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Access Denied?

What are the difficulties psychotherapists face when working with asylum seekers? Lucy Kralj offers an observation and a personal opinion.

This paper addresses the difficulties faced by asylum seekers and the potential consequences of the processes that they encounter. It does not aim to deal with the right (or otherwise) to migrate, but instead focuses upon the possible realities of the asylum seeking process within the UK and the potential impact that this has on both the mental health of the individual seeking asylum and the therapeutic relationship.

The terms asylum seeker and refugee are NOT used interchangeably within this article. However the terms victim and survivor are interchangeable and synonymous also with the terms asylum seeker and refugee.

A fundamental tenet of the psychotherapeutic relationship is the notion of safety. This concept is thrown into disarray when working with people seeking asylum in many Western countries. The asylum process can frequently re-enact the cycle of de-humanisation experienced by refugees in their original countries.

The term “asylum seeker” is often used interchangeably and erroneously with “illegal immigrant” or is qualified with adjectives such as “bogus”, “genuine”, “failed”, suggesting that many people choose to leave their homes, livelihoods, families, and possessions and make an, often long and treacherous, journey to western countries in search of “a better life” or even “a free lunch”. In reality, the term “asylum seeker” (a comparatively recent concept) means, precisely, a person seeking asylum, seeking refuge.

The term refugee was defined after World War Two as,: “A person who, owing to a well founded fear of persecution for reasons of race, nationality, membership of a particular social group or political opinion is outside the country of his nationality and is unable or owing to such fear is unwilling to avail himself of the protection of that country” (United Nations, 1951 Convention Relating to the Status of Refugees). An asylum seeker is an individual who is applying to a foreign state for refugee status. The European Convention of Human Rights (to which the UK is a signatory) sets out minimum living standards for all human beings, for example, the right to a private and family life, and to live a life free from torture, inhuman or degrading treatment.

Seeking asylum in the UK and its impact on health

Patterns of migration tend to mirror patterns of global conflict. There are varied reasons why a person may be forced to flee his or her homeland, including war, genocide, state-sponsored (political) torture, trafficking for sexual or labour exploitation, domestic violence, female genital mutilation, or threatened honour killings. Once people seeking asylum arrive in the UK they must navigate the complexities of our asylum system and its interpretation of international and domestic refugee and human rights legislations.

Research has repeatedly demonstrated that the mental and physical health of asylum seekers deteriorates following arrival in the UK (Burnett & Peel, 2001). Many asylum seekers arrive in western countries in extreme poverty and vulnerable health. However, health (neither physical nor mental) is often not a priority on arrival and there are numerous barriers to accessing effective healthcare (Kralj, 2003, Kralj, 2007). Denial of access to public funds and health and social care compound existing health problems. Asylum seekers can find themselves utterly destitute with no recourse to statutory services. Many clients referred to the Helen Bamber Foundation (a UK-based human rights organisation, formed in April 2005) are destitute at the point of referral having been refused asylum despite coherent histories and evidence of extreme human rights violations.

The Asylum Process

Asylum seekers must attend three Home Office interviews; these are conducted by government officials sometimes with little regard for gender or sensitivity towards issues likely to affect the communicative ability of the claimant. For instance, a woman who has been tortured and raped by government militia, may find herself interviewed by a male government official with a male interpreter from the very faction, clan or tribe that tortured her in her homeland. She is expected to provide graphic details of her experiences to the interviewing officer. Failure to do so can cast doubt upon the credibility of her claim and late disclosure can be regarded negatively at subsequent stages in the asylum process.

Despite media claims to the contrary the overwhelming majority of initial asylum applications are refused (73% in 2007, with only 10% being granted refugee status, Home Office, 2007). Critically 23% of appeals (most recent 2007 statistic, Home Office, 2007) are allowed. This highlights the weakness of initial decision-making and has been documented by Amnesty International (2004). Claims are generally rejected on credibility grounds or alternatively “risk on return”. Under normal circumstances there is one right of appeal. The tribunal environment is frequently experienced by the asylum appellant as intensely persecutory.

