Breaking the Relapse Cycle:

A Research Study on the Long-Term Mental Health Care of Migrants in Malta

Authors:
Ms. Marcelle Zanya Bugre, Ms. Elisa Ultimini, Mr. Joseph Sammut

The Foundation for Shelter and Support to Migrants (FSM) - V/O 444 - is a Maltese NGO working in
community development, adult education, research and service provision with diverse vulnerable third
country nationals, including asylum seekers and persons with international protection.

This research study is part of the project entitled: “Mental Health and Well Being – Reaching Third Country
Nationals at Risk” (Project No.: MCCF/C3/017/2016) co-financed by
the Malta Community Chest Fund Foundation (MCCF)

We would like to express our gratitude to

our Service Users
for always being a profound source of inspiration and human beauty,
H.E. the President of Malta, Ms. Marie Louise Coleiro-Preca
and the Malta Community Chest Fund Foundation
for co-funding the project,
our project partners Richmond Foundation
for providing training and support;
as well as the staff of Mount Carmel Hospital, Jesuit Refugee Service, Corradino Correctional Facility, the
Agency for the Welfare of Asylum Seekers, Jobsplus and Lino Spiteri Foundation for their kind cooperation.
We also thank the Directorate for Human Rights and Integration and the
School for Conflict Analysis and Resolution of George Mason University, Virginia
for their contribution to an awareness raising International Women’s Event.
Finally, we thank all migrant communities in Malta
for their constant support in communication, participation, outreach and practical help they offer us and the
beneficiaries of this project.

Copyright © Foundation for Shelter and Support to Migrants, 2019

Reproduction of information included in this report is permitted, provided that appropriate reference is made to the source.
 Mental Health and Well Being – Reaching Third Country Nationals at Risk - 2017-2019

PROJECT INFORMATION

This project, funded by the Malta Community Chest Fund Foundation (MCCFF), was led by the
Foundation for Shelter and Support to Migrants (FSM) in collaboration with Richmond
Foundation. The aim of the project was to support migrants at risk of mental health
deterioration towards social wellbeing and inclusion. The objectives of the project were:

1. Supporting migrants at risk of mental health deterioration or relapse towards independent

living and social inclusion

2. Promoting mental health awareness among migrant communities

3. Promoting sustainable and culturally sensitive practices to best support migrants with
mental health difficulties on the psychosocial level

The results of this project are:

(A) Psychosocial support to 44 migrants facing diverse mental health and social challenges
(4 women and 40 men), between the ages of 18 and 50 years of age, of different
nationality and protection status;

(B) Increased awareness and information on mental health to migrant communities

through 4 workshops, reaching a total of 34 persons from Somalia and Libya;

(C) Helping empower 49 women and men from 13 different nationalities to share stories
related to mental health and sexual and gender-based violence (SGBV) through the
International Dinner ‘Building Sanctuary’ for International Women’s Day 2018;

(D) Promoting good practices in the mental health care of migrants through a conference
at Mount Carmel Hospital (MCH), targeting 50 professionals from government and
Non-Governmental Organisations’ (NGO) services.

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Psychosocial Support

Service users in this project were mainly referred by other professionals working in
governmental institutions, such as MCH, Corradino Correctional Facility (CCF), the Agency for
the Welfare of Asylum Seekers (AWAS) and Appogg. Others were also engaged through
outreach interventions. Service users often presented with severe depression, Post-
Traumatic Stress Disorder (PTSD), psychosis and substance use. FSM supported the referred
persons in collaboration with the referees and other service providers (Jesuit Refugee Service
[JRS], Lino Spiteri Foundation [LSF], Jobsplus, Sedqa, and others) through the development of
customised care plans and specific interventions aimed at addressing the individual’s needs
and goals and promoting recovery and reintegration. Special attention was given to reducing
the fragmentation of care provision and enhancing its continuity in order to reduce the risk
of relapse, mental health deterioration, rehospitalisation or reincarceration. In order to do
this systemic and environmental challenges were addressed as they arose throughout the
recovery-reintegration process.

Mental Health Workshops

Workshops were designed and tailor-made in a culturally sensitive manner, to improve

mental health awareness among Somali and Libyan communities in Gozo and Malta. The
workshops included a break-down of relevant information, practical activities in small groups
and presentations to the whole group, questions and answers, as well as a safe space to share
personal experiences, cultural and religious perspectives, fears and hopes. A cultural
mediator was always available to facilitate the interactions. The suggested mental health
awareness workshops have shown not only interest but also the need to talk about such a
sensitive and important topic affecting individuals and their communities.

