Disclosure of personal information

There is a pervasive ‘culture of disbelief’ in Western asylum systems, whereby those claiming asylum are required to ‘prove’ their eligibility for legal protection. In the absence of personal documents (which are frequently left behind or lost during flight), asylum claims commonly rely on personal accounts. These claims are often heavily interrogated and scrutinised for any inconsistencies.^{Reference Wilbourn and Plotkin3} As a result, the sharing of a story becomes a means through which safety is guaranteed or rejected. It is difficult for immigration officials, lawyers and clinicians carrying out their assessments to ensure that consent is fully informed and free from coercion.^{Reference Jacobsen and Landau4} We have recently reported on the ‘narrative dilemmas’ asylum seekers often face in the process of recounting the experiences that led them to leave their countries of origin as well as during their asylum journeys.^{Reference Abbas, von Werthern, Katona, Brady and Woo5}

During the process of seeking refugee status, the expression of vulnerability can take on different meanings. Asylum seekers may need medical certification, providing detailed accounts of their physical and psychological symptoms, to ‘verify’ their claim of torture. However, ongoing mental illness may hinder their ability to recount their trauma because such disclosures can be re-traumatising. This may have an adverse impact on their asylum claim as well as leading to underreporting of mental health problems in research studies.

Cultural interpretations of mental illness

It has also been argued that Western classifications of mental illness have an inappropriately ethnocentric focus. As responses to trauma vary across cultural and ethnic backgrounds, it can be difficult to interpret manifestations of mental illness universally owing to the lack of a nomenclature for trauma that is valid across cultures.^{Reference Schnyder, Bryant, Ehlers, Foa, Hasan and Mwiti6} Thus, tools used for identifying groups who need specialist mental health attention may not be adequate among those from different cultural groups. This can make it difficult for clinicians to identify and diagnose those who may need specialist treatment and to make acceptable and effective care plans.^{Reference Bernak and Chung7}

Threat of return

In international law, a refugee is defined as a person who:

This remains a narrow legal definition, which excludes categories of people who have been displaced outside of these boundaries, for instance those fleeing natural disasters. Nevertheless, it confers a certain set of rights on the individual, including the right to live and work in the host country and subsequently to apply for permanent residence (in the UK, indefinite leave to remain (ILR)) or citizenship. For those fleeing generalised conflict or indiscriminate violence, a similar status of ‘humanitarian protection’ may be given. These statuses are both time-limited, and it is only when individuals are granted permanent residence/ILR or citizenship that their uncertainty over whether they will be forced to return to their country of origin can end. This may contribute to the findings of Henkelmann et al^{Reference Henkelmann, de Best, Deckers, Jensen, Shahab and Elzinga2} that length of stay appeared to be unrelated to prevalence of mental illness. As the authors note, the findings may be different if broken down by whether permanent status was granted.

An asylum seeker is anyone who has arrived in a host country and made an asylum claim. In the UK, while their case is being reviewed, they have the right to remain and are provided with a basic level of housing and subsistence, but (with very few exceptions) are not allowed to work. This existence ‘in limbo’, with the constant threat of imminent return, can represent a significant trauma in addition to their experiences in their country of origin and may increase their vulnerability to mental illness and impede recovery.^{Reference Katona9}

Traumatic journeys and post-migration factors

Less than 1% of refugees arrive in their host country through a resettlement programme in which they are given refugee status prior to arrival.¹⁰ These more favourable circumstances allow refugees to benefit from a greater degree of stability and certainty regarding their immigration status, along with the right to work or to claim mainstream benefits immediately.¹¹

However, owing to the highly restricted availability of this route, many asylum seekers and refugees make long and risky journeys, and may arrive in their host country after having been exposed to additional trauma, such as trafficking or destitution, during their journey. This may leave them more vulnerable to a traumatic asylum process.

Henkelmann et al's study rightly makes reference to some of the post-migration factors that can affect mental health, including migration status, socioeconomic position, long-drawn asylum procedures, unemployment and discrimination. These factors may also contribute to a range of mental health problems, including significantly higher rates of psychosis,^{Reference Hollander, Dal, Lewis, Magnusson, Kirkbride and Dalman12} a diagnostic group that was not included in the authors’ analysis.

Another diagnosis whose prevalence the study did not examine is ‘complex post-traumatic stress disorder’ (complex PTSD). This diagnostic concept, which is characterised by ‘disorders of self-organisation’ (impaired relationships, emotional dysregulation and negative self-concept) as well as core PTSD symptoms, has now been incorporated into ICD-11.^{Reference Cloitre, Shevlin, Brewin, Bisson and Roberts13} Complex PTSD is often found in the aftermath of multiple and repeated trauma^{Reference Cloitre, Stolbach, Herman, van der Kolk, Wang and Petkova14} – such as the torture, modern slavery, human trafficking and sexual abuse experienced by many asylum seekers.

The restrictive asylum systems in operation in most Western countries mean that, in addition to threat of return, asylum seekers have no right to work, and live in poor housing with minimal monetary funds for subsistence.¹¹ Many are placed in immigration detention, a process likely to have an adverse impact on their mental health.^{Reference von Werthern, Robjant, Chui, Schon, Ottisova and Mason15} Furthermore, despite social networks being recognised as key sources of support for asylum seekers, dispersal policies in the UK have made it increasingly difficult for asylum seekers and refugees to integrate into a community, in addition to making clinical and research follow-up more challenging.

Many forced migrants remain undocumented and therefore largely invisible to healthcare and other support services. Despite legal entitlement to primary healthcare services, many asylum seekers struggle to register with general practitioners owing to a lack of a fixed address, leading to substandard management of long-term health conditions. The COVID-19 pandemic has also served to highlight the precariousness of their situation, given the current need for testing and tracing as part of a public health response.

Within the Organisation for Economic Cooperation and Development (OECD), Canada has an explicitly inquisitorial asylum system.¹⁶ In Europe, a lack of common standards in asylum policies has led to varied treatment between countries, many of which are adversarial and unwelcoming in their approach to refugees and asylum seekers. However, one example to be commended is Germany's response to the large influx of Syrian refugees to Europe in 2015, wherein the government decided to accept a comparatively high number of asylum seekers as part of an organised resettlement programme for Syrians fleeing conflict. According to statistics published by the World Bank, in 2019 Germany remained the European country with the highest number of refugees (1.1 million, compared with the next highest country, France, with 400 000), with the UK hosting roughly 130 000 refugees.¹⁷