The politics of working with refugee survivors of torture

The plight of refugee people often results from structural inequalities and gross human rights violations, including genocide, ethnic cleansing, persecution, discrimination and torture, causing suffering and misery to individuals, their families and to whole communities. In considering the politics of working with refugee people as psychologists we may ask if we have a role at all and what it might be. Many of us would respond that it is important to address to the health concerns of refugee survivors of torture. In practice, and as the other articles in this special issue have described, there may be obstacles to providing a psychological service – such as feeling overwhelmed by the person's range and complexity of problems, by existing long waiting lists, by not having experience of working with interpreters and people from different countries and by facing the brutality of torture. Further, institutional racism preventing black or minority ethnic people from accessing talking therapies and psychologists can also affect refugee survivors of torture.   

Our work within a human rights organisation, and in the NHS, as well as our experiences as minority ethnic psychologists, with our own experiences of migration, exile and exclusion, have led us to believe that psychologists have limited, but important roles, not just in attempting to alleviate distress, but in confronting the many human rights abuses experienced by refugee survivors of torture, in their country of origins and in Britain. Torture is a political tool of control and repression, it is the abuse of power to render people powerless. Ethically, it is incumbent upon us to ask why people are tortured, by whom, how and in which contexts, how and why it continues with impunity, and what can be done to prevent such human rights abuses and atrocities? The extent to which this is possible, or even thought to be a legitimate role for psychologists, relates directly to one's view on whether psychology itself is political – contextually driven, value-laden, not neutral, biased and open to misuse and abuse. In our research activities, publications and clinical practices are our own thinly veiled political positions.

Working with refugee survivors of torture requires us to consider the many contexts, including the political context, which shape their experiences and which influence our own psychological practice.

Public perception and policy
The role of the media in depicting asylum seekers as 'bogus', 'scroungers', illegal or as criminals 'flooding' the UK and taking away scarce resources in health services, education and housing from local people, or as terrorists threatening our safety, has had an enormous negative impact on public perception. In turn this has influenced government policy, and related legislation has become increasingly punitive, with the fourth new Immigration Act in the last eight years introduced in 2006. Harsh measures have included the removal of essential safeguards for asylum seekers, by criminalising those arriving without documentation, establishing rebuttable presumptions as to their credibility because of the route taken and means used to come to this country, cuts to legal aid, accelerated appeals, preventing asylum seekers from working and limiting the leave to remain granted to refugees to a maximum of five years initially rather than for an indefinite period.

All of these legislative changes have potentially serious psychological consequences. Whilst access to health care available to asylum seekers has been left intact, entitlement to secondary health care, which can include psychological services, has been significantly restricted for failed asylum seekers with potentially lethal conditions (Burnett & Rhys Jones, 2006; Hall, 2006). Access to GP practices has become, in effect, discretionary. Experiences of total destitution abound for many whose applications for asylum have been rejected.  

The politics of psychological health services
Institutional racism within statutory health services has historically prevented equitable access to psychological services by people from black and minority ethnic backgrounds, including refugee people. Black and minority ethnic people in the UK have been overrepresented in acute psychiatric services; they are often offered higher doses of medication and for longer periods; they are more likely to be given ECT (Bhugra & Bhui, 1997); and they have been less able to access talking therapies through the statutory services (Patel, 2000).

In bringing the concept of institutional racism (which has been in existence for many years) into the public arena, the Macpherson Report (1999) forced changes within statutory agencies, resulting in the Race Relations (Amendment) Act. This requires statutory services, like the NHS, to not just react to racism, but to promote racial equality and to prevent racial discrimination. However, there is little evidence that this legislation has widely translated into the reality of providing equitable psychological services to marginalised (and often politically unpopular) groups such as refugee people.

