Abstract
Migrants living in Europe constitute over half of the world's international migrants and are at higher risk of poor mental health than non-migrants, yet also face more barriers in accessing and engaging with services. Furthermore, the quality of care received is shaped by the experiences and attitudes of health professionals. The aim of this review was to identify professionals’ attitudes towards migrants receiving mental healthcare and their perceptions of barriers and facilitators to service provision. Four electronic databases were searched, and 23 studies met the inclusion criteria. Using thematic synthesis, we identified three themes: 1) the management of multifaceted and complex challenges associated with the migrant status; 2) professionals’ emotional responses to working with migrants; and 3) delivering care in the context of cultural difference. Professionals employed multiple strategies to overcome challenges in providing care yet attitudes towards this patient group were polarized. Professionals described mental health issues as being inseparable from material and social disadvantage, highlighting a need for effective collaboration between health services and voluntary organizations, and partnerships with migrant communities. Specialist supervision, reflective practice, increased training for professionals, and the adoption of a person-centered approach are also needed to overcome the current challenges in meeting migrants’ needs. The challenges experienced by health professionals in attempting to meet migrant needs reflect frustrations in being part of a system with insufficient resources and without universal access to care that effectively stigmatizes the migrant status.
Keywords
Introduction
Of the 272 million migrants worldwide, over half reside in Europe (International Organisation for Migration, 2020). The term ‘migrant’ refers to a person who has moved from their country of birth to settle elsewhere temporarily or permanently, irrespective of the reason—including refugees and people seeking asylum (Zimmerman et al., 2011). Multiple factors place migrants at elevated risk of mental health problems, which may include the complex process of migration itself. While the European Union supports initiatives to improve migrant mental healthcare (Mental Health Europe, 2019), there continue to be substantial disparities in both the mental health and mental healthcare experienced by migrants living in Europe.
Many migrants experience adversities associated with leaving regions of conflict, persecution, and socioeconomic deprivation (Miller & Rasmussen, 2017). Once settled, communication barriers, social isolation, the loss and adjustment of cultural norms and religious practices, and experiences of discrimination systemic within government institutions related to healthcare, employment, and social services can negatively impact on mental health (Bhugra & Becker, 2005; European Monitoring Centre on Racism & Xenophobia, 2006; Wu et al., 2015). The migratory journey and post-migration issues related to poverty, uncertainty about the future, and a lack of social networks in the new country also take a toll on mental health (Kirmayer et al., 2011). Evidence suggests that migrants face escalating levels of xenophobia and racism in Europe related to political change (Jaskulowski & Pawlak, 2020), which contribute to their vulnerability and exploitation, and affecting mental health outcomes (Szaflarski & Bauldry, 2019).
Diversity among the migrant population presents a challenge to health organizations attempting to tailor services to meet their mental health needs (Bempong et al., 2019). Stigma and communication difficulties with healthcare professionals and lack of knowledge about services (Blignault et al., 2008) may prevent migrants from seeking mental healthcare, while undocumented migrants may fear deportation (Hacker et al., 2015). Once engaged with services, health professionals experience cultural and language barriers, limitations of legal entitlement (which also vary between European countries), inadequate training to meet need, and the complexity of dealing with trauma presentations (Barrington & Shakespeare-Finch, 2013). Limited and delayed access to interpreting services and a lack of political support are further structural issues preventing access to mental healthcare (O’Donnell et al., 2016; Wohler & Dantas, 2017).
Since mental health problems are often presented to and managed by a range of professionals within primary care (Wittchen et al., 2003; World Health Organisation, 2018), gaining the perspectives of a range of health professionals is important to understand how best to meet migrant mental health needs. Much of the work to date has focused on refugees. In a qualitative synthesis of professionals’ experiences of working with refugees specifically, mental health needs were identified as best met through interdisciplinary and psychosocial work, practical interventions, and advocacy (Karageorge et al., 2017), while a qualitative synthesis of refugee and professional perspectives highlighted the therapeutic relationship, cultural sensitivity, and the need to provide support to staff and adapt interventions to meet migrants’ needs (Duden et al., 2020). The therapeutic relationship, particularly regarding trust and flexible boundaries, has been evidenced as especially important in the field of migrant mental healthcare (Duden & Martins-Borges, 2020; Kirmayer et al., 2011). However, professionals’ experiences related to working with migrants are likely to shape their perceptions of and attitudes towards this group (Fox & Tang, 2016), and this may affect the professional–patient relationship (Zestcott et al., 2016) and clinical outcomes of migrants.
In view of the continued increase of migrants in Europe, the diversity of this group, and their increased mental health risk (Carta et al., 2005), a review of the qualitative research to date enables us to understand in depth the range of professionals’ experiences of providing mental healthcare to migrants and in navigating challenges, their attitudes towards migrant patients, and how they can be best equipped to provide high quality care to this group. Given that migrant mental healthcare is not limited to specialist mental health services or professionals, we explored these issues across a range of professional groups and service settings. The aim of this review was to identify professionals’ attitudes towards migrants and their mental healthcare in Europe, and to describe their perceptions of barriers and facilitators to service provision. The review also appraised the quality of the studies on this topic.