An Awareness Raising Dinner for Women on Mental Health and SGBV

As part of this project, FSM organized an International Women’s Dinner, together with the
support of the Directorate for Human Rights and Integration in Malta and the School for
Conflict Resolution of George Mason University. The event marked the occasion of the

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International Women’s Day and aimed at bringing women together to share their experiences
on the subject of mental health and SGBV. The dinner took place at the Palace Hotel in Sliema
on the 13th March 2018, entitled ‘Building Sanctuary: Women’s struggle for Freedom from
Violence’. Women from 13 different nationalities, and different cultural backgrounds, came
together to discuss the different forms of violence women face within domestic walls, on a
cultural, systemic and societal level, and, last but not least, throughout their migration
journey. Many stories and questions were raised, bringing up concern for the needs of
women, including migrant women, in breaking free from violence and finding support in
rebuilding their lives as important members of society.

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 ABSTRACT

Previous work with healthcare professionals in Malta has identified a recidivism problem for
migrants with mental health challenges who are admitted to MCH and fall into a recurrent
pattern of discharge and readmission. Identifying the causes of recidivism and opportunities
for long term recovery is therefore crucial. It is for this reason that this research study focuses
on:

1. exploring factors that cause migrants with mental health conditions to relapse;
2. exploring the challenges faced by professionals in helping migrants with mental health
difficulties, including the FSM psychosocial team;
3. identifying good practices and policies that would improve recovery and reintegration
outcomes.

This study used a qualitative approach and thematic analysis to identify underlying patterns
within the aimed areas of study. Data was collected through an anonymous online
questionnaire which was distributed among different governmental institutions working
directly or indirectly with migrants suffering from mental health conditions, such as MCH,
CCF, Appogg, and Jobsplus. The same questionnaire was answered by FSM psychosocial
support team, and additional data was gathered through their experience in the field.

The findings appear to confirm the main risk factors already identified in the literature: risks
related to inability to achieve or obtain legal status, decent housing, gainful employment,
social support, continuity of care and adequate resources in the community. In addition, the
presence of stigma, systemic deficiencies (including discrimination), and language and
cultural barriers negatively affecting individuals’ recovery and reintegration. Additionally, the
study finds there is a strong relationship between mental health deterioration and substance
misuse, as well as mental health deterioration and ineffective or unjust policies.
Such identified risk factors are major predictors of mental health deterioration and relapse,
often leading to hospital readmissions or reincarceration.
These findings have profound implications for service providers as well as policy makers.
Professionals are encouraged to identify and adopt good practices when working with

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migrant clients, including a holistic and collaborative approach, as well as culturally relevant
and advocacy-oriented interventions. However, these practices cannot be effective unless
there is an equal effort to create policies that are just and effective in promoting the support
and long-term inclusion of migrants in society.

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 TABLE OF CONTENTS

PROJECT INFORMATION ............................................................................................................ i

ABSTRACT ................................................................................................................................ iv
LIST OF ABBREVIATIONS ..........................................................................................................vii
TERMINOLOGY .......................................................................................................................viii
INTRODUCTION ........................................................................................................................ 1
Anticipated Outputs and Wider Relevance........................................................................... 3
LITERATURE REVIEW ................................................................................................................ 4
Local Research ...................................................................................................................... 4
International Literature and Implications for Research ........................................................ 6
METHODOLOGY...................................................................................................................... 10
Participants’ Recruitment ................................................................................................... 10
Data Collection and Analysis ............................................................................................... 10
Methodological Limitations ................................................................................................ 11
Ethical Considerations ........................................................................................................ 11
FINDINGS AND ANALYSIS........................................................................................................ 13
Services and Referral System .............................................................................................. 13
Challenges Faced by Migrant Service Users........................................................................ 19
Challenges Faced by Helping Professionals ........................................................................ 27
Good Practices .................................................................................................................... 34
Recommendations .............................................................................................................. 37
THE FIELD EXPERIENCE OF FSM PSYCHOSOCIAL TEAM .......................................................... 43
Challenges Faced by Migrant Service Users........................................................................ 43
Challenges Faced by Helping Professionals ........................................................................ 52
Good Practices and Recommendations .............................................................................. 53
REFERENCES ........................................................................................................................... 58

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 LIST OF ABBREVIATIONS

AWAS Agency for the Welfare of Asylum Seekers

CCF Corradino Correctional Facility
FSM Foundation for Shelter and Support to Migrants
JRS Jesuit Refugee Service
LSF Lino Spiteri Foundation
MCCFF Malta Community Chest Fund Foundation
MCH Mount Carmel Hospital
MMHSP Migrant Mental Health Support Project
NGO Non-governmental Organisation
PTSD Post-Traumatic Stress Disorder
SGBV Sexual and Gender Based Violence
THP Temporary Humanitarian Protection
UNHCR United Nations High Commissioner for Refugees
TCN Third Country Nationals

