Written evidence submitted by
NHS Greater Glasgow & Clyde Psychological Trauma Service

Acknowledgement

We would like to thank clients attending the Glasgow Psychological Trauma Service (GPTS) service user group and clinicians working at the GPTS for their helpful contributions and feedback.

1. Background

The GPTS was invited by Mr Graham O’Neill, Policy Officer at the Scottish Refugee Council to provide written evidence to the Committee on issues relating to asylum accommodation with a mental health perspective in mind.

In response, clinicians at the GPTS were asked to reflect on accommodation issues raised by clients in the asylum process and consider, from their perspective, the mental health impact. Service users attending our regular service user forum[1] were also given the opportunity to contribute any reflections relating to accommodation issues. Responses were collated and summarised below.

It is important to note, that the information below was gathered from a small sample of clinicians and service users within the GPTS and is therefore not necessarily representative of all clients we work with.

2. Glasgow Psychological Trauma Service (GPTS)

The GPTS is a tertiary level mental health service, which offers multi disciplinary psychologically informed interventions to clients who present with Complex Post Traumatic Stress Disorder (CPTSD) following experiences of complex trauma. As a service, we target some of the most vulnerable and marginalised individuals in society, including individuals seeking asylum and those granted leave to remain. We offer both individual and group interventions in line with a phased based model for Complex PTSD (see The Scottish Government. NHS Education for Scotland, 2015).
 

3. Complex trauma and Complex PTSD reaction

Complex psychological trauma represents extreme forms of traumatic stressors, which are often life threatening and or physically violating, overwhelming, terrifying, and typically chronic rather than one time-limited (Courtois & Ford, 2009). The repetitive and prolonged nature of such events and often lack of opportunity to escape can have a significant impact on the individual’s sense of self; ability to relate or trust others; perception of the world; sense of safety and ability to manage day to day life. Furthermore, individuals often present with chronic hopelessness and helplessness and feelings of disempowerment. Post Traumatic Stress Disorder symptoms are also typically apparent and are characterised by involuntarily remembering of the traumatic event(s) (e.g. intrusions, nightmares, flashbacks); hyperarousal (e.g. sleep disorders, problems with concentration, anxiety symptoms etc); avoidance of trauma associated thoughts, situations and actions; and negative cognitions and mood (American Psychiatric Association, 2013).

Examples of complex traumatic events/stressors include childhood sexual and physical abuse, recruitment into armed conflict as a child, being a victim of domestic violence, sexual violence, sex trafficking or slave trade, experiencing torture and exposure to genocide campaigns or other forms of organised violence.

Individuals reporting symptoms of CPTSD often describe a range of other co-morbid mental health difficulties including: depression; anxiety and acute stress disorders; dissociative disorders; and self-harm/suicidal behaviours.

4. Factors affecting the mental health of asylum seekers

a)      Pre-migration and Migration Issues

Many asylum seekers have been forced to leave their home countries because of multiple experiences of trauma (e.g. war, torture, violence) and human rights violations (e.g. persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion) (Hargreaves, 2002; Hollifield et al., 2002; Silove, Sinnerbrink, Field, Steel & Manicavasagar, 1997) and report trauma related mental health problems. PTSD has been shown to be prevalent in this population and in some cases more so than the general population in western countries (Johnson & Thomson, 2007; Fazel, Wheeler, & Danesh, 2005).

The process of migration is typically fraught with uncertainty and fear and can involve exposure to further trauma, significant loss and potentially life threatening events. For example: exposure to physical and sexual violence (Nakash et al., 2014); trafficking (Zimmerman, Hossain & Watts, 2011); loss of family and friends; and coercive control. As such, individuals arriving to the host country are vulnerable to psychological distress and mental health difficulties.

b)     Post migration Issues

On arrival to the host country, asylum seekers are often faced with the pressures of navigating their way through a complex and often protracted process of claiming asylum, whilst living with ongoing fear of further trauma if deported. The stressors faced at this time, such as poor socio-economic living conditions, separation from family and/or reduced support, employment restrictions; delayed asylum application process and social welfare have been shown to interact with mental health difficulties (Carswell, Blackburn & Barker, 2011; Ryan, Kelly & Kelly, 2009; Silove et al., 1997; Silove, Steel, McGorry & Mohan, 1998). Interestingly, some research has evidenced a higher risk of psychological morbidity associated with post migration stressors than previous trauma (e.g. Laben et al., 2005).

c)      Housing and mental health

There is some evidence to suggest that stressful living conditions (e.g. insecure, poor quality, overcrowded etc) can increase stress, and reduce empowerment and control, which has been linked to mental health outcomes (Evans, Wells & Moch, 2003). Although this research is not specific to asylum seekers, it shows that the quality of housing provision generally can affect mental health outcomes.