Method
Search strategy
Four electronic databases (PsycINFO, CINAHL, MEDLINE, Web of Science), selected for their coverage of literature pertaining to physical and mental health, patient care, and clinical practice, were searched using the following terms in the title, abstract, or keywords: (migrant* OR immigrant* OR asylum seek* OR refugee*) AND (satisfaction OR opinion* OR attitude* OR view* OR experience* OR perception* OR evaluation OR value* OR perspective* OR challenge* OR facilitator* OR barrier* OR assumption* OR belief* OR judgement* OR understanding*) AND (mental health OR mental health service* OR mental health provider*). Reference lists of the included studies were also searched. To identify studies relevant to current care provision in Europe (Knapp et al., 2007), studies included those published between January 2000 and October 2020. The review protocol was registered with PROSPERO (http://crd.york.ac.uk/prospero, registration number CRD42019155360).
Inclusion and exclusion criteria
Papers were included if they: 1) were written in English; 2) employed qualitative methodology (individual and/or group interviews) in whole or as a component; 3) focused on the perspective of the health professional; 4) focused on first-generation migrants (including specifically refugees or people seeking asylum) presenting with mental health problems; 5) were conducted in Europe; and 6) were published in peer-reviewed journals between January 2000 and October 2020.
Given the research questions were focused on understanding professionals’ experiences and attitudes, papers with a qualitative component were included as they offer more in-depth and rich information. The review focused on European studies due to the established European policy of migrant mental healthcare, high inter-European migration, and migrants often travelling through multiple European countries towards their end destination (Parliamentary Assembly, 2015), within which they may access mental healthcare. Studies related to migration from within and outside of Europe were included. Health professionals, irrespective of discipline, were included if the focus addressed mental health problems (i.e., any interaction between professionals and migrants in relation to their mental health).
The term ‘migrant’ was defined as anyone living in a country other than their place of birth, including undocumented migrants, people seeking asylum, and refugees. While differences between these groups are acknowledged, for this review, the term ‘migrant’ refers to all the above groups. Papers focused on the descendants of migrants were excluded as they have not experienced migratory processes first-hand, which may differentially impact on mental health (Schneider, 2016). Papers focused on children's mental healthcare, patient perspective, and physical healthcare provision were excluded, and have been reviewed elsewhere (Curtis et al., 2018; Robertshaw et al., 2017; Satinsky et al., 2019).
Study selection
Figure 1 outlines the search process based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher et al., 2009). All papers identified were imported into Mendeley (Version 1.19.4) and duplicates were removed. Initial screening of titles, abstracts, and full texts was carried out by the primary author. Agreement with a sub-sample screened by a second reviewer independent of the research team was 98% (kappa = 0.97) for initial screening and 100% (kappa = 1) for full-text screening. Disagreements were discussed with the team to reach a consensus.
PRISMA flow diagram.
Quality assessment
Using the Critical Appraisal Skills Programme (CASP) checklist (Critical Appraisal Skills Programme, 2018) to assess quality involved attributing a numerical value (No = 0, Can’t Tell = 0.5, Yes = 1) to checklist items (maximum total score = 10). The total CASP score referred to methodological quality as ‘high’ (>8–10), ‘moderate’ (6–8), or ‘low’ (≤5). Papers were rated by an independent reviewer to assess the reliability of quality assessment ratings. Agreement between raters was high (96%, kappa = 0.92) and any disagreement was resolved with discussion.
Data synthesis
A thematic synthesis (Thomas & Harden, 2008), an adaptation of thematic analysis (Braun & Clarke, 2006) to analyze primary qualitative data across multiple studies, was selected due to its lack of restriction to a particular methodology, good transparency, and suitability to the aim by staying ‘close’ to the results of the primary studies and facilitating the creation of new concepts and hypotheses (Barnett-Page & Thomas, 2009).
The three stages of thematic synthesis were: 1) free line-by-line coding of the findings of included studies; 2) the organization of these codes into related areas to create descriptive themes; and 3) the development of analytical themes. All text data under the heading ‘results’ within papers were extracted electronically and imported to NVivo software (QSR International Pty Ltd. Version 12, 2018) for analysis. Only data related to professionals’ experiences of mental healthcare were coded. Comparisons were made within and across studies, and a coding frame was developed from the derived codes. Coding discrepancies were resolved through research team discussion and the coding frame adjusted accordingly. All coding and theme development were completed inductively to capture the meaning and content of each sentence. Codes similar in content were grouped into descriptive themes, capturing patterns in the data. Each theme was recorded in tabular form, with coded data presented in each row to facilitate the constant comparison analytic process and show any divergence of findings in each theme. The final stage of synthesis involved the development of analytic themes by going beyond the primary data and interpreting their meaning in relation to the research questions. All stages were undertaken by the primary author, and the coherence of themes was established via discussion within the research team and a doctoral student independent of the team. A matrix of themes was created to demonstrate transparency and rigor, adhering to the ‘enhancing transparency in reporting the synthesis of qualitative research’ (ENTREQ) guidelines (Tong et al., 2012).
