Can community psychology meet the needs of refugees?

While there are many diverse approaches to mental health, services in England are predominantly organised around an individualised, professionally defined model of mental health. For ethnic minorities in general and refugees in particular there is a growing body of opinion that such a model reflects Western constructions of mental health problems and may not be appropriate for cultures where problems are not always seen as being located within the individual (e.g. Watters, 2001).

On a pragmatic level it is simply not possible to offer individual psychological therapy to all those refugees who have witnessed or been the victims of atrocities in their country of origin. This, coupled with the reluctance of many refugees to use formal psychological and psychiatric services, calls into question the usefulness of clinic-based services as the foundation of our response to the mental health needs of refugees (Miller, 1999).

Why adopt a community psychology approach?

Community psychology offers us opportunities to apply our psychological knowledge and skills to improve the mental health of communities in ways other than those of traditional psychological therapies.

It is best described by reference to a set of principles outlined by Orford (1992). These encompass the ideas that problems have social and interactional causes, should be analysed at the macro level, that service planning should be proactive and community-based and that practice should focus on prevention within everyday contexts and involve the sharing of psychological skills and knowledge with non-psychologists.

Community psychology is based on a set of values which seeks to address social and service inequalities and which acknowledges the political nature of this way of working. Philosophically it often draws on the ideas of social constructionism particularly when addressing issues of differential power and knowledge (McNamee & Gergen, 1992).

Community psychology offers us the chance to provide services for refugees which are more congruent with the community's own constructions of mental health problems. It strives to seek solutions that incorporate cultural understanding of mental health, enhance protective factors such as social support, avoid the stigma associated with mental health services, and that acknowledge and attempt to address the social and political causes of psychological distress in refugees.

All these approaches, however, are dependent on the assumption that there is a coherent notion of 'community' and that refugee clients wish to be connected into their community. Mistrust, political divisions and stigma around mental health may militate against this, as they may with any group. One example of working with 'communities' is the development of Timebanks, which give refugees and host communities the opportunity to earn time credits for voluntary work and to exchange these credits for the equivalent amount of time of someone else's skills, serving to develop links between refugees and host communities.

The social and political context

Research conducted by Gorst-Unsworth and Goldenberg (1998) indicates that refugees' experiences within the UK are often viewed by clients as more detrimental to their mental health than the atrocities they underwent in their countries of origin. Uncertainty and lack of control regarding legal status, lack of occupation and the associated loss of status and, racism all contribute to psychological distress. Most asylum seekers and refugees have escaped conditions of discrimination, domination and exploitation in their home countries, only to confront similar experiences in their host country. These problems can make integration and adjustment in the host country difficult and may serve to keep refugees in marginal positions and relative powerlessness.

Community psychology needs to facilitate refugees gaining a sense of control and influence over their environment. In order to achieve this, it can be argued that community psychology approaches must engage with the wider political and social context and challenge structures that maintain potentially damaging conditions. Addressing wider social inequities entails promoting social justice and social action and not just individual empowerment and compassion (Seedat, 2001). One small step towards this is asking refugee communities to define their own mental health needs and strengths rather than these being externally imposed. 

Voices of the community?

Just as psychological therapists increasingly seek to make their starting point the client's construction of their problems, so might community psychology start by seeking out the views of the community with which the psychologist is seeking to work. Such views can then be privileged above professional descriptions and can form the basis for planning project work and service developments. A further benefit is the development of positive working relationships upon which future project work can be built (Webster, 1998).

One limitation of the consultation approach is that some people, by virtue of their social position within their community, may be excluded from participating in community structures. For example, women, children and elders may not have equal status within their community and their voices may not be adequately represented.

The first author carried out one such set of consultations with refugee community organisations (RCOs) in Lambeth. Similar need assessments have been carried out in Waltham Forest (Harris & Maxwell, 2000), Great Yarmouth (Bowden et al., 2004) and Newham (Savcic-Sanders, 2003). The consultations sought to elicit responses to the following questions:

• How are mental health problems seen in your community?
• How does your community deal with mental health problems?
• How does your community see mental health services within the UK?
• What support, if any, does your community want from the NHS to deal with mental health problems?
• What are the strengths of your community?

Although there was much variation in responses from community to community, the following strong themes emerged from the Lambeth consultations:

• Many respondents reported considerable stigma around mental health within their communities, serving as a barrier to help-seeking.
• It was not possible to make meaningful statements about the extent of mental health difficulties from this study, but depression (not PTSD) was repeatedly cited as a common problem and linked with isolation, lack of opportunities, racism, loss and adjustment. 
• Family problems and relationship breakdowns were also frequently mentioned, often related to changes in gender roles.
• Respondents painted a negative picture of their experiences and perceptions of statutory mental health services. Concerns were expressed about information provision, difficulties in accessing services, poor communication with patients and their families and cultural appropriateness of services.
• Suggestions to improve services related to these above concerns. The need for more alternatives to medication, in particular talking therapies, the need for more training and education and the need to work in partnership were emphasised.
• The strength of social networks, family, places of worship and the commitment of volunteers were mentioned as being factors, which promote good mental health.