For asylum seekers, the level of perceived stress relating to accommodation is likely to depend on a range of variables. This might involve for example, pre-existing mental health conditions, cultural factors, existing coping resources, level of support available, and or/other external stressors. Lack of privacy and shared sanitary blocks have been mentioned as factors contributing to ill health (De Jonghe, Ee Van & Dieleman (2004)., cited in Laban et al., 2005). Furthermore, the frequent moves to different geographical areas-particularly when young children are involved-has been shown to be particularly stressful and undesirable, disruptive to family life and child development and detrimental to the children’s well being (Warfa et al., 2006).

5. Evidence

5 (a) the following themes are based on comments received from clinicians working within the GPTS

Communication

• Language barriers
• Difficulties were reported with clients not being able to understand important information during telephone calls with the accommodation provider due to language barriers.
• It was noted that there was a lack of sensitivity to English not being the first language, specifically, the housing provider employees not adapting their speech (rate/clarity) to facilitate understanding or using interpreters.

• Reporting concerns
• It was reported that clients’ often felt fearful pursuing complaints against the housing provider due to uncertainty about the impact this may have on their asylum claim or being moved out of the area, particularly when children had settled into nursery/school.
• On one known occasion when issues were raised to a housing provider about their accommodation, a client stated that they were denied the opportunity to speak to management.
• More generally, when clients’ raised concerns about accommodation issues to the housing provider, they perceived these were dismissed or minimised.
• A client reported being allegedly threatened with deportation by a housing provider employee when he/she spoke of making a complaint.
• The response from the housing provider when raising accommodation issues on behalf of a client was varied (resolution, no action and delayed action etc.).

• Lack of information
• Difficulties were reported in relation to the housing provider arriving on the premises without warning.
• It was noted that arrival of new tenants in the accommodation, without prior warning, particularly at night, was especially anxiety provoking for clients.
• Concerns were raised that locks were apparently changed whilst clients were out of the house. In one known incident, this resulted in increased distress and a suicide attempt in the context of the client being made destitute.

Environmental issues/quality of accommodation/ safety

• Sharing with other residents
• Difficulties were reported in sharing with others (e.g. due to other residents engaging in drug use, bringing friends to the house, or the individual’s own mental health difficulty).
• Difficulties coping with the frequent changes in tenants in accommodation, especially when not forewarned.
• Difficulties for parents of young children having to share accommodation.
• Difficulties for families being separated. For example, when families are reunited and are housed separately by the home office and local authority.
• There was concern that woman and children were being accommodated with unknown flatmates, raising an issue of child protection.
• It was reported that one woman delayed toilet training her child due to being in shared accommodation and worrying about the impact this may have on the other resident.

• Environment
• Clients reporting feeling culturally isolated in the location they were accommodated in.
• There was concern that the housing provider apparently did not show consideration about the level of disruption caused when moving individuals frequently, particularly those with young children and the impact this may have on school and nursery placements.

• Housing condition
• Reports of insect infestations, which although repeatedly treated still remained a problem.

Difficulties were noted in relation to accommodation not being accessible for clients with mobility issues.

• Reports of unsuitable furnishing (e.g. lying on springs on a bed as there was no mattress available despite requesting this repeatedly).

Human rights

• Lack of privacy
• Difficulties were reported with housing provider employees entering clients’ property without knocking or prior notification.
• Difficulties for clients not having a private space in shared accommodation aside from their own bedroom, particularly when they have young children.
• Clients reporting feeling unsafe or being unable to protect their privacy and belongings in their accommodation especially when sharing with others, due to inability to lock their bedroom door.

• Protection of property
• Having no secure system on internal or external doors was reported as a source of anxiety for some clients.

• Discrimination
• Clients feeling discriminated against because they were an asylum seeker. For example, allegedly being told by a housing provider employee that they had to put up with their circumstances because they were an asylum seeker/ they should be grateful they had a roof over their head.

• Lack of respect and dignity
• Reports of clients being spoken to by housing provider employees in what was perceived to be derogatory, rude or aggressive manner.
• Client not being given time to resolve issues before being evicted from accommodation.
• Concern was raised regarding the lack of availability of choice for male/female housing employees carrying out inspections. This is partially pertinent to vulnerable woman, who have experienced sexual violence and may be terrified of being in the company of male authority figures (e.g. woman who are trafficked for sexual exploitation). 

Interface between Serco, Orchard & Shipman and the GPTS

• Clinicians were concerned that there was lack of flexibility by the housing provider in responding to clients’ individual needs when issues were raised.
• It was felt that complaints were not always responded to in a satisfactory manner.
• Lack of two way communication between the housing provider and other agencies involved in clients’ care, especially when anticipating change in circumstances that could increase the client’s distress and negatively impact on their mental health and risk.

5 (b) the following statements were provided by service users attending our user group meeting on 22nd August 2016

• Accommodation is part of mental health because wherever you are and the type of accommodation will affect your mental health.

• There should be a minimum standard of what it should be like and these standards should be followed – if it isn’t up to standard then we could tell them.

• There should be clear information on who to contact if there are any problems.

• There are a lot of problems with accommodation.

• Consideration should be given regarding people’s beliefs and values.  People with different views/religion/sexuality.