Reflexivity statement
The review adopted a critical realist perspective, which accepts the existence of an independent social world that can only be understood through the perspectives and experiences of both research participants and researchers (Fletcher, 2016). The primary author was a trainee clinical psychologist, who previously worked with migrants in a range of UK mental healthcare settings. The research team consists of clinical and academic researchers with expertise in mental health and/or culture and diversity. The primary author is of migrant heritage, and a range of ethnic backgrounds are represented within the team. While these factors are considered as strengths in providing deeper understanding on the topic, the team's shared knowledge and experiences may also have influenced data interpretation. For instance, increased importance may have been placed on challenges in care provision which mirrored the researchers’ experiences, such as insufficient time for consultations. Care was taken to minimize the impact of prior assumptions through the use of reflection and team discussion.
Results
Characteristics of included studies
Twenty-three papers were identified for inclusion, utilizing individual (n = 20) or group interview (n = 3) study designs and conducted across seven European countries. Six papers included professionals from several European countries. Sample sizes were diverse, ranging from six to 240. Overall, there were slightly more male participants (n = 55) than females (n = 49) across the 10 studies that provided sample sex information; however, Samarasinghe et al. (2010) had a majority female sample (93%). Professionals included physicians (n = 278), nurses (n = 166), psychologists (n = 92), service managers (n = 75), social workers (n = 72), psychiatrists (n = 53), and psychotherapists (n = 24). Studies focused on patient groups of migrants (n = 4), refugees (n = 3), people seeking asylum (n = 1), or a combination of these groups (n = 15); however, several papers used these terms interchangeably. Most papers focused on professionals’ work with migrant groups from low socioeconomic backgrounds. The most common methods of analysis were thematic analysis (n = 8), grounded theory (n = 3), and constant comparative method (n = 3). Additional study characteristics are presented in Table 1.
Methodological quality of included studies
Studies were categorized as ‘high’ (n = 17) or ‘moderately high’ (n = 6) in methodological quality, so no studies were excluded on the grounds of low quality. While consistently high (>87%) on items related to aims, methodology, and findings, only 10 (43%) papers contained evidence adequately considering the researcher–participant relationship. Of the six ‘moderately high’ quality papers, five lacked detail on reflexivity, ethical considerations, and contribution to existing knowledge. Given that there is no widely accepted or empirically tested approach for excluding qualitative studies from synthesis on the grounds of quality (Dixon-Woods et al., 2006), the CASP was used to remind readers of potential influences which can present in studies but higher quality studies weighed more strongly in the interpretation of the findings.
Thematic synthesis
Three themes were created from the synthesis: 1) the management of multifaceted and complex challenges associated with the migrant status; 2) professionals’ emotional responses to working with migrants; and 3) delivering care in the context of cultural difference. Figure 2 depicts the relationship between the themes. Factors related to the migrant status posed challenges to the delivery of care (theme 1) and learning about the difficulties associated with the migrant status could evoke strong emotional responses for professionals (theme 2). Such responses may influence the delivery of care, including the development of negative attitudes towards migrants. Theme 3 represents the interface between migrant and professional, and the ways in which cultural barriers could affect care provision. See Table 2 for details of the quality assessment and matrix of themes across studies.
Proposed thematic relationships and their effects on the mental healthcare of migrants.
Theme 1: The management of multifaceted and complex challenges associated with the migrant status
Professionals identified several major factors that hinder engagement with services and clinical progress. Firstly, the stigma and discrimination attached to the immigrant status and mental health is reflected in healthcare services (Franks et al., 2007). Occupational therapists in Sweden encountered difficulty gaining support from other services when working with migrants: “if I have someone called ‘Svensson’ with me, it takes less time to find a contact person than if I have someone called ‘Ahmed’ with me” (Pooremamali et al., 2011, p. 114). Secondly, adverse socioeconomic conditions including poverty, housing insecurity, and social isolation also formed barriers to mental healthcare (Teunissen et al., 2015). Professionals from many countries agreed that addressing these adverse circumstances was a priority and described referring migrants to housing facilities, writing letters, and consulting with other professionals (Century et al., 2007). Thirdly, professionals noted the importance of identifying psychological trauma in this patient group, yet counsellors (Century et al., 2007) and primary care nurses (Suurmond et al., 2010) expressed reluctance to work with such trauma; for counsellors because “life for the client was so uncertain and sometimes unsafe” (p. 29) and for nurses because of a lack of confidence. Others were concerned with pathologising what they considered to be normal responses to adverse life experiences (Apostolidou, 2016). Fourthly, given the frequent need for multiple services, problems in collaboration between services were identified to be particularly relevant in the context of migrant care provision, preventing referral and information-sharing (Chiarenza et al., 2019) and hindering clinical outcomes. The range of needs presented by migrants and the barriers to accessing mainstream services meant that professionals considered effective liaison with specialist and voluntary services to be crucial in providing holistic care (Priebe et al., 2012).
