Mental health professionals, and indeed clinicians in all specialties, may encounter patients who are involved in the process of an asylum application. The condition for which they are treated may be directly or indirectly linked to pre-migration trauma, and this may sometimes be cited as a reason for seeking asylum. These patients often report the frustration of the long wait for resolution of their case, with the threat of deportation as a chronic stressor. Although history-taking often acknowledges the roles that pre-migration and post-migration adversities play in the history of the presenting complaint, clinicians are not always clear about the practical realities involved in making an asylum application. A series of Home Office regulations govern arrangements for applying to study, work or reside in the UK, as well as entitlement to benefits, and the UK Border Agency is responsible for enforcing them. The legal and administrative procedures governing these pathways are complex, even for those with English as a first language. This article outlines the immigration legal process for adults, setting it in the context of other post-migration adversities, to help clinicians understand the legal and socioeconomic challenges faced by some of their patients. This information should serve as clinically useful in formulating appropriate treatment plans, designing risk management plans, and in preparing medico-legal reports where requested for asylum applications. It should be noted that asylum applications for unaccompanied minors are processed quite differently and are not discussed here.

Defining the asylum-seeker population

The 1951 United Nations Convention Relating to the Status of Refugees defines asylum as protection provided for those who are unable to go back to their country because of a well-founded fear of persecution on grounds of race, religion, nationality, political opinion, or membership of a social group. Asylum-seekers are often defined as any individual who has applied for asylum on the basis of persecution within their country of origin, while refugees are those whose asylum application has been successful. ^{Reference McColl, McKenzie and Bhui1} However, under the Refugee Convention, a refugee becomes so at the point at which they leave their country of origin in fear of persecution, and thus accrues certain rights, even though it may be some time later that formal refugee status is conferred.

In the UK, applications for asylum are made to the UK Border Agency. Applicants who do not qualify for refugee status, humanitarian protection leave or discretionary leave, may attempt to apply for temporary permission to remain on humanitarian grounds. Those whose asylum applications are turned down, or whose temporary leave is not renewed, are expected to return home voluntarily or face deportation, a process termed removal by the Home Office. The UK Border Agency is also bound by the European Convention on Human Rights, which prevents a person from being deported to a country where there is a real risk that they will be exposed to torture, or inhuman or degrading treatment. These legal principles distinguish refugees and asylum-seekers from economic or traditional migrants, acknowledging the human rights violations responsible for these displacements. ^{Reference Mollica, Culhane, Hovelson, Gelder, Andreasen, Lopez-Ibor and Geddes2}

Of the 23 430 people who applied for asylum in the UK in 2007, the majority were of Afghan, Iranian, Chinese, Iraqi and Eritrean origin. ³ Those with low levels of proficiency in English, and inadequate numeracy and literacy would have experienced a greater struggle to find legal representation and subsistence during the long wait for resolution.

Burden of mental illness in the asylum-seeker population

The mental health of asylum-seekers has not been well investigated, partly because of methodological difficulties in data collection. Caution must be exercised in extrapolating from the evidence base on the mental health of refugees as psychosocial stressors differ in the two populations. Migrants held in detention centres are also a distinct population. ^{Reference Steel, Silove, Brooks, Momartin, Alzuhairi and Susljik4-Reference Robjant, Hassan and Katona7} There are questions about the appropriateness of diagnostic categories such as post-traumatic stress disorder (PTSD) in migrant groups ^{Reference Keller, Rosenfeld, Trinh-Shevrin, Meserve, Sachs and Leviss8} but the core symptoms may simply be articulated differently in Western society when compared with other cultures. ^{Reference Mollica, Culhane, Hovelson, Gelder, Andreasen, Lopez-Ibor and Geddes2} People do cope with adversity in very different ways, and although the World Health Organization recognises a spectrum of psychiatric morbidity in this population, it also warns against assuming that all refugees and asylum-seekers are in need of psychiatric care. ^{Reference Cohen9}

The existing epidemiological data do suggest high rates of PTSD and depression in refugees and asylum-seekers, but with widely varying prevalence rates. ^{Reference McColl, McKenzie and Bhui1,Reference Summerfield10-Reference Brundtland13} Australian data have shown an association between delays in processing refugee applications and likelihood of PTSD diagnosis. ^{Reference Brundtland13} Other studies have described a high proportion of somatic presentations in asylum-seeker and refugee populations, ^{Reference Murphy, Ndegwa, Kanani, Rojas-Jaimes and Webster14,Reference Silove, Sinnerbrink, Field, Manicavasagar and Steel15} but there is a concern that such medicalised concepts fail to capture the complexity of distress, demoralisation, and loss of autonomy experienced in this population. There is very poor recording of rates of self-harm and suicide in this group but existing data suggest the risk to be high among detainees. ^{Reference Robjant, Hassan and Katona7} Early feedback from local suicide audits indicates that an increasing proportion of cases were suicides by recent immigrants, ^{Reference Adams, Gardiner and Assefi16} yet it is not clear whether asylum-seekers are represented at a higher rate than expected, or indeed what proportion had diagnosable mental illness. Community-based asylum-seekers presenting with suicidal behaviour may represent the tip of a clinical iceberg given the problems this group experience in accessing primary care or psychiatric services, and in overcoming language barriers.

Asylum application process

Applying for asylum in the UK may be summarised in the following stages. As the system is subject to ongoing transitional changes, updates can be found on the UK Border Agency website.

