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Consider in depth a service that aims to meet some of the wellbeing needs of undocumented migrants (including trafficked people), asylum seekers, refugees or internally displaced persons and which may be viewed as an example of good practice in the field.
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Freedom from Torture (FFT) is a UK based charity that provides essential services and assistance to refugees and asylum seekers who have suffered from torture. In this essay, I will describe the services delivered by FFT that aim to meet the wellbeing needs of undocumented migrants who have experienced torture, including the challenges faced by the charity to provide and sustain these services and highlight the ways FFT can potentially improve those services to successfully meet the needs of survivors of torture. I have evaluated the services provided by FFT utilising an analytic framework on good practice, focusing specifically on access and entitlement, holistic service and culture and reflexivity.
In 2017, it was estimated that 25.4 million refugees were registered across the world (UNHCR 2019), many fleeing their country because of a ‘well-founded fear’ of persecution. By the end of 2017, there were 121,837 refugees, 40,365 pending asylum cases and 97 stateless persons in the UK (UNHCR 2019). Often, many have fled their country due to persecution, war or violence and travelled hundreds of miles at huge financial and emotional expense. Many refugees have experienced torture and organised violence in their own country, targeted for their political beliefs and activities or relating to aspects of their identity e.g. sexual orientation. Torture survivors can also include children who may have witnessed violence and abuse perpetrated towards their family members. When torture survivors arrive in the UK, they are often in great need for healthcare, legal support and housing but many remain untreated and unsupported. For example, the International Rehabilitation Council for Torture Victims estimates that only 4% of the 400,000 identified torture survivors in the UK have received psychological or medical treatment (Asociación and Refugiat 2016). Asylum seekers and refugees are “5 times more likely to have mental health needs than the general population and more than 61% will suffer serious mental distress” (Equality and Human Rights Commission 2017).
The Freedom from Torture (FFT) charity was established in 1985 and is the only organisation in the UK to provide a holistic service supporting the wide-ranging and complex needs of torture survivors. In 2017, FFT helped 838 people from 96 different countries and provided over 20,000 psychological therapy sessions. Of those, nearly a quarter were children and young people under the age of 25 years. The charity has five FFT centres in the UK, has an expanding volunteer workforce and provides training and expertise to partner organisations. They campaign to raise awareness and shape government policy and carry out research to develop their services.
FFT provides several services for torture survivors. These range from rehabilitation services to address physical and mental trauma, psychological therapies, support groups and practical legal support and advice to help torture survivors claim refugee status. Specialist physiotherapy and massage therapy is available to help those with physical injuries, such as scars, burns and poorly healed fractures. This can also help those suffering from chronic pain. Psychological therapies are also available to help torture survivors to cope with their traumatic and harrowing experiences. These include one-to-one psychotherapy, eye movement desensitization and reprocessing (EMDR) and music therapy. Psychological therapies can also help people to manage their chronic pain. In addition to physiological and psychological therapy, FFT facilitate creativity and social groups e.g. art and sport sessions. The Natural Growth Project for example, uses gardening as a therapeutic method and helps people to socially connect with others in their new community in the UK.
FFT also provides practical advice for torture survivors who are trying to claim asylum. FFT help asylum seekers by providing medicolegal reports and assisting them to navigate the numerous documents and various levels of bureaucracy involved in seeking asylum and in setting up their new lives. The UK systems and processes can be extremely difficult to navigate and can feel hostile and stressful for those who have survived torture. FFT provides interpreters to aid torture survivors to communicate effectively with healthcare professionals and officials they encounter in the asylum process.
FFT aims to provide good practice to its clients. They define ‘Good practice’ as:
“There is a general consensus that “good practices” constitute an action or series of actions that, resulting from the identification of needs, are systematic, effective, efficient, sustainable, and flexible; therefore they are planned and executed by all members of an organization and its beneficiaries with the help of the management board.” (Asociación and Refugiat 2016)
However, ‘good practice’ is a highly ambiguous and contested term, especially when dealing with vulnerable victims of torture. In this essay, I have used Charles Watters’ points on good practice (Watters 2011; Watters and Ingleby 2002) which provides an analytic framework from which to understand whether the services that are provided by FFT are utilised effectively to meet the wellbeing needs of torture survivors. I have focused specifically on access and entitlement, holistic service and culture and reflexivity. It is also important to frame good practice in Macro, Meso and Micro levels, to make sense of the laws and political context and ground level issues that I will expand on.
