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One in four of us is expected to suffer from a mental health problem at some point in our lives. For asylum seekers, absence of family and friends, and language and cultural differences can make existing problems worse.

Nearly all of the 3,000 new clients attending the Medical Foundation for the Care of Victims of Torture each year have a mental health problem. And although it is unusual for asylum seekers and refugees to develop psychoses, serious depression and post-traumatic stress disorder symptoms are prevalent.

Their ability to cope with what happened to them in their home countries depends on how they see themselves, says the Medical Foundation's director of clinical services Alex Sklan: "It's about being a victim and a survivor. There is a long journey between the two and people go up and down."

Sklan says the Medical Foundation aims to move people away from feeling victims to being survivors. "Some people are deeply affected by what appears to be relatively small amounts of torture and cope badly. Other people experience a great deal of torture and can seem to cope with it."

When they arrive in the UK, the fear that their asylum claim will be rejected and they will be sent home to face further persecution adds to their mental distress.

"Although they are adults they become like babies," says Aida Alayarian, clinical director of the Refugee Therapy Centre, herself an Iranian refugee. "They cannot communicate with anyone and lack knowledge about how the system here works and what the culture is."

Since it was established in 1999 the centre has dealt with 400 clients from more than 20 countries, 350 of whom have been in the past two years. Clients either self-refer or are referred to the centre by social services, GPs and psychiatric services and receive weekly counselling.

Refugee Action's well-being project in Manchester tries to help asylum seekers and refugees cope with their trauma. It was set up in October 2002 to promote well-being and prevent mental health problems through a range of activities. These include a football club (see panel, left), samba classes, tennis and photography.

The project's development worker, Tim Hilton, does not talk to refugees and asylum seekers about possible poor mental health because the condition is not seen as a separate issue from other social issues in some cultures. He says:"They see it as something that happens because they don't have any friends to visit or don't live in good housing." In some cultures mental health problems are seen as taboo and asylum seekers do not want to be labelled with a condition that would exclude them further.

The Nationality, Immigration and Asylum Act 2002 has not helped their plight. Under section 55, the government can refuse to support people who do not make their asylum claim "as soon as reasonably practicable".

Beba Parker, a training adviser at the Refugee Council, says denying asylum seekers basic support can lead to a deterioration in their mental health.

Hilton agrees that the system is a problem: "Asylum seekers are not allowed to work, spend a lot of time alone and feel isolated, which leads to mental health problems."

Sklan says the asylum system's fundamental problem is that it is designed to disbelieve asylum seekers and so leaves them feeling humiliated. Many clients tell the Medical Foundation about the "horrors of the asylum process", he says.

Asylum seekers and refugees seeking help for their mental health problems face the difficulty of finding appropriate services, says Mental Health Foundation chief executive Andrew McCulloch. "They do not know how to access services and they don't see them even being open to them."


Alayarian says there is not enough training and supervision of clinicians who want to work with asylum seekers and refugees with mental health problems. "This work is not as straightforward as work with the indigenous population and can be more challenging."

Working with asylum seekers and refugees can put off some professionals, says Parker. "Some practitioners can baulk at it because they do not understand much about it. They assume that all asylum seekers are deeply traumatised and they won't know how to help them."

But it doesn't have to be complicated. "If you simply listen, smile and show empathy it can help a lot," says Alayarian, who calls for staff to use appropriately trained and experienced interpreters to enable clients to express themselves in a comfortable way.

McCulloch advocates recruiting therapists from the same communities as asylum seekers and refugees so they understand the culture as well as language. He also wants to see an audit of their mental health needs to ensure no one is slipping through the gap. Without this we may fail to provide asylum seekers and refugees with the most basic mental health services. CC

- For more on the mental health of asylum seekers and refugees go to the Mental Health Foundation's website www.mentalhealth.org.uk/page.cfm?pagecode=PERF

It's all about confidence

Refugee Action's Manchester-based well-being project started a football club last January in an attempt to work positively with asylum seekers and refugees. Initially, a qualified coach ran open sessions and in March it was extended to two sessions a week. A Sunday league football team was set up called International Manchester Football Club and in September it started playing matches. So far the team has won four of the five matches it has played this season. About 80 asylum seekers and refugees have used the project and 30 regular members make up the team squad. Mohamed al Din, a Kurdish Iraqi, captains the team and is one of the three refugees on the club's management committee. He says joining the team has made him "happier than before" and given him the confidence to try new things and make friends.

Fred Diarra, 18, from the Ivory Coast, has attended the football sessions since they began. "I started coming because I wanted to make some friends," he says. "I made many good friends during the sessions. They helped me forget about all the bad things that happened in my country."

Edward Banya, from Uganda, has been playing football at the scheme for eight months. The 25-year-old says he felt very isolated before joining: "I couldn't talk to people or express myself, I felt very different. Now I can see that everyone is the same as me." (All names have been changed.)