Global Health Award 2016 Entries: Rosie Pelham
A Case Report highlighting the Mental Health needs and barriers to service provision affecting Unaccompanied Asylum-Seeking Children
The number of forcibly displaced people in 2013 was the highest on record, with 51.2 million people displaced as a result of persecution, conflict or human rights violations (1). Data also suggests that the number of unaccompanied asylum-seeking children (UASC) is rising; over 25,000 applications were lodged worldwide in 2013 (1) and 1,265 of these were in the UK (2). Unaccompanied minors are a particularly vulnerable group, not only living as refugees in another country, but without the protection of legal guardians.
Miss X is a 19 year old female who originates from Somalia, a country that has been in effective civil war for decades and remained without an elected government until 2012. Somalia was the third largest refugee producing country in 2013 with 1.12 million refugees worldwide (1). The risk of gender-based violence facing women and girls in Somalia is great, and may include early and forced marriage, domestic violence, female genital mutilation and rape (3); domestic violence is commonplace and is only illegal if it results in serious injury or death (3).
X arrived in the UK in 2013 at the age of 17 as an UASC. Her family provided a supportive and loving environment throughout her childhood and although she received no formal education she was home-schooled by her father. At the age of 15 however, she was married to a much older man at whose hands she suffered physical and emotional abuse. Her family was aware of the domestic violence, but she received no support in leaving him. She escaped her marriage and her country without telling family or friends and has been granted leave to remain in the UK. Since her arrival she has been supported by the Klevis Kola Foundation (KKF) who have provided emotional and social support, advocating for X and helping her to explore her opportunities and access to services.
Arriving alone and unsupported without family, friends, possessions or money to a country with a different language and culture makes an individual, and especially a child, exceptionally vulnerable. This is recognised by law and the duties outlined in The Children Act 1989 that require Local Authorities to provide support and accommodation for those in need applies to refugee and asylum-seeking children (4). Currently at 19 years old, X is entitled to support until at least the age of 21 under leaving care services.
Meeting X in October 2014, I found her to be engaging and insightful with excellent spoken English. Sadly, one week prior to this, X had attempted suicide by drinking household bleach. In X’s own, and very powerful words, she explains that: “it was really difficult to start my new life without my family and with the bad memories of my married life; all of this has had a very negative impact on me” (personal written communication). X called the ambulance herself and was discharged the same day from Accident & Emergency, having had her physical health and psychiatric risk assessed.
This occurred shortly after her new College course began and her place was unfortunately withdrawn on grounds of nonattendance. This not only represents a loss of structure and an educational opportunity, but has had serious financial ramifications: X’s entitlement to Income Support is linked to her education status. When I met X she had no access to food or travel funds. Further unpicking of her situation revealed that her housing benefit had stopped six months previously, and she has a debt of unpaid service charge which could be grounds for eviction.
My involvement in the case has been to support X to access alternative educational opportunities, to offer social support and to liaise with other professionals involved to ensure her financial situation is being addressed. X has been left largely unsupported by leaving care services, perhaps due to the assumption that she would ask for help when needed. Admirably, X has a great desire to be independent, but she needs appropriate support to understand her entitlements and navigate the complex system of benefits.
X suffers from depression and will intermittently isolate herself and ignore all attempts at contact. A primary concern is the extent to which she is receiving mental health care; X appears to be seeing her GP regularly, but from experience we are aware that she presents as a very stable and capable young person and are unsure of the extent to which she discloses her low mood and distress. In the face of a complex social situation, history of trauma, no support from relatives or long-term friends, X remains resolutely ‘OK’. This may be a manifestation of her resilience and a coping strategy for her, but it worryingly appears to be a barrier to her accessing health care and social support.
It is widely acknowledged that UASC are at risk of developing mental health problems. One study has shown 41% to 58% of unaccompanied refugee adolescents to have symptoms of anxiety, depression or post-traumatic stress disorder (5) and there are several factors that may explain this high prevalence. Traumatic experiences before and during flight, separation from family and loss of familiar environment, economic and social difficulty upon resettlement and uncertainty about the future may all harm the emotional well-being of an UASC (4). Despite clear need there are several barriers to providing care for this group.
Barriers to mental health services
While mental health services may have intrinsic barriers to care, such as long referral times and language difficulties, an issue of particular relevance in this case is that of cultural differences when understanding mental health and in help-seeking behaviour. Varying definitions of mental illness in different cultural groups may result in mental health problems going unrecognised and therefore untreated. Talking therapies are well-established within a Westernised healthcare system, but this is not the case globally (6) and may therefore be inaccessible for linguistic and cultural reasons among the refugee population.
The role of mental health professionals may not be well understood and the issue of stigma may also cause resistance to using services (7). A study looking particularly at a group of Somali adolescent refugees settled in the UK found low rates of mental health service use and found that they were more likely to turn to religious figures and school personnel (7). If mental health concerns are dealt with first in communities with the help of family or friends, individuals who have a sparse support network, like X, could be at greater risk of having unmet mental health needs.
When mistrust of mental health services is a factor, access to and engagement with services may be improved with the help of people who have already gained their trust (6); KKF staff have found this in practice, and regularly accompany another individual to Psychiatry appointments. X however, has chosen to attend GP appointments alone.
Several commentators have concluded that low uptake of services by refugee families is due to a failure of Western mental health systems to accommodate ethnically diverse populations (8), and I would agree that there is a need for services that are appropriate to the requirements of refugees. Health providers should be educated on mental health beliefs within refugee populations and interventions themselves should place importance on educating communities about mental health, perhaps drawing links between past trauma and current symptoms. There are plans within KKF to design a new project for precisely this purpose: to meet mental health need through a community-based programme focussing on mental health education and providing culturally-appropriate care. Improving the health care available and developing new services appropriate for this vulnerable group and using education to tackle stigma and misunderstanding about mental health may successfully break barriers which prevent individuals like X from accessing help.