Psychological services have been slow and reluctant to respond to the needs of refugee people. In particular, faced with survivors of torture, many psychologists are often overwhelmed and paralysed by the numerous difficulties survivors experience and by the horror and brutality of their torture. Responses we have encountered include 'we are not equipped to deal with such problems' or 'doing therapy with interpreters is impossible and ineffective', or 'there are no resources for such work, or working with interpreters' and 'they seem so traumatised, their problems are so complex and they require too many resources and we are not sure our service is the right place for them'. These responses not only reinforce institutional racism and exclusion, but constitute further human rights abuses in denying them the right to health. Paradoxically, torture survivors can attract curiosity and outrage at the injustices of their past experiences, as well as exclusion by services.

The politics of offering psychological technology
Of those refugee survivors of torture who reach psychology services, perhaps with an interpreter where necessary, some may be offered psychological assessment, and possibly therapeutic help. However, the political context that shapes the technologies we offer requires scrutiny. Who is offered or denied a service and why? What might be the reasons for accepting some people for treatment, and not others – are these reasons always based on health need, or on service criteria which make some unsuitable as research participants, or unsuitable for a particular model of therapy offered in the service, or unsuitable because they may need interpreters and demand further resources? In such cases it is unjustifiable to attempt to 'divert' people to already overstretched and underfunded voluntary services, when statutory services have a remit to serve all equally, and an obligation to rise to the challenge of developing appropriate services.

For those offered psychological therapy, a critical examination of the psychological models and tools that are used is also required. Psychology's eurocentric biases, evident in our theories, methods and research activities, are frequently disguised as universal and apolitical. Psychological technologies are often applied in ways that do not question the impact of imposing culturally-specific approaches, often racist in ideology and in application. Take the case of a refugee family, persecuted and tortured in their country, confined to their home in Britain for fear of going out since the father and children were physically attacked and threatened with unmuzzled dogs by racist neighbours. In this specific case, local psychologists had proposed that the parents could be helped to manage their anxiety and to better support and help their children to go out more; and that the children could be helped to build their confidence to go out more, and attend school (where they were also experiencing racist bullying). The racist attacks resonated for the whole family who had experienced years of persecution in their country, and where the children had witnessed their father being tortured.

The politics of psychological assessment and research also requires consideration. The unquestioned use of assessment tools – sometimes translated, but rarely validated for the population concerned – is problematic and unethical. In the past, similar criticisms in relation to research with other black and minority ethnic people led to demands from community organisations, service users and mental health practitioners for guidance on more ethical research with black and minority ethnic people (see Patel, 1999). Importantly, we must ask what constitutes ethical research with this population, and whose interests does it actually serve.

Challenges for psychologists
In addressing human rights violations such as torture, experienced by refugee people, psychologists can contribute at many levels. At the primary level, psychologists can offer psychological assessments, support and therapy within the context of health services adhering to ethical principles in relation to refugee torture survivors (see Patel, in press); and they can work with refugee community organisations and other agencies with the aim of preventing further deterioration in emotional health and well-being. At the secondary level of prevention, psychologists can contribute to assessment and formal documentation in support of allegations of torture in the asylum process, to ensure legal protection under relevant international human rights law. At the tertiary level, psychologists can contribute to research, training and advocacy aimed at changing policy, at promoting the principles of international human rights and humanitarian law and at changing the practices of the police, judiciary, health professionals and others in states where torture is practised.

But all these activities demand that we rethink our theories, that we conduct more socially responsible and relevant research, develop more equitable and appropriate psychological services and provide more just psychological support in ways which address the issues and experiences of oppression in people's countries if origin, in Britain and within our own psychological services (Patel, 2003). As clinicians, this requires that we recognise and uphold the right of refugee people to appropriate psychological services (Mahtani, 2003) and that as psychologists we actively seek ways to confront our own eurocentricity, our racism and our political positions in the face of gross human rights violations.

Dr Nimisha Patel is a consultant clinical psychologist at the Medical Foundation for the Care of Victims of Torture, and a senior lecturer in psychology at the University of East London. E-mail: [email protected].
Aruna Mahtani is a consultant clinical psychologist at the Medical Foundation for the Care of Victims of Torture, and at Tower Hamlets Primary Care Trust.
E-mail: [email protected]. 