The results of this consultation were used as the basis for an action plan for South London and the Maudsley NHS Trust, a bid to develop community psychology services for refugees in partnership with RCOs, and a series of community-based workshops around service provision and stigma. Strategies were developed to manage the interface with the mental health system and to initiate conversations within communities regarding the stigma attached to mental health problems. Feedback received indicated that the workshops served to facilitate communication between various refugee communities and to reduce the sense of isolation through sharing experiences and strategies.

Another partnership project designed to enhance social networks and support involved clinical psychologists offering training, support and consultation to volunteers from refugee communities in Newham (Savcic-Sanders, 2003). Activation of social support networks seems to be a protective factor in the prevention of the development of mental health problems in this group (Allodi, 1989).

Another illustration of community consultation is a project aimed at understanding the mental health needs of refugees and migrant workers in Great Yarmouth (Bowden et al., 2004). Based on the findings of this consultation, an action plan was developed to address the experiences and conditions that were perceived to contribute to mental health problems.

This plan covered:

• material conditions (e.g. improving access through partnerships with colleges and job centres);
• stigma (e.g. an arts based anti-stigma campaign);
• awareness of services (e.g. mental health information in appropriate languages);
• relationship factors (e.g. education to promote women's rights and reduce domestic violence);
• cultural differences (e.g. mental health staff training about diversity and migration); and
• social conditions (e.g. facilitating participation in social activities).

Challenges

In the face of funding constraints and a drive to develop models of best practice, psychologists need to demonstrate the efficacy of their interventions. Conducting effective research of community projects presents psychologists with exciting challenges for a variety of reasons including an absence of appropriate comparison groups, multiple outcomes and the implementation of diverse strategies and initiatives (Hausman, 2002). Whereas qualitative and action-based research may most suit the philosophy underpinning a community psychology approach, this may not be congruent with the language of evidence-based practice most valued by service planners and funders.

Community psychology is an approach which attempts to recognise the social and political realities that are integral to the refugee experience, and seeks to intervene accordingly. But the approach is a relatively new one, and as such presents psychologists with a number of challenges as well as opportunities in terms of concepts, applications and research.

- Adrian Webster is Head of Lambeth Directorate Psychology, South London and Maudsley NHS Trust.

- Mary Robertson is a Consultant Clinical Psychologist & Service Manager, Traumatic Stress Clinic, Camden & Islington Mental Health and Social Care Trust.

Discuss and debate

• What can you do to make your service/clinical practice more accessible and relevant to the refugee community?
• Is it possible to meet the clinical needs of refugees without addressing social and political contextual factors which may be contributing to their distress?
• Can the NHS accommodate a community psychology approach?
• Is individual therapy the most appropriate way to intervene with refugee's mental health problems?

Weblinks

• Refugee Council: www.refugeecouncil.org.uk
• Information, advice, guidance and learning materials in community languages: www.multikulti.org.uk
• Psychologists Working With Refugees and Asylum Seekers: www.psyras.org.uk

References

• Allodi, F. (1989). The psychiatric effects in children and families of victims of political persecution and torture. Danish Medical Bulletin, 27, 229–232.
• Bowden, G., Franks, W. & Gawn, N. (2004, October). Working with refugees, asylum seekers and migrant workers to promote mental health. Paper presented at UK Community Psychology Conference, Exeter.
• Gorst-Unsworth, C. & Goldenberg, E. (1998). Psychological sequelae of torture and organised violence suffered by refugees from Iraq. British Journal of Psychiatry, 172, 90–94.
• Harris, K. & Maxwell, C. (2000). A needs assessment in a refugee mental health project in north-east London: Extending the counselling model to community support. Medicine, Conflict and Survival, 16, 201–215.
• Hausman, A. (2002). Implications of evidence-based practice for community health. American Journal of Community Psychology, 30, 453–466.
• McNamee, S. & Gergen, K. (Eds.) (1992). Therapy as social construction. London: Sage.
• Miller, K. (1999). Rethinking a familiar model: Psychotherapy and the mental health of refugees. Journal of Contemporary Psychotherapy, 29, 283–306.
• Orford, J. (1992). Community psychology theory and practice. Chichester: Wiley.
• Savcic-Sanders, D. (2003). Community psychology in Newham – Needs assessment. Internal document. Newham Psychology and Counselling Service.
• Seedat, M. (Ed.) (2001). Community psychology theory, method and practice: South African and other perspectives. Cape Town: Oxford University Press
• Watters, C. (2001). Emerging paradigms in the mental health care of refugees. Social Science and Medicine, 52, 1709–1718.
• Webster, A. (1998). Working in partnership with the voluntary sector: Setting up a counselling service for Asian elders. Clinical Psychology Forum, 122, 36–39.