When a claim fails, the applicant faces an existence of abject poverty, depending upon charity hand-outs and begging from community members or faith groups. These conditions are fraught with hazards; personal relationships tend to break down, mental and physical health deteriorates and the person lives in constant dread of detention and deportation, or abuse at the hands of exploitative black-market traders. Confusion prevails regarding access to healthcare. Asylum applicants are frequently erroneously denied access to primary care while access to secondary and tertiary care remains restricted or prohibited.

Dehumanisation

Many of the terms used in relation to asylum seekers might be seen as dehumanising. For instance “dispersal”, “processing” and “trafficking” are words used in farming, animal husbandy and the meat trade whilst “claimant” and “appellant” are part of the language used within the criminal justice system. Asylum seekers are all issued with photo ID cards and are assigned a registration number which is often used instead of their name. All asylum seekers are finger-printed at the point of claiming asylum, and contrary to immigration guidelines many individuals with a longstanding history of torture are detained for indefinite periods in immigration removal centres. Release from a detention centre is contingent upon good quality legal representation and former detainees are frequently electronically tagged following release and subject to stringent reporting requirements. These people have committed no crime and have been through no trial. It is worth noting that in many languages there is no differentiation in vocabulary between “trial” and “process”.

Access Denied
Given the above strains upon the individual, deterioration of mental health is hardly surprising. The search for asylum, sanctuary and a sense of home is both internal and external. People are commonly referred from one voluntary organization to another, in a desperate and, by now, perennial search for asylum, sanctuary, acceptance and belief. Practical needs and emotional needs can go unmet throughout the asylum process and many agencies to which these people turn feel overwhelmed by the level of need, the complexity of the situation and their inability to assist with the most basic of human necessities. Forward referrals are sometimes made in desperation to assist; the asylum seeker being sent to yet another stranger, hoping for “help”.

“Help” can be an ambiguous word for this client group. Huge amounts of energy can be poured into securing some kind of accommodation, ensuring that a person is able to eat at least once a day, obtaining clothes, or a sleeping bag, searching for new legal representation, or simply being there, bearing witness to the unbearable difficulties of continued existence. Although “help” may be needed with all aspects of life, once in receipt of this “help” people often experience increasing despair as they realise that the internal trauma, grief and desolation does not abate.

Re-enactment: Revictimisation

Well-meaning professionals may encourage asylum seekers to seek out experts with whom to “talk about your past, talk about your problems”. Referrals are often made to specialist post traumatic stress disorder services who rarely accept failed asylum seekers precisely because their lived reality is so fraught with danger that there is no hope of achieving the sense of safety and security necessary for trauma-focused work. Although agencies coming into contact with the asylum seeker may refuse treatment or assistance for eminently sensible and ethically appropriate reasons, the individual experiences repeated refusals, rejections, rebuttals and an unacceptably high level of exposure as their story is shared time after time. This repeated exposure seems to enhance the already highly disassociated state of many traumatized people who have been compelled to tell their story but lack the emotional support network to contain the acute distress levels that are triggered (Henry, 2005) .

There is considerable debate surrounding the diagnosis of post traumatic stress disorder, when working with populations who are, by definition, both victims and survivors. Summerfield (2001) rebutts the diagnosis of PTSD amongst asylum seekers and refugees, arguing that this psychiatric diagnosis undermines the resilience of individuals that should be celebrated. Others (eg de Zulueta, 2005) concur with the resilience model but also offer PTSD as an extremely useful diagnosis when working with feelings and experiences of disequilibrium following gross trauma. Herman (1992) offers the diagnosis of complex traumatic stress in the aftermath of a prolonged period of totalitarian control, taking account of the complexities of abuses experienced by many asylum seekers. Le Feuvre (2005) suggests the notion of “ongoing traumatic stress disorder” which neither negates the asylum seeker’s experiences nor confines the traumatisation to the past.

Many survivors speak of deep-seated feelings of being “not human”. The denial of public systems to which all other citizens have access serves to emphasise this feeling and belief. Acts of torture and extreme abuse necessitate the passivity of the victim and lead to a sense of helplessness. The individual is similarly forced into a position of passivity during the asylum process, repeatedly uttering the words, “I have no choice” as an explanation of their physical and emotional destitution. In this position, homelessness, destitution and disenfranchisement often become internalized, adding to pre-existing psychic disturbance (Adlam, 2005). The survivor, caught up in the process commonly finds him/herself in the position of passive recipient, having things done to, or done for, him/her, resulting in an ongoing lack of autonomy and potential vulnerability to further abuse. The impact of disbelief has a deeply damaging effect and accusations of fabrication are devastating, reinforcing a sense of silent passivity and giving rise to a sense of madness, both internal and external, to which words cannot do justice. Such a climate of disbelief has a profoundly disturbing impact upon a person’s ability to trust and to engage in meaningful relationships, disrupting a sense of meaning and faith in self and other.

