Refugee Mental Health and The Role of Place

Mental health remains a pressing issue for displaced people. Recent scholarship has unequivocally recognised the importance of pre- and post-migration factors, including flight and resettlement, for people's mental health and wellbeing. Yet, increasingly hostile treatment of asylum seekers is but one sign that the post-migration context does not guarantee the peace of mind and safety associated with refuge. As well as experiencing precarious and uncertain conditions until asylum is granted, refugees have the added challenge of adapting to a new sociocultural environment, which can be difficult because of structural racism, discrimination, and marginalisation. The role of place is salient given refugees have often little or no control over where they live and are more likely to experience the kind of adverse neighbourhood factors that have been more broadly associated with poor mental health. Furthermore, refugees can be isolated geographically because of dispersal policies which entails providing people with accommodation in often impoverished and isolated areas of the country. All these factors have been linked to worse mental health outcomes and a decrease in the quality of life for refugees.

During the workshop we asked how notions of place, neighbourhood, community, location, dwelling and home-making relate to mental health among refugees. How time shapes perceptions of place, memory-making, and sense of loss and belonging. How the ‘hostile environment’ policy, anti-immigration laws and structural racism create a sense of displacement and emplacement. What role agency plays in mental health as people face potentially disorienting institutional, material, and moral environs.

Below are some of the key themes that emerged during the workshop which we intend to explore further as we are building an interdisciplinary and intersectoral platform for people working on refugee mental health in the UK and beyond.

Key Themes

Terminology

A vague use of terms, such as economic migrant, refugee, asylum seeker, saturates the public-political discourse on migration and national borders. As the state seeks to differentiate ‘illegal’ economic migrants from ‘genuine’ asylum seekers, the latter often end up in Immigration Removal Centres while their case is being considered. Yet people around the world are facing increasingly complex and multifaceted perils, making it more and more difficult to differentiate between, for instance, forced displacement because of armed conflict or violence and concomitant forced migration because of famine or climate change. Consequently, ambiguous use of terminology can be deliberate to fuel anti-asylum and anti-immigration rhetoric or result from bureaucratic oversight whereby people fleeing persecution are being classed as ‘illegal migrants’.

Research literature can also fall short on critical differentiations between people seeking asylum and refugees. This can lead to confusing discussions, given that the experiences of asylum seekers and refugees are continuous but qualitatively different. The terminology that researchers use, such as ‘refugee’ and ‘asylum seeker’, are also labels that people may object to or instrumentalise in certain ways. As labels, they shape people’s experiences, including mental health and illness, and research needs to be mindful of that. These labels can entail certain stigmatising attachments and negative connotations, not only in host societies but also in refugee communities. The misapplication of concepts relating to people’s status prevents us from hearing their stories, and not hearing stories means not getting justice.

Places

Place characteristics such as environment and climate, local communities and histories, institutions, and political economies make up the post-migration context for refugee mental health. As such, the places where refugees end up living are highly relevant for their mental health. While awaiting a decision, asylum seekers with social capital and the means to support themselves can choose where to settle and usually can do so after they receive leave to remain. However, those who are dispersed often find themselves in impoverished areas removed from social and economic networks. Furthermore, ‘hostile environment’ policies aimed at reducing immigration make the UK less hospitable for refugees who try to settle and attain a sense of belonging.

Places shape how people can survive and thrive, and how they can challenge and deal with disadvantaged status created by the invalidation of their previous work experience or education. At the same time, it is important to highlight that refugees have agency in that they actively shape the social, physical and political environments where they live, by creating institutions and economies that cater to their communities. Places are not static but change over time along with people who inhabit them and this change unfolds at the intersections between refugee agency and settlement structural conditions and processes.

Precarity

Precarious conditions of refugee settlement begin with the length of the asylum process and not knowing the outcome. Bolstered by short-term accommodation, such as hostels, and subpar living conditions, experience of precarious existence frequently crosses over into refugee post-migration settlement. Constraints on asylum seeker’s rights to work severely limit their contact with local communities, people, and institutions from the outset. Many people may find themselves in informal labour or sharing crowded accommodation with others.