Professionals lacked clarity on the entitlement and eligibility of different groups of migrants to receive mental healthcare (Chiarenza et al., 2019), further complicated by administrative procedures for treating undocumented migrants (Dauvrin et al., 2012) and legal migrant difficulties obtaining health insurance (Priebe et al., 2012). Undocumented migrants were considered particularly vulnerable: “illegal immigrants have no rights to anything … they feel like they were shadows. The barriers are everywhere: inside, outside” (Straßmayr et al., 2012, p. 4). All professionals who raised legal and administrative issues reported willingness to treat migrants regardless of legal entitlements (Priebe et al., 2011) and that access to healthcare should not entail reporting to authorities (Chiarenza et al., 2019). Professionals circumnavigated the barriers in various ways, including altering administrative processing, submitting prescriptions in their own name, and not charging for services: “we are doctors and we do not care whether the patient is illegal or not” (Teunissen et al., 2016, p. 122).
Professionals described working with migrants in ways that empathized with and recognized their struggles. Firstly, physical and mental health professionals focused on the importance of developing trusting relationships using empathy “because people need a long time before they will disclose things, especially painful things” (Suurmond et al., 2010, p. 824). Counsellors stressed the need to “give witness” and “offer validation” (Century et al., 2007, p. 33) to engage migrants and build rapport, while Nonnis et al. (2020) highlighted sharing stories as a powerful way to build relationships between professionals and migrants. Secondly, due to the complexity of need relative to available resources, some primary care staff reported focusing on more ‘addressable’ issues rather than mental health problems (Teunissen et al., 2016). Meeting the needs of migrants also required more flexible administrative procedures and offering longer consultations (Priebe et al., 2011).
Theme 2: Professionals’ emotional responses to working with migrants
The specific struggles faced by migrants, particularly refugees and people seeking asylum, elicited polarized responses, including among those occupying roles delivering therapy. Some spoke about their patients with admiration and warmth for the courage and resilience shown in the face of adversity: “it's the inner strength of the person … you can feel that flame and you think I shall want to keep it alight, I don’t want it to be crushed anymore” (Century et al., 2007, p. 32). Awareness of the social injustices faced by migrants produced an “activist way of being” (Apostolidou, 2016, p. 14) for some professionals, resulting in them adopting a role of advocacy on behalf of their patients, often beyond the context of mental healthcare provision: “I get them lawyers so they can see a GP” (Apostolidou, 2016, p. 14). Nonnis et al. (2020) found that words such as “pleasure” and “passion” were used more frequently by professionals who were engaged in their work, many of whom were “willing to go above and beyond for [migrants]” (Harris et al., 2020, p. 7).
However, other professionals used negative, untrusting language, such as feeling “manipulated” and “suspicious,” to describe their feelings about undocumented migrants and refugees (Holmqvist & Andersen, 2003, p. 296). Professionals in Swedish and UK-based studies particularly questioned the legitimacy of undocumented migrant claims upon public health resources, with some viewing migrants as having a sense of “entitlement to welfare” (Century et al., 2007, p. 33), querying whether they exaggerated their mental health symptoms in support of their application for housing or legal status to remain (Hultsjö & Hjelm, 2005). Whilst some professionals empathized that this was out of desperation (Teunissen et al., 2015), others reported what they perceived as exploitation of the system: “we have had situations where it has been obvious afterwards that they were just faking” (Hultsjö & Hjelm, 2005, p. 280). However, Nonnis et al. (2020) found that some professionals held negative attitudes towards migrants related to frustration in reaching mutual understandings, leading them to attempt to distance themselves from this group.
Feelings of hopelessness were reported with respect to the patients’ mental health (Jensen et al., 2013), primarily by physicians and psychotherapists, and using “weary and defeated” language (Century et al., 2007, p. 34). These feelings were associated with reduced confidence in the ability to deliver mental healthcare to migrants (Suurmond et al., 2010). Physicians in Norway reflected that working with migrants could leave them feeling unprepared despite their training: “It was a big shock. I felt like I almost couldn’t use anything of what I had learned during my education and that was very strange” (Harris et al., 2020, p. 6). Professionals described negative feelings about failed interactions with migrants and used words relating to exhaustion and excessive use of personal resources: “I’m mentally exhausted, tired of working in this sector. I’m tired of dealing with difficult clients” (Nonnis et al., 2020, p. 13).
Vicarious traumatization was raised by some psychotherapists and counsellors. Hearing migrants’ stories profoundly affected clinicians, which could make it difficult to control feelings during sessions and maintain boundaries (Century et al., 2007). The following quote from psychotherapists in Holmqvist and Andersen’s (2003) study demonstrates how such narratives could permeate the therapeutic space: “I was without protection, I had no defences against such things, it went right into me” (p. 298).
The use of supervision to manage emotional responses was reported; however, some psychotherapists reflected that a lack of specialist supervision could result in inadequate professional support: “I think the problem is that supervisors often have less experience than you do in working with [migrants]. And that is really troubling … they are in a position of trying to guide you, but they can’t really guide you” (Apostolidou, 2016, p. 12).