Challenges for services
- Early identification of vulnerable survivors of torture in health services is important to ensure their right to health; as well as aiding efforts to ensure their legal protection under international human rights law.
- Torture is a deliberate, political act, often in the context of historical devaluation and persecution  – it is not an accidental trauma, disease or illness. Psychological services must guard against pathologising or excluding survivors of torture, and instead support them towards better health, and towards re-establishing a connection with other human beings, and a belief in a just society.
- Work with survivors of torture requires a commitment to ongoing critical self-reflection and exploration of our biases, histories, motives and our experiences and re-enactments of power.

Weblinks
Medical Foundation for the Care of Victims of Torture: www.torturecare.org.uk
United Nations High Commissioner for Refugees: www.unhcr.org
Refugee Therapy Centre: www.refugeetherapy.org.uk

References
Bhugra, D. & Bhui, K. (1997). Clinical management of patients across cultures. Advances in Psychiatric treatment, 3, 233–239.
Burnett, A. & Rhys Jones, D. (2006). Health care for asylum seekers. Rapid Response, BMJ Online, 4 August (Accessed 6 August 2006 www.bmj.com).
Hall, P. (2006). Failed asylum seekers and health care. BMJ, 333, 109–110.
Macpherson, W. (1999). The Stephen Lawrence Inquiry Report. London: Home Office.
Mahtani, A. (2003). The right to appropriate psychological services. International Journal of Human Rights, 7, 40–57.
Patel, N. (1999). Ethical guidelines for mental health research with black and minority ethnic people. London: TCPS/MIND Publications.
Patel, N. (Ed.) (2000). Clinical psychology, 'race' and culture: A training manual. Oxford: BPS/Blackwell.
Patel, N. (2003). Human rights and clinical psychology: Reinforcing inequalities or facilitating empowerment? International Journal of Human Rights, 7, 16–39.
Patel, N. (in press). 'What are my human rights if I am not even human?' Developing psychological services for refugee survivors of torture. In S. Fernando & F. Keating (Eds.) Mental health services in a multiethnic society (2nd edn). London: Brunner Routledge.

The plight of refugee people often results from structural inequalities and gross human rights violations, including genocide, ethnic cleansing, persecution, discrimination and torture, causing suffering and misery to individuals, their families and to whole communities. In considering the politics of working with refugee people as psychologists we may ask if we have a role at all and what it might be. Many of us would respond that it is important to address to the health concerns of refugee survivors of torture. In practice, and as the other articles in this special issue have described, there may be obstacles to providing a psychological service – such as feeling overwhelmed by the person's range and complexity of problems, by existing long waiting lists, by not having experience of working with interpreters and people from different countries and by facing the brutality of torture. Further, institutional racism preventing black or minority ethnic people from accessing talking therapies and psychologists can also affect refugee survivors of torture.   

Our work within a human rights organisation, and in the NHS, as well as our experiences as minority ethnic psychologists, with our own experiences of migration, exile and exclusion, have led us to believe that psychologists have limited, but important roles, not just in attempting to alleviate distress, but in confronting the many human rights abuses experienced by refugee survivors of torture, in their country of origins and in Britain. Torture is a political tool of control and repression, it is the abuse of power to render people powerless. Ethically, it is incumbent upon us to ask why people are tortured, by whom, how and in which contexts, how and why it continues with impunity, and what can be done to prevent such human rights abuses and atrocities? The extent to which this is possible, or even thought to be a legitimate role for psychologists, relates directly to one's view on whether psychology itself is political – contextually driven, value-laden, not neutral, biased and open to misuse and abuse. In our research activities, publications and clinical practices are our own thinly veiled political positions.

Working with refugee survivors of torture requires us to consider the many contexts, including the political context, which shape their experiences and which influence our own psychological practice.