Beneficence/Non-malfeasance

The principles of beneficence and non-malfeasance are fundamental ethical principles of all health and social care and are key to the establishment of any therapeutic relationship. The start of any therapeutic work with this client group begins with a gradual process of re-humanisation that may or may not involve sophisticated therapeutic interventions. Due to the complexities of the asylum seeker’s daily existence, the therapist will often be required to work in new and creative ways, confronting difficulties that may not ordinarily be encountered.

Thus working with this client group raises any number of ethical questions and hurdles; one key aspect of many asylum claims is medical evidence. Although the standard of proof is low, the burden to achieve this standard of proof lies with the individual asylum seeker who has to prove his/her experiences of atrocity and loss and fear of future persecution. Mental health evidence, indicative of a person’s extreme distress and traumatisation, is often heavily relied upon by Home Office and tribunal decision-makers. Ordinarily the content of the therapeutic relationship remains strictly confidential but therapists working with asylum seekers are routinely asked to supply medico-legal reports as essential components of the asylum seeker’s claim. To submit this evidence by definition involves disclosing deeply personal and sensitive information; to withhold this information could be to risk the person’s success in their asylum application. Credibility can be called into account and a claim disbelieved where a psychotherapist has refused to provide evidence of mental distress/trauma. Ethical principles of confidentiality, beneficence and non-malfeasance become deeply intertwined and perplexing. The asylum seeker will often be prepared to disclose any personal information in order to save their lives and secure future safety; the therapist may feel deeply uneasy about such disclosure.

The client often enters the relationship in a state of extreme desperation, but with a tentative degree of hope that the therapist can offer a cure or resolution. When faced with such extraordinary needs, the therapist may feel inadequate, while the client may be inherently sceptical, full of mistrust and fear. The Western therapist may feel suddenly conscious of his or her nationality and skin colour and may experience a range of counter-transferential responses including inadequacy, impotence, shame, guilt and responsibility. The client may need much, much more than the therapist feels able to offer. Does this render the relationship impossible?

This article has endeavoured to point to the complexity of the work involved and the potential issues that may confront the therapist working with asylum seekers. The therapeutic relationship may be the only place in which the client experiences a sense of safety, belonging and beneficence. Should this be denied simply on the basis that the complexities are too great.

References:
Adlam, J. (2005) Personality disorder and homelessness: Membership and “unhoused minds” in forensic settings. Group Analysis 38 (3) 452-466
Amnesty International (2004) Get it right: How Home Office decision making fails refugees. London. Amnesty International
Burnett, A., Peel, M. (2001) Asylum seekers and refugees in Britain: Health needs of asylum seekers and refugees. British Medical Journal. 322: 544-547
De Zuluetta, F. (2005) Personal Communication with the author.
Dinsmore, A., (2008) The time is right for a bill of rights. Observer: 10/08/08
Henry, N.N. (2005) Disclosure, Sexual Violence and International Jurisprudence: a Therapeutic Approach. PhD thesis. Department of Criminology. University of Melbourne [online] Available:
www.law.arizona.edu/depts/upr-intj/DSVIJTA.pdf [accessed 10/08/07]
Herlihy, J., Turner, S., Scragg, P. (2002) Discrepancies in autobiographical memories – implications for assessment of asylum seekers. Repeated interviews study. British Medical Journal, 324: 324-327.
Herman, J.L. (1992) Trauma and Recovery: from Domestic Abuse to Political Terror. London: Pandora
Home Office (2007) Asylum Statistics United Kingdom 2007.
Le Feuvre, P. (2005) Personal Communication with the author.
Summerfield D, (2001), The invention of post traumatic stress disorder and the usefulness as a psychiatric category. British Medical Journal: 322: 95-98