Theme 3: Delivering care in the context of cultural difference
This theme captures the interface between the professional and patient, noting how challenges in delivering mental healthcare can arise from variations in belief systems, culture, and communication. Professionals reported adapting their practice to engage migrants and meet their mental health needs.
Professionals described migrants as having either a “lack of” or “different” understanding of mental health problems (Franks et al., 2007, p. 10), which has led some to reflect that “westernized ideas of depression may not be appropriate” for migrants (Misra et al., 2006, p. 252). Both physical and mental health professionals reported that migrants’ culturally informed understandings of mental health problems present challenges in providing care, especially when they differ markedly from the biopsychosocial model that prevails in most of Europe (Feldmann et al., 2007). Dutch physicians struggled to discuss depression and psychosis due to migrants’ spiritual explanations of symptoms: “it is difficult to discuss [mental illness], they have the idea that they are demonized … they often have magical thoughts” (Teunissen et al., 2015, p. 86). Some professionals acknowledged that a lack of knowledge about a migrant's cultural background could lead to misunderstandings of what was considered a socially acceptable response to the patient or what indicated psychopathology (Sandhu et al., 2013).
Professionals noted the tendency of migrants to focus on somatic symptoms without connecting them to mental health problems (Teunissen et al., 2015). They hypothesized or perceived that migrants may be more prepared to speak about somatic symptoms due to cultural stigma (Pooremamali et al., 2011), may prefer to communicate non-specific health problems to avoid revealing trauma-related experiences (Chiarenza et al., 2019), or may lack psychological insight (Feldmann et al., 2007).
The challenges of explaining psychological and behavioral symptoms in the host country's language also contributed to difficulty identifying psychological distress: “linguistic difficulties can sometimes give the impression that the patient is psychologically disturbed when all he is trying to do is express things that belong to another culture” (Straßmayr et al., 2012, p. 5). Most studies highlighted the implications that language barriers can have on care provision; including restrictions on treatment options (Jensen et al., 2013) as most interventions are focused on talking therapies. Professionals adapted their practice to facilitate access and engagement with services, including the adoption of a client-led approach and adjusting pacing (Priebe et al., 2012).
Interpreter issues were reported by most studies to add challenges to care provision, including variability in access, poor quality of interpretation, and a lack of interpreters with mental health-related training (Griffiths et al., 2017; Harris et al., 2020). There was a sense of professionals disliking joint work with interpreters and preferring to try and communicate independently with patients: “It was a heart-sink piece of work … even though I could see that talking was working … I didn’t enjoy doing it … I was heavy-hearted about it at each session, and it was just about what hard work it was” (Century et al., 2007, p. 31).
Some professionals reported problems related to migrant patients choosing not to work with professionals of the opposite sex (Dauvrin et al., 2012). While some services were able to meet this requirement on request, others struggled to do so (Priebe et al., 2011). Gender roles were also highlighted as a difficulty in providing care to migrants, particularly when the professional was female and the patient male (Pooremamali et al., 2011).
Responding to cultural differences appropriately was considered crucial to building trust and providing effective care; specialist training and improved cultural competence were viewed to inform such responses (Straßmayr et al., 2012). This notwithstanding, professionals described adopting an “open” (Pooremamali et al., 2011, p. 116) and “curious” (Century et al., 2007, p. 30) approach to enquire about cultural values and beliefs, which enabled them to “reach more accurate diagnoses and provide appropriate treatments, while meeting patient needs for cultural acceptance and understanding” (Priebe et al., 2011, p. 8). Chiarenza et al. (2019) reported that professionals considered intercultural mediation services as crucial in the overall development of a culturally competent healthcare system.
Discussion
This review of qualitative studies of professionals’ experiences of delivering mental healthcare to migrants across a range of healthcare settings yielded 23 mostly high quality papers. Despite the variation in healthcare professions, settings, and countries, similar challenges of delivering migrant mental healthcare were reported—associated with the migrant status, emotive reactions evoked by working with this group, and differences in culture. Moreover, there was general consensus on how to overcome the identified barriers to provide high quality care. Twenty (87%) of the included studies were published post 2007, suggesting that this is an area of research that has grown in popularity. In particular, there has been growth over the last decade in studies of refugees and people seeking asylum linked to conflicts in the Middle East.
Theme 1
Professionals perceived great challenges in delivering mental healthcare to migrants, including the lack of clarity regarding eligibility for mental healthcare and the extra work involved in delivering such care. Professionals reported migrant experiences of stigma and discrimination within healthcare, poor socioeconomic conditions, social isolation, and trauma, which mirrored the findings of studies undertaken from the migrants’ perspective (Derlet & Deschietere, 2019; Dow, 2011) and which contribute to the marginalization of migrants (Andersen et al., 2009). The complexity of trauma, and presentation of trauma symptoms as somatic complaints (Gupta, 2013) affected primary care health professionals’ confidence and perceived ability to manage such presentations (Green et al., 2011), and often present in physical healthcare settings with staff without specialist mental health training.