• Take into account personal circumstances – a lady was asked to move out of her flat in one hour – she was heavily pregnant.

• Orchard and Shipman never give any notice, so you can’t take your belongings and furniture with you.

• Treated like an animal.

6. Conclusion 

The multiple and repeated traumatic events experienced by asylum seekers can increase their vulnerability to psychological distress and mental health difficulties. With already diminished resources, lack of social support and threatened stability and safety, additional stressors such as those caused by accommodation difficulties may amplify distress and exacerbate mental health difficulties.

Clinicians in the GPTS service were concerned that clients’ needs for safety, respect, and privacy in relation to their accommodation were not always responded to. Consideration was not always given to the needs of women or children and processes and procedures were not trauma-informed.

Clinicians at the GPTS often find themselves advocating for clients through written correspondence, making telephone calls and helping them navigate multiple complex systems. Such tasks are typically protracted and unclear often without successful resolution. Furthermore, managing distress associated to post migration issues can impede progress in therapy and prolongs traumatic symptoms.

7. Recommendations

A sense of safety and stability is essential to people’s psychological well-being and mental health and is the foundation of trauma focused psychological therapy. A person’s home should be more than basic shelter and instead be a place of comfort, security, stability and privacy.

Given the high incidence of trauma in asylum seeking population, the GPTS would encourage all public services working with individuals who have experienced complex trauma to work in a trauma informed way. This involves recognising the widespread impact of trauma, being able to identify this and respond in an integrated manner to avoid further harm/re-traumatisation. The key principles of trauma informed care include: Safety (physical and emotional); trustworthiness; choice; collaboration; and empowerment (Fallot & Harris, 2009).

The recommendations below are in response to the evidence provided in this document and are consistent with the key principles of a trauma informed care.

Communication

• That anyone working with asylum seekers whom English is not their first language, make use of interpreters, speak in everyday language avoiding jargon and adapt their communication style to facilitate understanding of information.
• Asylum seekers are provided with clear written and verbal instructions (with support from an interpreter) of how to make a complaint about accommodation issues when such issues arise and that complaints are taken seriously.
• Asylum seekers should be provided with a written response detailing their complaint and actions taken within a timely manner. This should be copied to the person supporting their complaint and opportunities to discuss actions should be provided.
• The procedure for making complaints should be simplified and easily accessible online.
• Asylum seekers should be informed about their rights, including acceptable standard of their accommodation. This would enable them to make valid complaints.
• Asylum seekers should be forewarned in writing about visits; new tenants moving in; being moved to another geographical location; and/or any other significant changes occurring in respect to their accommodation.
• Asylum seekers are communicated to in a respectful and compassionate manner.
• Clinicians working with asylum seekers are forewarned of any significant changes in their accommodation circumstances to enable the potential distress to be managed in therapy and allow for risk assessment/management.

Environmental issues/quality of accommodation/ safety

• Asylum seekers are offered a choice of having a male/female housing provider employee carry out inspections of their accommodation.
• Woman and children should not be in a shared flat as this raises child protection concerns and potential impact on meeting developmental milestones.
• That consideration is given to disrupting children when moving families, avoiding where possible multiple changes in geographical areas.
• Consideration for housing families together under family reunification circumstances to enhance support and coping.

Housing condition

• Consider moving if infestation problems persist.
• Consider mobility issues and make necessary adjustments and/or identify suitable accommodation.

Human rights

• Be respectful of asylum seekers rights for privacy. As indicated above, providing clear warning of visits, knocking prior to entering properties and giving the individual time to respond.
• Ensuring that all asylum seekers have a bedroom of their own.
• Consideration is given to the option of allowing asylum seekers to lock their bedroom door to maintain safety and secure belongings.
• To be offered a private space to discuss issues confidentially.
• Having a secure system on external doors.
• To ensure that asylum seekers rights for being treated equally are maintained, that they are not discriminated against because of race, religion, being an asylum seeker etc.
• Asylum seekers are treated with respect and dignity.

We are grateful for the opportunity to be able to contribute to this inquiry by providing some comments, reflections and recommendations. We hope that the information provided and will help to inform developments and standards relating to accommodation provision for asylum seekers, particularly considering the mental health impact of some of the issues raised.

Dr Suzanne Aziz, Clinical Psychologist; Rachel Morley, Consultant Clinical Psychologist, on behalf of the Glasgow Psychological Trauma Service

References

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Carswell, K., Blackburn, P., & Barker C. (2011). The relationship between trauma, post-migration problems and the psychological well-being of refugees and asylum seekers. International Journal of Social Psychiatry, 57(2), 107-119.

Courtois, C. A., & Ford, J. D. (2009). Treating Complex Traumatic Stress Disorder: An Evidence-Based Guide. The Guilford Press. New York.

Evans, G. W., Wells, N.M., & Moch, A. (2003). Housing and Mental health: a review of the evidence and a methodological and conceptual critique. Journal of Social Issues, 59(3), 475-500.

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