Volume of work

In 2007, a total of 14 935 asylum appeals were heard by the Asylum and Immigration Tribunal, of which 23% were allowed and 72% were dismissed. ^{Reference Steel, Silove, Brooks, Momartin, Alzuhairi and Susljik4} Between 2005 and 2008 the Court of Appeal saw a 77% increase in appeal applications for asylum and immigration cases, together with a rise in reconsiderations of decisions by the UK Border Agency or Asylum and Immigration Tribunal. ²² It is this rise in appeals, rather than new applications, which accounts for a substantial backlog of cases, exacerbated by the 2004 creation of a single-tier system bottlenecking cases through the High Court. Pressure groups such as the Public Law Project challenged this arrangement as breaching Article 6 of the European Convention on Human Rights which guarantees an effective court system. Such have been the delays in hearing cases that the timeframe for an asylum application involving appeals has been typically 1–2 years. Clinicians can encounter patients who have waited over 5 years. A 2008 ruling to bring more judges into the system was intended to increase the rate of asylum and immigration appeals heard from the existing 8000 per year and to reduce waiting times. ²² In early 2010, following a period of consultation, a new unified tribunals framework was established to replace the Asylum and Immigration Tribunal, and the impact of this is yet to be evaluated.

Sources of financial support

The personal resources required to lodge an asylum application and to support oneself and any dependants throughout the process can leave an applicant in a state of economic hardship. The UK Border Agency has funds available to those applicants who are unable to support themselves or their families, but eligibility is not guaranteed. Those who make their application some time after their arrival in the UK may meet these eligibility criteria. This presents a problem for people who travel to the UK and subsequently learn of the persecution of friends or family members back at home, raising their own risk on returning there. Unless they can be supported using resources accessed from the voluntary sector, they may have to rely on the goodwill of their own ethnic or religious communities.

An assessment is made of financial need at the start of the application process and the applicant is given details of local One Stop Services for further advice. The advice in these regional centres is provided by independent charitable organisations such as the Refugee Council, Refugee Action, the North of England Refugee Service, and Migrant Helpline. If the case owner judges that an asylum-seeker is eligible, short-term financial support is available in the form of money, food vouchers and accommodation, provided by the National Asylum Support Service, established under the Immigration and Asylum Act 1999 and provided within the Home Office. These amounts depend on age and number of dependants but are less than the equivalent income support payments for British residents. Any failure to fulfil reporting requirements may result in the cessation of financial support and possible detainment. Many applicants face geographical and financial barriers in meeting reporting requirements. Factors such as acute illness, a sick dependant, or transport disruptions such as strikes undermine an applicant's attendance record, threatening both their access to support and the success of their legal case.

Where accommodation is provided, no choice is offered over the geographical location. Provision in the south-east of England is very limited. It is common for applicants in London or the south-east who need longer-term accommodation to be dispersed to housing in other regions of the UK. This might arise, for example, if an individual's application process was extended or if their financial circumstances changed. The government's controversial dispersal policy is designed to even out responsibility for the provision of support but has a potentially disruptive effect on continuity of care, particularly for those being treated for mental health problems or in tertiary centres, and on any support networks already established. ^{Reference Summerfield10} For patients with severe psychiatric disorder the UK Border Agency will accept a challenge from the responsible clinician and consider deferral of dispersal on grounds of safety to self and others and continuity of care. ^{Reference Pourgourides23} For other recipients a refusal to move may result in termination of support. A dispersal order may therefore constitute a post-migration adversity regardless of outcome.

Patients often perceive decisions over dispersal or non-eligibility for support as being made on the apparent whim of a nameless official, and can feel let down by the Home Office, the UK Border Agency, the local authority, or their solicitor, engendering feelings of powerlessness and frustration. If an application is rejected, short-term support may be available while waiting to return to the country of origin under the terms of Section 4 of the Immigration and Asylum Act 1999. This Section 4 support is very restricted, involves vouchers or pre-payment cards and accommodation, and may require any involved medical professionals to account for specific medical reasons or other physical barrier preventing that person from leaving the UK.

Other post-migration adversities

A range of psychosocial stressors affect asylum-seekers awaiting the outcome of their application, including racist abuse, racially motivated crime, destitution, social stigma, and ineligibility to work. ^{Reference McColl, McKenzie and Bhui1} Racist abuse may be worse in economically deprived areas or during periods of economic decline and unemployment, and media coverage tends to feed negative perceptions. ^{Reference Cohen24} Asylum-seekers describe a stigma associated with the use of food vouchers and with housing stock set aside for the National Asylum Support Service. Ineligibility to work applies to all those who have waited less than a year for their application to be decided. Even then permission to work is restricted to certain types of work (e.g. self-employment is not allowed) and is only given if the applicant has not been judged responsible for any delay in the UK Border Agency reaching an initial decision on the application. Asylum-seekers have access to free National Health Service (NHS) healthcare unless their application fails. Following a 2009 Court of Appeal ruling, failed asylum-seekers are only entitled to emergency care or care at the discretion of the relevant NHS trust. In tension with concerns about increasing pressures on primary care, ^{Reference Arnold, Ginn and Wistrich25} and on NHS budgets as a whole, ^{Reference Gibb26} are arguments about the ethics and public health impact of withholding healthcare from those in need. ^{Reference Ani27,Reference Conay, Beutin, Horvath, Hubert, Lerais and Smith28}

Conclusion

British legal systems appear to be struggling under the weight of asylum applications and appeals, with cases remaining unresolved for anumber of years. This description of the immigration legal process illustrates the range of chronic and acute psychosocial stressors involved: the chronic threat of removal, the strain of non-resolution, and the acute anxiety precipitated by the arrival of each decision letter. These constitute a potential threat to psychological health, particularly for those with a history of pre-migration trauma. In understanding this process more fully mental health professionals are better able to contextualise their patients' problems, helping to predict and interpret fluctuations in risk, and formulate culturally appropriate management plans. Although improvements in the immigration courts are in process, health and social care and other government agencies may need to work together more closely in order to harmonise what society can provide with the needs of those seeking asylum.