However, professionals reported various ways in which they attempted to overcome these challenges, such as treating migrants irrespective of legal status, as aligned to reviews of physical healthcare provision (Robertshaw et al., 2017). While the sustainability of professionals circumnavigating policies to provide care has been questioned given the implications for the appropriate funding and human resourcing of services (Ingleby et al., 2019), studies have shown that providing care to all migrants is beneficial for host countries, public health, and social cohesion (Trummer et al., 2016).
In recognition of the vulnerable backgrounds of many migrant groups and their general distrust in healthcare providers (Warr, 2010), the review highlighted the importance some professionals placed on building a positive and trusting professional–patient alliance when working with migrants, in line with previous reviews (Duden et al., 2020). A process of reciprocal learning and patience are needed to facilitate mutual understanding that provides the foundation to a trusting relationship (Karageorge et al., 2017). Professionals’ attitudes relating to migrants’ entitlement to receive care and the ability of migrants to understand and engage in mental healthcare can influence the professional–patient relationship in healthcare contexts (Ferguson & Candis, 2002) and influence the quality of the therapeutic relationship and subsequent care provision.
Another strategy reportedly used by professionals was to focus on addressable issues or more immediate concerns rather than complex mental health needs. Time pressures motivate this, particularly in primary care, and are seen in physical healthcare (Suphanchaimat et al., 2015). However, this also highlights professionals’ awareness that practical support may be more helpful to and preferred by migrant groups, such as problem solving and promotion of self-efficacy (Karageorge et al., 2017; Marusiak, 2013). A phased approach to mental healthcare may be appropriate for migrants; firstly, to address immediate resettlement needs and provide emotional support, followed by a referral for more intensive intervention (Rousseau & Frounfelker, 2019).
The review highlighted inter-agency collaboration as crucial yet challenging for meeting the complex needs encountered in migrant mental healthcare, as recent studies of such initiatives have found (Anguiano et al., 2019; Duden & Martins-Borges, 2020). Working with other agencies may also be necessary for reducing the emotional burden felt by mental health professionals, who may assume responsibility beyond their role (Duden et al., 2020). Migrants may be more likely to trust non-governmental organizations (Dwyer & Brown, 2005). Support of migrant mental healthcare from other community organizations with professional supervision (e.g., Goodkind et al., 2014; Karageorge et al., 2017) may help increase service use by reducing stigma and increasing engagement in culturally meaningful ways (Wong et al., 2006). Such inter-agency working may also positively impact on health professionals’ perceptions of addressing the mental health of migrant groups.
Ultimately, however, professionals need longer consultations to explore the complexity of needs among migrants (Scheppers et al., 2006), and to recognize the need to build professional–patient trust (Yohani, 2010) and mutual understanding (Sveaass & Reichelt, 2001) when working with migrant communities, as well as the frequent need for interpreters (Wiking et al., 2013). Given the short time allocated to primary care consultations (Irving et al., 2017) and minimal mental health-related training (England et al., 2017), it is not surprising that physicians struggled to address both psychological and physical health problems. Failure to address mental health concerns could, however, inadvertently reinforce migrants’ beliefs that mental health is a taboo subject (Schnyder et al., 2017), which may reduce help-seeking. Without appropriate allocation of resources to recognize such need, migrants will continue to not have their mental health needs appropriately met.
Theme 2
Working with migrants evoked a range of emotive reactions among professionals, with notably polarized responses towards refugees and people seeking asylum. Among mental health professionals, some adopted a stance of admiration and others reported suspicion, replicating quantitative findings of health workers’ attitudes towards migrants (Dias et al., 2012) and the experiences of third sector organization staff (Barrington & Shakespeare-Finch, 2013). Regular therapeutic sessions with these patients seemed to increasingly polarize professionals’ attitudes—leading to more rapport, empathy, and positive attitudes, or more suspicion and negative attitudes. Studies in the current review which reported on the perceived exploitation of services (e.g., to further applications for asylum) were conducted in countries that offer very limited or no free public healthcare to undocumented migrants (e.g., Sweden). These findings and others (Rousseau, 2018; Vanthuyne et al., 2013) may suggest that legality influences professional attitudes, or that their attitudes—irrespective of experience and training—reflect the wider political sentiment in that society towards healthcare and migrants, including or exacerbated by negative media coverage about migrants (Kosho, 2016; Michaelsen et al., 2004).
While no professionals who participated in studies on this topic refused to offer treatment, negative, suspicious attitudes would likely influence the provision of care, such as different treatment recommendations (FitzGerald & Hurst, 2017) and unspoken cues reflecting implicit biases picked up by service users that professionals are unaware of (Aggarwal et al., 2016). While there was little explicit mention of possible biases by professionals in the treatment of migrants, clinician biases are potential key barriers to effective mental healthcare that may be mistaken as cultural barriers (though the two may be related). Unsurprisingly, such behavioral changes and biases, whether implicit or explicit, impact on migrants’ trust of healthcare professionals and contribute to health disparities (Hall et al., 2015). Addressing bias is inherently extremely challenging to do, but implicit bias awareness training, educating professionals about the unique difficulties associated with migration and seeking asylum, and reflective practice are necessary for the indiscriminatory practice of mental healthcare.
