The mental health services for detained asylum seekers in Malta.

Approximately 17 000 individuals have claimed asylum in Malta over the past 10 years. Maltese law stipulates mandatory detention. Here, we review Malta's asylum procedures and detention policy, and explore the impact of detention on mental health. We review the current mental health services and make recommendations to help fill the gaps.

Malta’s asylum procedures and detention policy

Approximately 17 000 individuals have claimed asylum in Malta over the past 10 years, with the majority having entered the country as unauthorised boat arrivals – 92.3% of asylum applicants between 2005 and 2014 according to the United Nations High Commissioner for Refugees (UNHCR, 2015). The majority of these arrivals hail from sub-Saharan Africa, with more than half originating from Somalia and Eritrea. Between 2004 and 2014, 65.3% of all asylum applicants were offered some form of protection (UNHCR, 2015).

Maltese law stipulates that every individual who enters, or is present in, Malta without authorisation is subject to a removal order that triggers mandatory detention. In practice this means that, although such individuals can apply for asylum, they will be detained while their application is being processed. If granted some form of protection they are immediately released from detention. According to Maltese immigration law, asylum seekers can be detained for a maximum of 12 months, while detainees whose application is rejected before the lapse of a year are detained for a maximum of 18 months. The only exemption to the regime of mandatory detention applies to individuals who are deemed vulnerable (Aditus, 2014).

Before 2014 these rules were strictly adhered to, but recent changes in Malta’s detention policy have led to a change in practice. In January 2014, a legal provision (Regulation 11(8) of the Common Standards and Procedures for the Return of Illegally-Staying Third Country Nationals) was introduced obliging the Principal Immigration Office to conduct regular ex officio reviews of each individual detention case at regular intervals, which should not exceed 3 months. The implementation of this provision has resulted in a significant proportion of asylum seekers being released before their asylum application is decided and of failed asylum seekers being released before spending the maximum of 18 months in detention. It therefore seems that this provision may result in detained migrants spending on average a shorter time in detention and that those detained for 18 months will now be migrants for whom, according to immigration authorities, there is a realistic prospect of repatriation (Aida, 2014).

Safeguarding of vulnerable individuals in Maltese detention centres

As mentioned above, the only exception to mandatory detention concerns individuals who are vulnerable due to age, pregnancy, disability or chronic/serious physical or mental health problems (Ministry for Justice and Home Affairs & Ministry for the Family and Social Solidarity, 2005).

The Agency for the Welfare of Asylum Seekers (AWAS, a government body) is responsible for deciding whether a particular detainee qualifies for release on vulnerability grounds. In theory, any agency or individual can refer a case to the AWAS for vulnerability assessment, but given that access to detention is restricted and that Malta’s detention services employ no personnel trained in psychosocial care, identification and referrals of detainees with mental health problems tend to be unsystematic and heavily dependent on the non-government organisations that are granted access to detention centres (Rossi & Caruana, 2014).

Finally, it is important to note that despite their exemption from detention, in practice, all vulnerable individuals are placed in detention upon arrival and are only released after a process of assessment and obtaining clearances that can take several months.

Mental health of asylum seekers

The refugee experience is well documented as one which frequently involves trauma in the premigration, flight and post-migration periods. Examples include loss of family and homeland, sexual and gender-based violence (SGBV) during transit and stringent asylum policies, including detention practices, in the host country. Such acutely distressing events, particularly the combined losses of home, status and culture that characterise the refugee experience, have been linked with powerful demands on the individual’s psychological realm that may lead to outcomes such as the loss of meaning and hope (Fischman, 2008) and the upheaval of personal identity (Alcock, 2003). A meta-analysis of 181 surveys investigating the health of 81 866 refugees (Steel et al, 2009) found high prevalence rates of post-traumatic stress disorder (PTSD) (30.6%) and depression (30.8%). In relation to the Maltese context, a local study reported a relatively high incidence of psychosis in asylum seekers (Camilleri et al, 2010).

Impact of detention on mental health

Immigrant detention has been described as a ‘system that by its very nature causes psychological harm’ (Fazel & Silove, 2006, p. 252), be it through the stressors it imparts or by exacerbating the trauma experienced before arrival in the host country. A meta-analysis of 10 studies investigating the psychological impact of immigrant detention found an association between this practice and poor mental health outcomes, with high levels of anxiety, depression and PTSD being noted in all of the studies (Robjant et al, 2009).

Mental health impact of Maltese detention centres

An in-depth review of immigrant detention in Malta (Jesuit Refugee Service, 2010) that took into account the perspective of 89 detained asylum seekers has helped shed light on the negative impact of a number of aspects of life in Maltese detention centres. Around 75% of participants viewed the physical conditions in Maltese detention centres as highly distressing, mentioning factors such as overcrowding, poor sanitation, restricted space and lack of privacy. Restricted access to basic services and activities was another problematic issue highlighted; 50% reported lack of regular access to outdoor space and 50% reported being unable to contact medical staff more than once a week. The report also indicated that the social conditions in detention, including physical assault by fellow detainees, verbal abuse from staff and the arbitrary and inadequate application of rules, generally led to an atmosphere where detainees felt unsafe and undignified. In conclusion, this research indicated that the physical and social conditions in Maltese detention centres seem to have a tangible deleterious effect on migrants’ well-being, with 62% reporting the emergence of physical health problems and 80% reporting deterioration in their mental health since their arrival.