Access and entitlement issues are omnipresent in torture survivors’ lives. Entitlement is what the refugees have a right too, and access is how refugees reach the service or how the service reaches them. They are relational, each one affecting the other, therefore I will refer to them in conjunction. There are many services that torture survivors are offered at FFT, although entitlement problems may prevent many of them from accessing these services. Lack of adequate financial resources can be a barrier to accessing FFT services. Refugees and Asylum seekers on government benefits only receive £36.95 per week (Lyons 2017), an extremely low amount for someone to live off in the UK, and this is compounded by penalties imposed (i.e. benefits are reduced) if they are late to benefit appointments. In a FFT study, 17 out of 28 of their clients said they did not have enough money to even call Freedom from Torture, and 14 said they could not afford to fax documents to solicitors (Pettitt 2013). In a survey by FFT, 67 people reported being below the poverty line. Lack of funds can prevent clients from travelling to appointments with FFT clinicians and other healthcare professionals. FFT’s five main centres provide access to their services but those living in other parts of the UK may not be able to afford the travel to reach the help at the centre.
Currently, Asylum seekers must initially must provide an upfront payment for a solicitor service at FFT, although the amount is not set and depends on the case. People can claim back the fees through legal aid, but this takes time and creates an unfair hierarchical system where most torture survivors who have fled their home country have arrived with nothing and cannot afford this service. Access to this service depends on the finances available to survivors. Almost all other services are free to torture survivors, FFT are not able to provide this services for free. In order to improve access to their services, FFT must evolve and adapt in their approaches and services by expanding their entitlements to asylum seekers when concerning free solicitor work for medico-legal reports.
Temporary housing is also a barrier to accessing FFT services. Although social housing may be provided, this of little comfort to most torture survivors as it is often temporary, and they can be moved at short notice. FFT have tried to improve access to their services by setting up the Partnership Project in the West Midlands (Asociación and Refugiat 2016) because it is an area where refugees and asylum seekers have difficulties accessing their services . The project provided counselling specialising in psychological trauma to torture survivors and was highly successful, with 85% of those who received counselling reporting improved mental health outcomes. However, despite FFT wanting to continue work with these clients, they were prevented from doing so because clients were in temporary housing and were relocated to another part of the UK which disrupted clients’ therapy.
Other access issues prevent torture survivors from accessing the service, the process of referral requires either the refugee self-referring or an acquaintance such as a GP filling out an online form. As many people are in temporary housing, in communities where transport access is poor, this means many people are unlikely to have a support network. Their acquaintances tend to be other asylum seekers or refugees who cannot provide help. This combined with the reduction of English classes making a website or an advertisement of the charity difficult to comprehend creates a multitude of boundaries which are hard to overcome. I have so far highlighted access and entitlement barriers which are both internal and external to the charity preventing them from meeting the needs of a wider audience.
Trust is a barrier to many Asylum seekers accessing services. They do not approach agencies for help because they often fear being wrongly deported a feeling that must engulf a person’s everyday existence especially if they have suffered from torture, they may be distrustful of services as fear they could report them and get them deported. These trust issues are base of very real facts, figures suggest that it could be up to a fifth of asylum seekers have been wrongly denied health care. This may because of discriminatory views and racial bias, socialized into GPs and others, this is a covert power of which Luke’s theorized, that is hard to observe but perpetuates and supports the current power order, preventing the wellbeing needs of people being met. Whereas entitlement is ‘first dimension power’, which is observable, as I have shown in the facts and figures. Trust issues highlight even more the importance of torture survivors gaining access to rehabilitation and other Holistic work provided by FFT as they help build the confidence of those have been silenced in our society.
A lack of continuity is a continuing theme in access to health for refugees and asylum seekers provided by both charities and NHS services. This can cause a lack of trust between clients and health workers, severely inhibiting the success of rehabilitation.
Holistic approaches to wellbeing aim to nurture the mind, body, soul and spirit by encompassing both physical and mental problems. FFT’s progressive holistic work is in line with the current understanding that the mind and body are interrelated whereby each one effects the other, rather than traditional western views that the mind and body are separate and distinct [Cartesian Dualism]. The separation of mind and body in healthcare can be problematic for the wellbeing of refugees as it fails to understand the interconnectedness of physiology, psychology and emotions which can vary across cultures.
People who have survived torture all have suffered different experiences of which are internalised uniquely to them, thus their wellbeing needs being different. The FFT website gives examples of how their clients’ needs differ:
“One had run frequently from the therapy room, leading to a number of incidents in which they tried to harm themselves.”
“One was convinced that the guards from their prison were chasing them throughout London and right up to the therapy room door.”
“All were still living the immediate experience of abuse and trauma.”
FFT provides individuals with a holistic approach which is moving away from dualism so as not to define survivors of torture as having either physical or psychological problems. There are a range of FFT services such as one to one psychotherapy and support through therapy groups which provide torture survivors with a sense of community. For example, one refugee who attended a group choir stated, “one of the first things about torture is that it silences you… the choir has given me back my voice”. Participation in these groups encourage relationships which are an important part of wellbeing, helping people feel connected and close to others. The holistic approach also suggests that it may be more appropriate for clinicians to ask refugees about their experiences so that refugees are taking a more proactive role in identifying their needs rather than the clinician prescribing from a traditional dualism perspective. One example of empowering torture survivors is where they meet in a group (called ‘Rite for Life’) and write down past traumatic events and personal stories, whilst in a safe and welcoming environment, which helps people process torture and helps give refugees a voice.
