Little research exists concerning the needs and stressors related to living as an asylum seeker or refugee in exile, especially in the context of the mental health of asylum seekers (Silove, Steel, & Watters, 2000). In psychiatric fieldwork with asylum seekers, the interde-pendence of human rights, mental health and social development is self-evident, yet the current policies threaten both them. Instead of freedom, asylum seekers are kept in reception centers, often sharing one room with the whole family or with strangers; instead of being accorded re-spect and dignity, they are rejected as intruders; instead of receiving opportunities to regain their autonomy, they face restrictions, enforced dependency, discrimination and marginaliza-tion. In consulting with refugees, it is evident that people do not forsake their livelihoods, fami-lies and possessions unless there are compelling reasons. Silove and colleagues (2000) moreo-ver report that the remoreo-verse is more common – even under semoreo-vere threat, most choose to delay flight as long as possible in the hope that stability will return, and leave their homes only if a level of intensity is reached that threatens survival. Accordingly, many refugees have problems in the process of acculturation and suffer from homesickness even if they know, that they would be in danger in their home country, and that their families would be disrupted (van Wil-ligen, Hondius, & van der Ploeg, 1995).
As discussed above, displaced people are at high risk of PTSD (see 5.2.2). Depressive and other co-morbid symptoms are repeatedly and in varying prevalence rates reported (see 5.3) (Smith Fawzi et al., 1997; Terheggen et al., 2001). A safe, supportive and predictable environ-ment is important in the recovery process after massive traumata (see above and Silove, 1999).
In addition, early recovery is important since remission is less likely the longer the symptoms persist (Kessler et al., 1995; S. M. Weine et al., 1998a).
Instead of gradual adaptation, a common pattern in refugees once they reach a place of safety, asylum seekers tend to show a deterioration in psychological functioning, substantially attributable to imposed restrictions (Reijneveld, de Boer, Bean, & Korfker, 2005; Silove, 2002). Asylum seekers are trapped in a continuum of threat, with conditions fostering a con-vergence and compounding of insecurities from the past, present and future. Memories of past dangers and humiliations intermingle with current feelings of uncertainty; this, in return, mag-nifies fears of future persecution should detainees be repatriated. Recollections of past
impris-onment merge with recurrent feelings of outrage at being confined behind razor wire in the country in which the asylum seeker has sought freedom (Steel et al., 2004). The future is per-ceived as being entirely in the hands of an ‘impersonal bureaucracy’, intensifying feelings of helplessness and loss of control over one’s personal life. Silove and others (2000) found that the testing of refugee claims can provoke anxiety and, in those previously subjected to interro-gation, torture and other abuse, dissociative reactions. Furthermore, during the inquiry, memo-ries can become incoherent, interfering with the capacity to provide a consistent account. Yet, inconsistency is often cited as reason to dismiss a claim.
Considering the 1951 Refugee Convention, it gave centrality to the principle, that some-where in the world, people fleeing persecution could feel assured of achieving refuge. When this faith is eroded, particularly in asylum seekers who have been waiting for a final court deci-sion for a long time, psychological disintegration is likely. In such cases, depresdeci-sion is often diagnosed. Yet, underlying these symptoms is a capitulation to hopelessness when the asylum seeker is confronted with the reality that security and a life with dignity may be beyond reach.
Sultan und O’Sullivan (2001) report concerning the average time spent in a reception center a time span of six months up to indefinite duration. Furthermore, the situation in refugee camps / reception centers in combination with legal stressors, such as a pending residence permit, af-fects the mental health of asylum seekers, especially of people, who have survived persecution and traumatic experiences before their flight (Steel & Silove, 2001; Sultan & O'Sullivan, 2001). Many asylum seekers experience a marked decline in socioeconomic status, as well as difficulties accessing health care (Schouler-Ocak, 2003; Sinnerbrink, Silove, Field, Steel, &
Manicavasagar, 1997).
In the context of mental health, Silove and others (1997) report that PTSD in asylum seek-ers is associated with greater exposure to pre-migration trauma, delays in processing refugee applications, difficulties in dealing with immigration officials, obstacles to employment, racial discrimination, and loneliness and boredom. Eisenbruch (1991) reports in this context, that those refugees, who had the option to engage in at least some traditions in exile, felt better as compared to others, who felt rather restricted. Some authors state, that the individual recovery from PTSD is based upon the restoration of social and economical structures, cultural facilities as well as the respect for human rights (Bracken et al., 1995; Pedersen, 2002). Others found, that a greater number of war traumas, a greater number of resettlements and social isolation (Blair, 2000; K. E. Miller et al., 2002) as well as poor language skills, unemployment, being in retirement or disabled, and living in poverty (Marshall et al., 2005) were associated with an increased risk for PTSD and Major Depression. Miller and colleagues (2002) suggest, that
so-cial isolation might be bidirectionally linked with PTSD. Concerning Major Depression, finan-cial distress (Blair, 2000; Lavik, Hauff, Skrondal, & Solberg, 1996), daily activity and sofinan-cial isolation (K. E. Miller et al., 2002) were found to be risk factors. However, prerequisites for a residence permit are often proofs of integration such as employment or language skills. Yet, the former is mostly restricted. Often, asylum seekers are not allowed to work. If they have the permit to work, the working conditions are often bad because of poor education.
Migration stressors produce different consequences, which can add to the perceived stress.
For example, Miller and colleagues (2002) found that those refugees who attended a mental health clinic were significantly less employed as compared to a community sample. Language skills on the other hand have been found to be impaired because of mental illness. Sondergaard and Theorell (2004) report that the symptom load of PTSD is inversely related to the speed of language acquisition. Many asylum seekers are trapped in a vicious cycle of pre- and post-migration stressors and related consequences with regard to social functioning, quality of life and mental health, which add to a predominant feeling of helplessness and hopelessness. De-spite these findings, Steel and colleagues (2002) report, that – even though the conditions of post-migration environment influences the outcomes - trauma exposure was the most potent, and the only consistent, predictor of current mental health illness in resettled Vietnamese refu-gees, even when post-migration factors were taken into account. The authors conclude, that post-migration stressors might diminish after prolonged resettlement, but the effects of high exposure to pre-migration trauma can persist. In contrast, Lavik and others (1996) report that past traumatic stressors and current existence in exile constitute independent risk factors for mental disorders.
Van Willigen and others (1995) found that those refugees who had been to the Nether-lands for more than a year presented higher average number of mental complaints than those who had been to the Netherlands for less than one year. Haasen and Yagdiran (2000) describe a phase of decompensation which takes place after 6 to 9 years living in exile. According to the authors, disorders such as substance use, psychotic disorders, affective disorders as well as stress disorders and somatoform disorders are likely to appear during that period of time – if they have not been present before.
Finally, it stands out, that mental health issues and circumstances in exile are interlinked and can interact. Therefore, it is necessary, to act on both sides. From the clinical point of view it is indicated, that multifaceted and comprehensive treatment is needed. In this context PTSD should be focused on at an early stage to avoid the disorder becoming chronic if possible.