The feelings of hopelessness reported by psychotherapists and physicians in relation to their work has also been reported elsewhere (Tynewydd et al., 2020). While only psychotherapists referred to such experiences as vicarious trauma (Baird & Kracen, 2006), possibly reflecting their training, the psychological impact of working with migrants is seen across healthcare (Crumpei & Dafinoiu, 2012). Professionals are often expected to provide care whilst being restricted by a range of factors, such as lack of resources or cultural training. Additionally, many of the difficulties professionals encounter when working with migrants relate to contextual factors, such as a lack of housing, rather than being solely related to mental health problems (Hynie, 2018), which can add to this perceived sense of hopelessness (Guhan & Liebling, 2011). To manage such feelings, clinical supervision is crucial (Berger & Quiros, 2014), particularly specialized supervision from organizations experienced in working with these groups (Duden et al., 2020), and peer supervision (Barrington & Shakespeare-Finch, 2014). Ensuring all professionals have a safe environment to discuss personal responses to their work is important in maintaining their wellbeing (Tomlinson, 2015). Online and telephone methods of communication could be used to facilitate networks between professionals in different geographical locations or for those working in remote areas to share skills.
In relation to professionals’ positive feelings about working with migrants, some showed warmth and admiration for the challenges overcome by some migrants, and some were motivated to adopt roles of social activism. Others have also called for professionals to adopt roles of social activism to challenge the societal contexts impacting their patients and to promote social change in the wider community (Apostolidou, 2015; Marsella, 2011). This requires an understanding of the social structures that shape mental health presentations and health inequalities (Metzl & Hansen, 2014). Some professionals in our review took on the role of advocacy on behalf of migrants to support them in overcoming the challenges of belonging to a marginalized group, which has been shown to build trust between patients and professionals (Puvimanasinghe et al., 2015) and help empower migrants (Goodkind, 2006; Rawlett, 2014), offering them an exit from the medicalization of what are arguably socio-political problems (Drožđek, 2007).
Theme 3
Differences in cultural understandings of mental health and the challenges to providing culturally competent mental healthcare are well documented (Carbonell et al., 2020). Since much of mental healthcare practice emerged from ‘Western’ understandings of the human condition (Wildeman, 2013), such conceptualizations of mental health have proved problematic when applied elsewhere without careful consideration (Fernando, 2014). The review found that professionals voiced feeling incompetent or ill-equipped to address the mental health of this population, perceiving migrants to either have a lack of mental health understanding or an understanding that differed from the Western biomedical perspective. The former assumes that Western biomedicine itself is not culturally embedded but a universal truth (Gopalkrishnan, 2018; Rondelez et al., 2016), leading professionals to assign responsibility to migrant patients for their feelings of unpreparedness in dealing with non-biomedical perspectives.
The perspective of accepting a ‘different’ understanding of mental health could be a starting point for professionals’ respectful exploration of migrants’ cultural belief systems to reach a shared understanding of problems (Karageorge et al., 2017; Procter, 2016). A person-centered approach that shifts from the perspective of “what's wrong with you?” to “what happened to you?” (Harris & Fallot, 2001) may be particularly helpful for professionals trying to make sense of presentations that may differ from the host country's social norms. Adopting an open and curious approach to exploring differences further facilitates culturally competent practice (Bansal, 2016; Epner & Baile, 2012). On the other hand, therapist avoidance of such discussions may be due to time pressures (Filler et al., 2020), anxiety from a lack of knowledge and over appearing insensitive (Guregård & Seikkula, 2014), or professionals considering such discussions irrelevant if they expect migrants to assume the host country's cultural norms (Al-Roubaiy et al., 2017). However, such absence of discussion around cultural understanding of the issues is noticeable by patients (Al-Roubaiy et al., 2017).
The need for improved cultural competence training identified in this review is an issue across healthcare settings (Kaihlanen et al., 2019; Matthews, 2020). Systems-level cultural competence training and training in specific culturally adapted evidence-based interventions (Rathod et al., 2018) have been associated with improved clinical outcomes. However, the training received varies hugely between countries, organizations, and type of health professional, and according to personal motivation. Our review suggests that professionals view migrants as somatizing their psychological symptoms, supported by migrants’ perspectives (Lanzara et al., 2019), although the inherent mind–body dualism of the ‘Western’ biomedical approach has been questioned (Al-Busaidi, 2010; Mumford, 1993). However, given that migrants are more likely to access physical health services than specialist mental healthcare (Credé et al., 2018), there is a need to ensure physical health professionals feel competent addressing trauma presentations. The review found that nurses who felt more able to work with trauma relied on rapport-building and allowing the patient to narrate their story. In a review of refugee mental health interventions, bearing witness to personal testimonies of adversity was highlighted as an essential component of ‘healing’ (Murray et al., 2010), suggesting that trauma-related training in primary care need not be overly technical and could build on existing skills around building therapeutic relationships and containment to facilitate discussion of sensitive topics.