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Despite the success of FFT’s holistic work, it is not without its pitfalls. The holistic work does not address the financial worries of everyday life that refugees and asylum seekers face. This may be because a therapist has ignored post-migratory causes of illness and focused too much on the past. There can be the overcategorization and overdiagnosis of mental health problems, as Summerfield put it (Summerfield 1999) “condemns the approach that pigeonholes refugees as suffering from PTSD and pays little attention to their perceptions and interpretations of distress.” Overdiagnosis may exist in FFT because government funding and asylum seekers granted refuge is often dependant on data. Categorisation of mental health can result in the essentialisation of culture and ignores the actual wellbeing needs of the individual.
To evaluate whether FFT has ‘good practice’ or not, I assessed and considered if they were in tune with the multiplicity of cultures their clients are from, as this is vital to providing the right therapy for each client. Acceptability of a therapy facilitates effectiveness. FFT are aware of cultural bereavement, as this is something assessed in psychotherapy and group projects, which try to connect people from similar cultures, to help ease their integration into the UK.
FFT also hire a team of interpreters which allows staff and volunteers to communicate with clients, allowing them to match services to client need. In the ‘Rite for Life’ project that I previously mentioned, Jade Amoli-Jackson a refugee, highlights the cultural differences between the queuing system which was not respected in her home country and the stark difference of the ‘first come first serve’ culture in the UK. She talks about the class inequalities that the queuing system reveals in her home country, where business men in suits can jump to the front of the queue. Even what appear to be the smallest of cultural differences can cause offence and cultural tolerance.
FFT provide an online platform to those of have fled torture and it has the powerful potential to change stigmas with more general society. This could help those torture survivors who feel isolated in society becoming part of the collective community which is an essential part of wellbeing. There are numerous group projects such as the Natural growth projects and Music Therapy groups which are successful among a range of torture survivors, as natural beauty and music are both things which translate across cultures.
There is some contention around whether FFT’s therapies are culturally sensitive. In order to meet the wellbeing needs of an individual from a vastly different culture of your own, you must have a ‘client led approach’(Bhugra et al. 2011). Therapists need to be aware of human fundamentals, such as sensory experience and bias. Classen, one of the pioneers of sensory anthropology puts it perfectly “before we perceive the world sensory perception is the culture- reveals that societies aspiration-preoccupations-divisions-hierarchies and interrelationships” (Classen and Howes 1996). It is extremely difficult for a therapist born and trained in the UK (of which most of their therapists are)it is difficult to understand other cultures’ sensorium without having spent a considerable time studying it For example, western medical or therapeutic techniques may not be that useful to a torture survivor from the Navajo tribe, because when someone is ill in their culture, they are viewed as being ‘decentred from the cosmos’. A ritual is performed in order to re-centre them in the cosmos that involves sitting in the middle of art and special rituals performed by a shaman, and sometimes the use of ayahuasca (Classen and Howes 1996). FFT should ensure that therapies are adaptable to torture survivors from diverse cultures.
Torture survivors may come from collectivist societies and struggle to fit into a heavily individualistic society like the UK (Bhugra et al. 2011). It could be argued that ‘wellbeing’ is an individualistic concept that may not be useful to those from other societies. Wellbeing could also entail that it is down to the individual get better rather than state intervention or help from the community (Watters 2001), Freedom from Torture should abide by a range of wellbeing meanings in order to remain integral to their clients.
In my opinion Freedom from Torture fails give sufficient cultural consideration to the services they provide. People who have survived torture have complex needs because of the harrowing experiences they have experienced pre-migration and post migration. FFT’s service is of vital importance in providing a holistic response to both the physical and mental needs of their clients. However, access and entitlement issues prevent refugees and asylum seekers who have suffered from torture from using these services, an issue caused for the most part by a lack of state funding and inhospitable attitudes towards them visible throughout British society. In response to these issues, FFT must evolve and adapt as an organisation. They must increase their outreach programmes, helping those who cannot utilize the services they offer because of access and entitlement issues. They must become more culturally sensitive with the therapeutic care they provide to ensure that it meets individuals’ wellbeing needs. More importantly we need a more coordinated, interagency approach to refugee wellbeing. The government must work with charities to ensure that policies are a help, not a hinderance to these peoples’ rehabilitation and integration into life in the UK. Additionally, more needs to be done to change general societal attitudes regarding refugees and asylum seekers for them to feel welcome within their communities.
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