Public perception and policy

The role of the media in depicting asylum seekers as 'bogus', 'scroungers', illegal or as criminals 'flooding' the UK and taking away scarce resources in health services, education and housing from local people, or as terrorists threatening our safety, has had an enormous negative impact on public perception. In turn this has influenced government policy, and related legislation has become increasingly punitive, with the fourth new Immigration Act in the last eight years introduced in 2006. Harsh measures have included the removal of essential safeguards for asylum seekers, by criminalising those arriving without documentation, establishing rebuttable presumptions as to their credibility because of the route taken and means used to come to this country, cuts to legal aid, accelerated appeals, preventing asylum seekers from working and limiting the leave to remain granted to refugees to a maximum of five years initially rather than for an indefinite period.

All of these legislative changes have potentially serious psychological consequences. Whilst access to health care available to asylum seekers has been left intact, entitlement to secondary health care, which can include psychological services, has been significantly restricted for failed asylum seekers with potentially lethal conditions (Burnett & Rhys Jones, 2006; Hall, 2006). Access to GP practices has become, in effect, discretionary. Experiences of total destitution abound for many whose applications for asylum have been rejected.  

The politics of psychological health services

Institutional racism within statutory health services has historically prevented equitable access to psychological services by people from black and minority ethnic backgrounds, including refugee people. Black and minority ethnic people in the UK have been overrepresented in acute psychiatric services; they are often offered higher doses of medication and for longer periods; they are more likely to be given ECT (Bhugra & Bhui, 1997); and they have been less able to access talking therapies through the statutory services (Patel, 2000).

In bringing the concept of institutional racism (which has been in existence for many years) into the public arena, the Macpherson Report (1999) forced changes within statutory agencies, resulting in the Race Relations (Amendment) Act. This requires statutory services, like the NHS, to not just react to racism, but to promote racial equality and to prevent racial discrimination. However, there is little evidence that this legislation has widely translated into the reality of providing equitable psychological services to marginalised (and often politically unpopular) groups such as refugee people.

Psychological services have been slow and reluctant to respond to the needs of refugee people. In particular, faced with survivors of torture, many psychologists are often overwhelmed and paralysed by the numerous difficulties survivors experience and by the horror and brutality of their torture. Responses we have encountered include 'we are not equipped to deal with such problems' or 'doing therapy with interpreters is impossible and ineffective', or 'there are no resources for such work, or working with interpreters' and 'they seem so traumatised, their problems are so complex and they require too many resources and we are not sure our service is the right place for them'. These responses not only reinforce institutional racism and exclusion, but constitute further human rights abuses in denying them the right to health. Paradoxically, torture survivors can attract curiosity and outrage at the injustices of their past experiences, as well as exclusion by services.

The politics of offering psychological technology

Of those refugee survivors of torture who reach psychology services, perhaps with an interpreter where necessary, some may be offered psychological assessment, and possibly therapeutic help. However, the political context that shapes the technologies we offer requires scrutiny. Who is offered or denied a service and why? What might be the reasons for accepting some people for treatment, and not others – are these reasons always based on health need, or on service criteria which make some unsuitable as research participants, or unsuitable for a particular model of therapy offered in the service, or unsuitable because they may need interpreters and demand further resources? In such cases it is unjustifiable to attempt to 'divert' people to already overstretched and underfunded voluntary services, when statutory services have a remit to serve all equally, and an obligation to rise to the challenge of developing appropriate services.

For those offered psychological therapy, a critical examination of the psychological models and tools that are used is also required. Psychology's eurocentric biases, evident in our theories, methods and research activities, are frequently disguised as universal and apolitical. Psychological technologies are often applied in ways that do not question the impact of imposing culturally-specific approaches, often racist in ideology and in application. Take the case of a refugee family, persecuted and tortured in their country, confined to their home in Britain for fear of going out since the father and children were physically attacked and threatened with unmuzzled dogs by racist neighbours. In this specific case, local psychologists had proposed that the parents could be helped to manage their anxiety and to better support and help their children to go out more; and that the children could be helped to build their confidence to go out more, and attend school (where they were also experiencing racist bullying). The racist attacks resonated for the whole family who had experienced years of persecution in their country, and where the children had witnessed their father being tortured.

