. “Asylum Process and Psychological Dis-tress: A Two Waves Temporal Pattern?” In Second Annual Conference of the nccr – on the move. Neuchâtel, 23–24 June 2016, 2016.

Goguikian Ratcliff, Betty, Claudio Bolzman, and Théogène Gakuba. “Déqualification des femmes migrantes en Suisse: Mécanismes sous-jacents et effets psychologiques.” Alterstice 4, no. 2 (2014): 63-76.

Inter-Agency Standing Committee (IASC). “IASC Guidelines on
Mental Health and Psychosocial Support in Emergency Settings.” Geneva: IASC, 2007.

Jurado, Dolores, Renato D. Alarcón, José M. Martínez-Ortega, Yaiza Mendieta-Marichal, Luis Gutiérrez-Rojas, and Manuel Gurpegui. “Factors Associated with Psychological Distress or Common Mental Disorders in Migrant Populations across the World.” Revista de Psiquiatría y Salud Mental 10, no. 1 (2017): 45-58.

Laban, Cornelis J., Hajo B. P. E. Gernaat, Ivan H. Komproe, Bettine A. Schreuders, and Joop T. V. M. De Jong. “Impact of a Long Asylum Procedure on the Prevalence of Psychiatric Disorders in Iraqi Asylum Seekers in the Netherlands.” Journal of Nervous and Mental Disease 192, no. 12 (2004): 843-51.

Maier, Thomas, Martina Schmidt, and Julia Mueller. “Mental Health and Healthcare Utilisation in Adult Asylum Seekers.” Swiss Medical Weekly 140, no. 13110 (2010): doi: 10.4414/smw.2010.13110.

Premand, Natacha, Baeriswyl-Cottin, Marianne Gex-Fabry, Brigitte Coraboeuf, Panteleimon Giannakopoulos, Ariel Eytan, and Javier Bortolomei. “Soins psychiatriques pour les requérants d’asile à Genève.” Revue médicale suisse 9 (2013): 1664-68.