As well as cultural considerations specifically, migrants’ current socioeconomic situation in the host country is also important (Duden et al., 2020). Previous research has identified that psycho-education, coping strategies, and creative therapies were considered helpful to migrants (Koch & Weidinger-von der Recke, 2009). Moreover, equitable cultural partnerships between services and migrant communities and diversification of the workforce could help towards promoting shared understandings of different cultural explanations of distress.
Finally, while it is possible that some interpreters find translating for mental health-related matters more challenging (Costa, 2011), the language barriers and interpreter-related problems frequently reported in the current review are echoed in the wider healthcare literature (Ahmed et al., 2017) and from migrants’ perspectives (Hadziabdic et al., 2009). Therefore, this reflects a wider issue that exacerbates health disparities in the migrant population which can only be addressed by creating clearer, more straightforward, and thus less time-consuming procedures around the financing and administration of interpreting services (Basu et al., 2017; Jaeger et al., 2019) and by improving the training provision of healthcare professionals on consulting through interpreters, as other research indicates that healthcare staff are perceived to be unclear about how to work with interpreters (Kai et al., 2011). Such training would build on the numerous available guidelines on how to achieve the best outcomes from interpreted sessions (Tribe & Thompson, 2008) and highlight the features of effective communication, for example non-verbal communication.
Strengths and limitations
Due to limited interpreting capacity, the review only included English language papers, introducing bias as non-English studies may encapsulate a wider range of experiences. The search strategy only included papers published in peer-reviewed journals; whilst promoting academic rigor, this introduced publication bias. Omitting keywords relating to specific professional groups in the search strategy may have led to relevant studies being missed; however, the number of search returns identified and included studies is comparable with other reviews on similar topics, suggesting the review was sufficiently comprehensive. The inclusion of diverse professional backgrounds was considered appropriate given the aims of the review, and consideration was given to the potential differences between professions when analyzing the data; however, some studies included a combination of professional backgrounds and it was not always possible to match the professional to the data.
The time span allowed for included studies potentially limited the relevance of some papers as it is possible that attitudes of health professionals have changed in line with societal attitudes, therefore earlier papers may be less representative of current practice. All content themes identified were represented in published papers within the last 16 years, suggesting that the attitudes both are relevant and align with the systemic biases that continue to persist in healthcare today (FitzGerald & Hurst, 2017).
Although some studies included migrants without a precarious legal status, there was no explicit mention of advantaged or settled migrants, such as expatriates or international students. The generic term ‘migrant’ is problematic as it makes it difficult to determine samples and could be considered a value-laden description and may elicit a stereotype in professionals. Given participants may have been referring to migrants other than those of a higher socioeconomic or professional status, findings may have limited applicability to more advantaged groups.
Although some studies referred to the extent of professionals’ experience of working with migrants, many gave no details about their backgrounds or whether they had received cultural training. Limited information about sample and contexts provided by primary studies is a previously documented issue in qualitative synthesis (Paterson et al., 2001). Whilst completing the review from the perspective of the professional provided valuable insights, patients are, ultimately, the expert in their own experiences and their perspective needs to be considered in future research.
Whilst several studies included countries from across Europe, most were conducted in Western and Northern European countries, so findings may have limited applicability to other parts of Europe. Relevant international papers were excluded if not conducted in Europe; whilst this needs to be recognized as a limitation, the review compared the findings with international literature to draw out similarities and differences. Findings may have been influenced by policies of the various countries included; however, it is difficult to specify given access to healthcare across European countries varies and, even when legal accessibility is available, differences and inequalities still exist in accessing healthcare (Lebano et al., 2020).
Excluding quantitative papers potentially led to missed relevant studies which could have provided triangulation of data, such as attitude measurements. Future research may wish to consider conducting a review of quantitative research or employing a mixed methods approach. Despite these limitations, all papers scored ‘high’ or ‘moderately high’ in quality assessment. However, there has been debate regarding the applicability of one set of quality criteria for multiple qualitative epistemological and methodological approaches (Mays & Pope, 2000).
Conclusion
Challenges arise in the provision of migrant mental healthcare which relate to the migrant status, strong emotive reactions evoked in professionals working with this group, and cultural barriers at the interface between professional and patient. Professionals implemented various strategies in attempting to overcome such challenges. Key recommendations for professionals and services include: increased flexibility to offer longer consultations; effective collaboration with voluntary organizations in relation to supporting additional needs and specialist supervision for professionals; building partnerships with migrant communities; and the adoption of a person-centered approach. Policymakers and commissioners should consider additional funding to enable services to meet migrants’ needs; the provision of further mental health-related training for physical health professionals; training for all professionals on how to work with interpreters; and the extension of universal access to care to undocumented and uninsured migrants.
Characteristics of included studies.
Only data from participants that meet the inclusion criteria for the review are presented.
Other methods of data collection may have been used in the included studies but only data gathered from interviews or focus groups are included in the review.
Only themes derived from professional interviews or focus groups have been included.
Included studies, methodological quality scoring, and identified themes.
Key: ✓ = Theme present.
x = Theme not present.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship and/or publication of this article.
