Another country

The death of Firsat Yildiz in Glasgow has highlighted the
problems facing asylum seekers as they try to make a new life in a foreign
country. Mike George talks to Jim Mullan and Patricia Clarke about a Kurdish
refugee fleeing from torture and his battle with depression and loneliness.

Behind the tough rhetoric and policies employed by the
government against asylum seekers and refugees, social care and health staff
are left to struggle to support these vulnerable people as best they can.

This can be a tough job, especially as it often involves
people who have been traumatised by persecution and torture.

Abdul Hassan (not his real name) is Kurdish; he is a
political refugee who fled here many years ago after being imprisoned and
severely tortured in Iraq. He is now in his early sixties, and continues to
suffer from post-traumatic stress disorder. He also has painful arthritis
caused in some part by the torture.

As a result of his severe depressions, suicidal thoughts and
self-harming he has been admitted to hospital several times. As a consequence,
he is on anti-depressive medication, and several years ago was referred to the
community mental health team. The team’s staff have provided support, monitored
his medication, and have attempted to dissuade him from binge drinking, not
least because that is when he is at most risk of self-harm.

A couple of years ago Jim Mullan, a community psychiatric
nurse in the team, and his approved social worker colleague, Patricia Clarke,
were assigned to co-work with him. This decision was made directly after he had
set fire to his flat, while he was in it, and within a few hours of him telling
his brother that he would kill himself. Luckily, Hassan was not hurt badly, and
after self-discharge from an accident and emergency department he went to stay
with his sister. He was immediately charged with arson and intent to endanger
life. "This arrangement created problems for his sister, mainly because he
was binge drinking frequently. So we arranged for bed and breakfast
accommodation, which wasn’t ideal, but was the least risky course of
action," says Mullan.

Once there, his behaviour and mood improved. "One or
other of us saw him weekly, and he was willing to be helped, for example,
through day centre activities," says Mullan. "He was also seeing
family members living in the area, and some friends. However, the fire had
clearly upset him, and he was becoming very worried about his forthcoming court
appearance."

In the meantime, Clarke and Mullan had been liaising with
the housing department, and repairs to Hassan’s home were under way.

Once the flat was repaired he returned there, and although
he complained about the racist behaviour of a neighbour, his mood and behaviour
continued to improve. He resumed regular contact with a clinic specialising in
post- traumatic stress disorder, and agreed to an admission to a
neuropsychological unit because he was having memory lapses, such as forgetting
that he had left the cooker on.

As Mullan and Clarke were planning his discharge from this
unit they heard from a colleague in the unit’s forensic team that Hassan had
been to court, had received a four-year custodial sentence, and had been taken
to a high-security prison. "This was a complete surprise to us. Hassan hadn’t
told us, neither had his solicitor, or anyone else officially, and it would
have been useful to have had the opportunity to support him at the
hearing," he says.

Mullan was contacted by the outreach community psychiatric
nurse who was working at the prison, and the local forensic team, in an attempt
to ensure that they had Hassan’s full history. Through these contacts Clarke
and Mullan heard that Hassan’s mental condition had deteriorated rapidly; an
assessment by a forensic psychiatrist concluded that he was at great risk of
self-harm, and was in a psychotic depressive state. Consequently, he was
transferred to a secure hospital unit under section 37 of the Mental Health Act
1983. When there, anti-psychotic medication was administered, and he began to
improve.

He was there for six months. "We attended the discharge
meeting, and it was agreed that while he should be discharged back to his flat,
the level of risk was so high that a nurse from the local forensic team would
join us in working with him. In addition, we had been talking a great deal to
his daughter and other family members, who were very supportive," Mullan
says.

Unfortunately, within a week following discharge he had
relapsed and was drinking again. Clarke says she and her colleagues became seriously
concerned about Hassan harming himself, or even others: "For example, on
one occasion when I saw him he had a blade in his hand," she says.

She and Mullan had also seen the race-hate notes posted
through his door.

Despite this, they maintained that his interests would be
best served by staying in the community, and held out against a proposal by a
psychiatrist for compulsory hospital admission. Clarke says that their decision
was largely based on information from his daughter, who said that he would
often binge, then cease "after he had got it out of his system". At
the same time, Clarke adds, they tried to help him to understand that while his
daughter and sister were supportive, they were worried about him staying with
them, which was what he wanted to do.

"By this time, after much effort, I’d helped to arrange
a move to another flat in another neighbourhood, and a short while ago he moved
there, with community psychiatric nurse support. He’s now much more settled, he
has started to attend a mosque, and has stopped binge drinking," says
Clarke.

