Mental health policy and practice across Europe: an overview

Care of asylum seekers and refugees 365
the emergence of increasingly restrictive policies towards asylum seekers and
illegal immigrants in America, Europe and Australasia. Measures have included
confinement in detention centres, enforced dispersal in the community, the
implementation of more stringent refugee determination procedures, increasingly
severe restrictions on access to work, education and housing and restrictions
in access to health care (Silove et al. 2000b). Researchers have examined
the relationship between factors relating to bureaucratic procedures, living conditions,
low social support and discrimination in the post-migration environment
and concluded that these can have a significant impact on the increased
risk of PTSD symptoms among traumatized asylum seekers (Silove et al. 1993).
Increased levels of depression have been shown to be associated with low levels
of social support and financial difficulties. On the basis of a study of 84 Iraqi
refugees, Gorst-Unsworth and Goldenberg conclude that, ‘Social factors in exile,
particularly the level of “affective” social support, proved important in determining
the severity of both post-traumatic stress disorder and depressive reactions,
particularly when combined with a severe level of trauma/torture. Poor
social support is a stronger predictor of depressive morbidity than trauma
factors’ (1998: 90). According to Silove et al., ‘salient ongoing stressors identified
across several studies included delays in the processing of refugee applications,
conflict with immigration officials, being denied a work permit, unemployment,
separation from family, and loneliness and boredom’ (2000b: 606).
Internationally there has been a significant increase over the past decade in
the detention of asylum seekers. A number of studies have been undertaken to
examine the mental health implications of detention. Research in the United
Kingdom indicated that psychological distress is evidenced through the high
incidence of attempted suicide and hunger strikes (Pourgourides et al. 1996). As
reported in research undertaken on 25 detained asylum seekers in Australia,
there were higher rates of depression, suicidal ideation, post-traumatic stress,
anxiety, panic and physical symptoms among the detained asylum seekers as
compared to compatriot asylum seekers, refugees and immigrants living in the
community (Thompson et al. 1988).
What these studies indicate is the interrelationship between specific policies
towards asylum seekers and refugees and the mental health problems experienced
by this group. Increasing restrictions on the facilities and support offered
to refugees and the tightening of bureaucratic procedures may be significant
‘stressors’ that are detrimental to mental health. A recently developing area of
study has shifted the emphasis from a clinical focus on the impact of policies of
deterrence on mental health status to a more sociological approach that examines
the impact of ill health, including mental ill health, on the socio-legal
contexts in which asylum applications are generated and status is determined
(Fassin 2001; Watters 2001a). This research is influenced by Zolberg’s seminal
paper in which he directs attention to the impact of state immigration policies
on patterns of migration and away from early neo-classical push/pull theories
(Zolberg 1989).
The routes taken by asylum applicants have been described as ‘avenues of
access’ that are influenced by the prevailing immigration laws and policies
(Watters 2001b). The ‘avenues’ followed by asylum seekers may be influenced by
the extent to which they are experiencing health and mental health problems