Friday, 3 November 2006

Refugees, Uncertainty and the Absence of Control

Claire Smith is an occupational therapy lecturer at the University of Teesside in the North East of England. She also works with health care providers and assists them to develop skills in meeting the mental health needs of refugees.

For the past two years, she has also been working as a psychological therapist at the Personal Medical Services General Practice, "Arrival," which provides primary health care to people seeking asylum and refugees who live in the North Tees Primary Care Trust area.

She has spoken at national and international conferences on "lifespan issues" for refugees as well as on the importance of social capital and the need to increase opportunities for refugees.

In an e-mail interview with Ambrose Musiyiwa, which took place between Sept. 19 and Nov. 2, Claire Smith talked about the work she has been doing and about the challenges faced by health care providers in meeting the mental health needs of refugees.


Musiyiwa: You work with health care providers, asylum seekers, as well as refugees. How did it all begin?

Smith: I trained as an occupational therapist, qualifying in 1991 and have worked in a number of adult mental health day services across the County Durham area. In that capacity I have worked in group and individual therapies with a wide range of clients with diverse needs, and over time began to find a special interest in working with people who had experienced traumatic life events, including sexual abuse, domestic violence, and support after [witnessing] murder and manslaughter.

I undertook a Masters in Counseling at the University of Durham, which I completed in 1999, and I joined the occupational therapy teaching team at the University of Teesside. I have been teaching on a range of issues, particularly practice skills around communication and mental health. I have spoken at conferences on issues around trauma and social exclusion.

Which conferences were these and what did you speak on?

I spoke at the fourth World Congress of the World Federation for Mental Health in Oslo on "lifespan issues" for refugees (specifically the sense that the experience of asylum interrupts adulthood and stops people engaging with all the really important tasks of adulthood, like work and family life).

I have also spoken at occupational therapy conferences and for MIND and Diverse Minds, encouraging staff to increase opportunities for refugees and on the importance of social capital.

You have been doing a lot of work with health care providers. How did that start?

About three and a half years ago, I saw an advert for a post for a development worker to develop skills in meeting the mental health needs of refugees. The post was funded by Health Action Zone monies, and coordinated by an organization called Alliance Psychological Services, who have the contracts to provide psychological therapies locally in primary care. I was successful at interview and took the post in addition to part time teaching at the University, delivering workshops for staff from a wide range of backgrounds — school nurses, midwives, therapists, reception staff, etc.

The workshops were designed to provide general information about asylum issues — focusing on myth busting and [on creating] a realistic impression of the challenges faced by refugees in the local area.

What are some of the myths about asylum seekers and refugees? Where do the myths come from and how prevalent are they?

The myths are mostly generated by ignorance and misinformation — and they often hinge around refugee entitlement, genuineness of claims, perceived threat, etc.

Locally there was a lot of grumbling about benefits and services, assuming that refugees got all sorts of extras, when in fact they receive far less than people thought. Much of this is created by negative media stereotypes, but also by the fact that this is an area of low ethnic density and local people were unfamiliar with people from different cultural backgrounds.

I think the prevalence of this myth-based thinking is quite high, and runs through large sections of the population. Even some people who wish to be sympathetic are anxious about some of the issues, and for others, refugees have become scapegoats.

Most people are able to change their minds if they are better informed, but others will hold fast to their beliefs because they serve some other purpose for them.

What was the reception to the workshops you were running like?

I was greatly encouraged by the fact that many people were genuinely keen and willing to help — but aware that they felt deskilled and were concerned that their abilities were unsuitable for meeting the needs of the clients. The key things seemed to be the fear of making a mistake with cultural needs, (as ours is an area of very limited ethnic diversity) and feeling overwhelmed by the wealth of need.

The main aim of the workshops was to allow staff to feel enabled, and to encourage them to use their transferable skills.

You have also been actively involved in the Personal Medical Services (P.M.S.) General Practice. What is the P.M.S. General Practice?

The P.M.S. practices were set up as a pilot project to permit more flexibility at primary care level, and stands for Personal Medical Services (as opposed to General Medical Services).

They were to offer new, tailored and creative approaches in areas of deprivation or complex needs — to be more flexible and to instigate change, and have often been used to provide specific care to particular groups.

There are a number of P.M.S. practices specifically for refugees, heroin users and other groups who may have complex needs.

How did your involvement with P.M.S. start and what do you do there?

The therapy post at our local P.M.S. General Practice, "Arrival," became available and I was approached to take it. The Arrival practice, opened in Stockton-on- Tees in April 2003 and it provides primary health care to people seeking asylum and refugees living in the North Tees Primary Care Trust area. It currently has about 650 patients, around half of whom are from Africa and half from the Middle East.

I have been there for two and a bit years, working one day a week as a psychological therapist (obviously, using both my occupational therapy and my counseling background). I am based within the practice, taking referrals from other team members, and providing individual therapies.

As an occupational and psychological therapist, what would you say are your main concerns?

I am keen to promote the potential for therapy with refugees and people seeking asylum and have spoken at national and international conferences on a number of facets of refugee work.

I started with the "feel the fear" stuff, encouraging people to get involved and use their skills, then I have been looking at social capital theory and refugees and now at adulthood and lifespan issues. I want colleagues from a range of disciplines to see potential and be keen to help, and to look at tapping into the resourcefulness of their clients rather than feeling overwhelmed. Some of the biggest challenges my clients face are around how to "live" in the short term, with such a difficult past, an impoverished and isolated present, and a future that is so totally unknown.

The primary challenges [they face] seem to be practical — managing day to day in an unfamiliar environment with little money and very limited support. Beyond that though I think there are huge difficulties associated with living long term with an uncertain future, adjustment and acculturation, managing loss (personal, social, cultural), building a necessary social network, finding occupational opportunities, and engaging with the natural tasks associated with their stage in the lifespan.

The people I see struggle endlessly to put the past behind them. Tormented by intrusive and often horrific memories and enormous loss, they struggle with the impoverished and isolated life in the here-and-now and they are moving towards the total unknown. This is particularly destructive — most of us kid ourselves that we know what the future holds, and have some control over it, but refugees can have no such illusions. For them they can't be sure whether to invest in life in this country or hold back for fear of losing anything they establish here.

Are these challenges peculiar to refugees and asylum seekers or are they also found in the general population where you are working?

Most of the challenges are found, in part, with any population (particularly from my experience of working in mental health) — but the uncertainty and the absence of control is something that is certainly greater for refugees (to my mind).

In previous work I may have been looking at exactly the same kind of issues — and people may have a host of barriers to better mental health — but here I have a huge barrier that is immovable by me, and over which the client has no control — the asylum decision. This is unusual and specific and leaves [the] client, and me, in a passive position (exactly where I don't want us to be, therapeutically).

Under current U.K. legislation, asylum seekers can only seek permission to work if their claim remains outstanding for longer than 12 months without a decision being made on it and providing the reason for the delay cannot be attributable to the asylum seeker. Those whose applications for asylum have failed are not allowed to work. What effect does this have on mental health, and why is it important for asylum seekers to be allowed to work?

I think this is one of the most destructive aspects of current policy. There is evidence from past experience in Sweden that suggests that engaging with the labor market is of great value and has better outcomes than psychological therapies in maintaining good mental health. People face the crushing experience of waiting day to day for [a] decision to be made about their future, without any real sense of productivity, and anything gainful to occupy their time. Most feel that they are wasting their critical early adult years, and feel a sense of disgrace at having to accept money from N.A.S.S. [the National Asylum Support Service] when they are well and able to work for their own money.

This article has also been featured on OhmyNews International and the World Press Review.