Case notes

Practitioners: Jim Mullan and Patricia Clarke

Field: Community psychiatric nurse and approved social
worker respectively in a community mental health team

Location: Croydon, south London

Client: Abdul Hassan (not his real name) is in his early
sixties, and has been in this country for many years, after fleeing from
torture and imprisonment in Iraq. He has post traumatic stress disorder, is
subject to deep depressions, and often engages in binge drinking and
self-harming.

Case history: He has been admitted to hospital several
times, but is managed on a weekly basis by Mullan and his approved social
worker colleague, Clarke. About two years ago Hassan set fire to his flat in an
apparent attempt to kill himself. He was admitted to hospital, and subsequently
charged with arson and intent to endanger life. Mullan and Clarke found
temporary bed and breakfast accommodation for him, and his emotional state
improved.

A year ago he was admitted to a neuropsychological unit for
assessment of his increasing memory failures. While Mullan, Clarke and their
colleagues were arranging discharge they discovered that he had been given a
four-year custodial sentence in a high security jail. Hassan became suicidal
and psychotic. Mullan and Clarke were involved in an assessment, which led to a
transfer to a secure hospital unit under section 37 of the Mental Health Act.
He was subsequently discharged, and returned to his (repaired) flat, where his
behaviour became very risky.

Dilemma: When he has been drinking he is at high risk, but
living in the community helps him to keep in close contact with family and
friends.

Risk factor: He has suicidal thoughts, which he has tried to
act upon.

Outcome: He is in new accommodation, and is coping better.

Arguments for risk

– Hassan has been known to statutory health and social care
agencies for many years. His condition is well known, and he is monitored quite
closely.

– Much of the time he is willing to accept support from
agencies and clearly wants to live as normal a life as possible.

– He is capable of forming good relationships with others,
including Mullan and Clarke.

– His binge drinking occurs mainly, although not always,
when he is feeling very stressed. It is not a lifestyle choice in any sense.

– He has several members of his family living nearby, all
are supportive, especially his daughter, and all have co-operated and worked
with Clarke and Mullan.

– Some of his risky behaviour can be attributed to his
reaction to racist actions by a neighbour, or as a result of difficulties with
family members.

– He has never posed a risk to anyone else, even when he set
fire to his flat his intention was to kill himself, not harm others.

– He was capable of recovering from the enormous trauma of
being locked up in a high security prison.

– Any long-term, especially enforced, stay in an
institutional setting is likely to cause further mental distress.

Arguments against risk

– Despite numerous hospital admissions and attendance at
specialist clinics he still suffers from the consequences of post-traumatic
stress disorder.

– His past self-harming behaviour could be extreme and
extremely risky; apart from setting fire to his flat he has stabbed himself on
previous occasions, once quite seriously.

– He assumes that female family members have a duty to look
after him and should attend him whenever he wants; their refusal to go along
with this (possibly culturally based assumption) has confused and upset him at
times.

Independent comment

The Medical Foundation for the Care of Victims of Torture
specialises in providing medical, psychological and social help for survivors
of imprisonment and torture, writes Alex Sklan. These comments will therefore
focus on this dimension of the problems facing Abdul Hassan.

He, like many other Iraqi Kurdish people, would have been
imprisoned and tortured by the Iraqi authorities. The objective of the torture
would be to destroy any individual who opposes the regime, physically,
psychologically and spiritually.

Having survived this ordeal Hassan would have had to flee
the country and a hazardous journey would be undertaken. On arrival in this
country people in Hassan’s situation are subjected to a system designed to deter
would-be asylum seekers, starting when they explain their story to immigration
authorities.

Under current arrangements Hassan would then be offered
vouchers and accommodation without choice or discussion. The standard of
accommodation is basic and in some cases unhygienic.

At this stage the survivor of torture is also suffering a
culture shock of coming to an unfamiliar environment and all the factors
associated with becoming a refugee, such as loss of family, friends, status,
profession and work.

The experience of torture itself is likely to leave an
individual with a sense of depression, lack of self-worth and memories of
degradation and humiliation – feelings worsened by the four-year prison
sentence. This would trigger off memories of past imprisonment and torture.

In our experience the most important aspect of therapeutic
work is to assist an individual in making sense of what has happened to them
and finding a way of regaining their self-respect. The role of family in
providing accommodation is of great importance, but the client will need help
in coming to terms with the changing culture that prevails in this country and
his position as head of the family. This may, of course, also involve working
with the family.

Alex Sklan is director of clinical services, Medical
Foundation.