Precarious conditions are particularly damaging to unaccompanied children and younger refugees in general because of repeated moves of place of residence, school and inability to make friends. As a consequence, many if not most refugees have faced incapacitating uncertainty from the outset of their post-migration experience. For instance, detention in Immigration Removal Centres or dispersal of asylum seekers to impoverished areas can deprive people of already diminished support networks. We discussed these practices as a politics of 'enforced instability' because conditions that underpin such practices are determined by asylum policies and politics of refugee and migrant governance. Instead of the sanctuary that people have been looking for, they are thrown into the system that undermines their attempts to settle. All this has profound implications for long-term mental wellbeing.

Mental Health

Data can be used as a powerful tool to advance and argue for meaningful health and mental health interventions. However, the evidence on prevalence of mental health problems among refugees in the UK is difficult to determine. Available quantitative data is often incomplete, and refugees are not easily identified in the health records, making them into a ‘hidden population’. There are ways to address these limitations. For instance, good examples of detailed health records are found in Denmark and Sweden. Moreover, qualitative research can improve our understanding of how psychiatric professionals in the UK perceive refugees and their needs, and how they record mental health data. Researchers need to take stock of what data and evidence is lacking, what is available and what would be the main priorities at this time.

Furthermore, it was noted that there is a ‘translation gap’ between research on PTSD and UK asylum policy. People may be too vulnerable to undergo invasive psychiatric evaluations but without the diagnosis of PTSD, they may not receive the help they need. And this can happen despite available evidence for the traumatic impact on mental health of people who come from war-torn countries. This is where policy meets practice meets research, highlighting the need to re-evaluate and clarify political and clinical priorities. Access to better and more impactful data depends on bridging the gap between refugee and asylum seeker communities and the host nations into which they are trying to settle and integrate.

We consider the ethical aspects of the way we do research about and with refugees to be particularly important. The ethical responsibility of academics and researchers as well as governing institutions should go beyond defining risks and safeguards. Foregrounding critical questions around vulnerability is of key importance to working with communities in more reciprocal rather than extractive ways. There is a need for critical engagement and more collaboration in setting priorities in those areas that would benefit the asylum process and refugee experience by challenging and shifting the policy environment. This may involve certain positions that academics could take regarding policy recommendations, such as asylum decision waiting times, or management and communication of the refugee settlement process, including support to gain education and employment.

In conclusion: key areas for research and advocacy

At the end of the workshop, we highlighted key areas for research and advocacy that we believe should be pursued collaboratively by researchers, practitioners and activists.

• There is a need for more refugee research using health records data, which could be facilitated by including, for example, flags for asylum seekers and refugee backgrounds while retaining full anonymity.
• There is a need to explore refugee mental health through multi-method approaches combining qualitative and quantitative research and longitudinal designs.
• We need to better understand barriers to seeking treatment and to investigate the unmet need for mental health interventions among refugees who do not come into contact with the services.
• We need to highlight co-produced research with the aim to democratise knowledge generation, interpretation and dissemination.
• We need to better understand how the experience of age, gender, and life-cycle transitions of refugees are shaped by the places where people live and with what implications for mental wellbeing.
• There is a need to evaluate the post-Covid-19 asylum landscape and its potential consequences for refugee mental health.
• We need an improved conversation between academic and public discourse on refugee and asylum seeker’s experiences and mental health.
• There is a need to monitor and evaluate the effects of the proposed reforms to the UK’s Asylum System on mental health and well-being.
• The asylum process needs systemic change to become more transparent and predictable for those seeking refugee status.

WORKSHOP PARTICIPANTS

• Dr Peter Schofield – King’s College London
• Dr Hanna Kienzler – King’s College London
• Dr Guntars Ermansons – King’s College London
• Zara Asif – King’s College London
• Fatuma Farah – The Minster Centre
• Sohail Jannesari – King’s College London
• Dr Mina Fazel – University of Oxford
• Dr Matthew Hodes – Imperial College London
• Prof. Cornelius Katona – University College London
• Dr Francesca Meloni – King’s College London
• Dr Elaine Chase – University College London
• Dr Ayesha Ahmad – St George's University
• Dr James Kirkbride – University College London