A more recent study seems to corroborate these results, as it found that, within a 6-month period (December 2013 to June 2014), from a population of around 500 detainees, 74 individuals required in-patient psychiatric care (Rossi & Caruana, 2014).

Mental health services for detained asylum seekers

Detained asylum seekers in Malta with mental health needs should be able to access the same services that are available to the general population. In such cases, detained asylum seekers are referred to mental health services in Malta through a general practitioner or via emergency services. Once a referral is made, the migrant attends an out-patient session accompanied by security personnel and an interpreter where possible. Although the Department of Health employs trained cultural mediators, their availability is limited and they do not cover the range of languages required. Consequently, informal, untrained interpreters are often used. Cultural mediators, together with linguistic interpretation, also help service providers to understand and be aware of cultural practices that might have a bearing on the way users approach the service.

Should out-patient services be required, the asylum seeker is escorted for regular visits to the health centre for consultations with relevant professionals (e.g. a psychiatrist, a doctor working in mental health services, a social worker or a psychologist). If individuals require in-patient treatment, they are referred for admission to the national psychiatric hospital and accommodated on a specific ward – namely, the Asylum Seekers Unit (ASU). The ASU is a medium-secure psychiatric unit that caters for 10 individuals, operates on a ‘mixed gender’ policy and includes the presence of a police officer at all times, for security purposes (Mental Health Service, 2011). The reason for the latter is that detention regulations stipulate that, outside of the closed centre, detained migrants need to be accompanied by security officers at all times. It is these regulations that limit the options available for recreation and rehabilitation activities for in-patients, who are, as such, confined to the ward for the duration of their stay.

Lacunae

There are a number of lacunae in how the mental health needs of detained asylum seekers are met. The inability to access general hospital wards, together with the physical conditions on the ASU, including design, layout and amenities, emphasise security at the expense of rehabilitation and do little to foster the appropriate therapeutic environment required for individuals with mental health problems. Furthermore, as has happened in the past (Rossi & Caruana, 2014), when a surge of asylum seekers arrive in an irregular manner there is the severe risk of overcrowding on the ASU.

The inconsistent availability of trained cultural mediators and the consequent dangerous use of untrained interpreters highlight another concerning lacuna. The lack of training and professional expertise may lead to these interpreters being more prone to distort the assessment or treatment processes by misinterpreting key concepts, omitting or altering messages or intervening directly. Moreover, cultural differences between the service provider and patient and the absence of an appropriate mediator between the two may reduce the efficacy of treatment, as well as act as a barrier to informed consent (Blake, 2003).

The current set-up of the mental health service provided to detained asylum seekers is somewhat fragmented and once discharged from the in-patient facility a significant part of the responsibility for the care (i.e. dispensing medication and escorting to follow-up appointments) of the patient rests with the staff in the detention centre. Currently, detention centres are manned by custodial staff and healthcare providers in the form of a general practitioner and a nurse (who are not available, however, on a daily basis). This has inevitably led to problems with ensuring continuity of care. A recent report found that 6 individuals out of a sample of 74 were not escorted to their review appointments once they were returned to the detention centre after a period of hospitalisation (Rossi & Caruana, 2014).

Given that the general practitioner has contact solely with the detainees who self-refer and the fact that there is no mental health professional in the detention centres taking on a screening role, referral to mental health services occurs mainly after deterioration in the individual’s psychological health up to the point that a crisis or emergency emerges. Furthermore, it is relevant to note that there is no specialised service targeting the specific mental health needs of refugees and migrants.

Recommendations

In order to safeguard the mental health of detained asylum seekers in Malta, we recommend a review of the local detention policy aimed at minimising the deleterious impact detention has on mental health and providing safeguards for psychologically vulnerable individuals that operate in an expeditious manner. We also recommend that those responsible for local service provision take account of general clinical key recommendations and guidelines such as those outlined by the European Psychiatric Association (2015) and that changes to meet these recommendations are made. These would include:

ensuring the reliable availability of easily accessible interpreting and cultural mediation services in order to permit effective communication between detained asylum seekers with mental health needs and healthcare providers

working towards ensuring that long-term psychiatric and psychological care is guaranteed for asylum seekers throughout their stay in detention and after their release into the community

shifting the focus of the services provided beyond the treatment of acute mental health needs and towards prevention and early intervention

providing training and education about refugee and cross-cultural mental health to healthcare personnel across all healthcare sectors

supporting asylum seekers to access healthcare by developing a strong link between national mental health services and healthcare provision in detention centres

implementing a campaign targeting the stigma of mental health problems and psychiatric and psychological treatment in the migrant population.

While achieving these recommendations would require substantial input from various stakeholders, reforming the current set-up of mental health services available to refugees and asylum seekers could go a long way towards this.

The setting up of a multidisciplinary treatment centre for victims of trauma operating within the national psychiatric service and specialising in the treatment of PTSD and other trauma-related disorders, as well as comorbid presentations, could represent a useful first step. This centre would provide the ideal basis for the formation of a team, equipped with the necessary expertise about cross-cultural and refugee issues, that is dedicated to the mental healthcare of refugees and asylum seekers suffering from trauma-induced disorders and that could provide consultations for other mental health services, as well as offer a liaison service in detention. By establishing a regular presence in detention centres, through screening individuals considered at risk of mental health problems and conducting initial consultations of detained asylum seekers, this team could provide the much needed link between the detained individual and national mental health services.