The politics of psychological assessment and research also requires consideration. The unquestioned use of assessment tools – sometimes translated, but rarely validated for the population concerned – is problematic and unethical. In the past, similar criticisms in relation to research with other black and minority ethnic people led to demands from community organisations, service users and mental health practitioners for guidance on more ethical research with black and minority ethnic people (see Patel, 1999). Importantly, we must ask what constitutes ethical research with this population, and whose interests does it actually serve.

Challenges for psychologists

In addressing human rights violations such as torture, experienced by refugee people, psychologists can contribute at many levels. At the primary level, psychologists can offer psychological assessments, support and therapy within the context of health services adhering to ethical principles in relation to refugee torture survivors (see Patel, in press); and they can work with refugee community organisations and other agencies with the aim of preventing further deterioration in emotional health and well-being. At the secondary level of prevention, psychologists can contribute to assessment and formal documentation in support of allegations of torture in the asylum process, to ensure legal protection under relevant international human rights law. At the tertiary level, psychologists can contribute to research, training and advocacy aimed at changing policy, at promoting the principles of international human rights and humanitarian law and at changing the practices of the police, judiciary, health professionals and others in states where torture is practised.

But all these activities demand that we rethink our theories, that we conduct more socially responsible and relevant research, develop more equitable and appropriate psychological services and provide more just psychological support in ways which address the issues and experiences of oppression in people's countries if origin, in Britain and within our own psychological services (Patel, 2003). As clinicians, this requires that we recognise and uphold the right of refugee people to appropriate psychological services (Mahtani, 2003) and that as psychologists we actively seek ways to confront our own eurocentricity, our racism and our political positions in the face of gross human rights violations.

Dr Nimisha Patel is a consultant clinical psychologist at the Medical Foundation for the Care of Victims of Torture, and a senior lecturer in psychology at the University of East London. E-mail: [email protected].
Aruna Mahtani is a consultant clinical psychologist at the Medical Foundation for the Care of Victims of Torture, and at Tower Hamlets Primary Care Trust.
E-mail: [email protected]. 

Challenges for services
- Early identification of vulnerable survivors of torture in health services is important to ensure their right to health; as well as aiding efforts to ensure their legal protection under international human rights law.
- Torture is a deliberate, political act, often in the context of historical devaluation and persecution  – it is not an accidental trauma, disease or illness. Psychological services must guard against pathologising or excluding survivors of torture, and instead support them towards better health, and towards re-establishing a connection with other human beings, and a belief in a just society.
- Work with survivors of torture requires a commitment to ongoing critical self-reflection and exploration of our biases, histories, motives and our experiences and re-enactments of power.

Weblinks
Medical Foundation for the Care of Victims of Torture: www.torturecare.org.uk
United Nations High Commissioner for Refugees: www.unhcr.org
Refugee Therapy Centre: www.refugeetherapy.org.uk

References
Bhugra, D. & Bhui, K. (1997). Clinical management of patients across cultures. Advances in Psychiatric treatment, 3, 233–239.
Burnett, A. & Rhys Jones, D. (2006). Health care for asylum seekers. Rapid Response, BMJ Online, 4 August (Accessed 6 August 2006 www.bmj.com).
Hall, P. (2006). Failed asylum seekers and health care. BMJ, 333, 109–110.
Macpherson, W. (1999). The Stephen Lawrence Inquiry Report. London: Home Office.
Mahtani, A. (2003). The right to appropriate psychological services. International Journal of Human Rights, 7, 40–57.
Patel, N. (1999). Ethical guidelines for mental health research with black and minority ethnic people. London: TCPS/MIND Publications.
Patel, N. (Ed.) (2000). Clinical psychology, 'race' and culture: A training manual. Oxford: BPS/Blackwell.
Patel, N. (2003). Human rights and clinical psychology: Reinforcing inequalities or facilitating empowerment? International Journal of Human Rights, 7, 16–39.
Patel, N. (in press). 'What are my human rights if I am not even human?' Developing psychological services for refugee survivors of torture. In S. Fernando & F. Keating (Eds.) Mental health services in a multiethnic society (2nd edn). London: Brunner Routledge.