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 TERMINOLOGY

The term ‘migrants’ is used throughout the research as an umbrella term referring to the
categories of persons targeted by this project: namely third country nationals living in Malta,
which may be refugees, asylum seekers or non-asylum-seeking persons arriving from non-EU
countries.
We are aware that often the term ‘migrant’ is regarded negatively as it depersonalises the
individual and reduces different cultural and status groups into an undifferentiated category,
which often increases stigma and prejudice against such persons and groups. At the same
time, common terms used by policy makers and the general public can enhance the impact
of this work (Bakewell, 2008; Zetter, 2015) by reaching more readers and preventing
confusion. Therefore, the following terms will be used:

Third country nationals: non-EU persons who may or may not have applied for asylum.
Asylum seekers: third country nationals who have submitted an application for international
protection, whether the application pending, rejected or accepted.
Refugees: asylum seekers who have been granted refugee status, as defined by the Geneva
Convention and International Refugee Law.
Subsidiary protection: another form of international protection granted to individuals who
would face a real risk of serious harm if returned to their country of origin.
Temporary Humanitarian Protection: a form of national protection granted to migrants who
are not deemed eligible for international protection but should not be returned to their
country of origin as minors or due to medical and other humanitarian reasons.
Failed asylum seekers or migrants with rejected status: third country nationals whose
application for international or national protection has been rejected by the competent
authorities.

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 INTRODUCTION

Mental health care, along with the need to improve and reform its delivery, is a high-profile
issue in the Maltese press and among policymakers. In 2012 the Mental Health Act signalled
a desire to move towards a more community care model, and also introduced a Commissioner
for Mental Health to supervise overall mental health services. However, the Commissioner’s
reports and the Maltese press seem to highlight continuing problems within the mental
health care sector.
In 2017, the President of the Maltese Association of Psychiatry, Dr Etienne Busuttil, argued
that mental health provision is under resourced, overly focused on inpatient treatment, and
that there is a ‘chasm’ between inpatient and outpatient services, which often leaves patients
falling through the gaps (Dalli, 2016, January 17). Additionally, concerns such as overcrowding
in the national psychiatric hospital, Mount Carmel, (Commissioner, 2017, p.144) as well as a
high readmissions rate have also been recently reported by the Commissioner for Mental
Health (Commissioner, 2017, p.154).
Pertaining to migrants’ mental health, previous national research has highlighted the unique
challenges this particular population face during their resettlement in the host country. For
instance, studies specifically focused on the situation for migrants in detention have stressed
how this condition might exacerbate pre-existing vulnerabilities or even trigger mental health
problems (Collantes, et al., 2011; Taylor-East, et al., 2016). Collantes et al. (2011) have also
identified various factors that seem to contribute to the deterioration of migrants’ mental
health and hinder their access to adequate treatment. These factors include migrants’ often
precarious legal status, their difficult living and working conditions, the lack of knowledge of
their own rights, and discriminatory practises at institutions to name but a few.
In light of the aforementioned challenges, in March 2017 FSM was awarded a grant by the
Malta Community Chest Fund Foundation of the President of Malta, to provide psychosocial
support to migrants with mental health concerns who are at risk of relapse and
rehospitalisation. The hereby developed Migrant Mental Health Support Project (MMHSP)
aimed to move individuals towards long-term recovery, independent living and social
inclusion post-discharge, while facilitating the continuity of care provision. For this purpose,
FSM appointed a psychosocial support team which was formed by a project coordinator and
a psychosocial support officer. Throughout the project, the psychosocial team, together with

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the 44 referred service users and other involved service providers from different agencies -
such as MCH, CCF, JRS, AWAS, Jobsplus, LSF, Appogg and Sedqa, to name but a few - has
worked on collaboratively developing a tailored and holistic care plan to address personal
needs and goals. Individual, systemic as well as environmental challenges have also been
assessed and tackled as they arose. An additional key role of the psychosocial support team
has been to take on the coordination and revision of the care plan through a wide mandate
of interventions. These included accompaniment to appointments, emotional support and
counselling, regular communication and follow ups with the service users as well as with other
involved professionals, provision of culturally sensitive consultancy to care providers,
continual care plan revision and tailored adjustment, systemic advocacy, as well as any other
interventions that could further aid the individual’s psychosocial recovery.
Service users could self-refer or be referred by family members, friends, and professionals
from a variety of agencies. Service users were mainly referred by professionals working at
MCH, CCF, Appogg, and AWAS. Nevertheless, some individuals were also referred by
community members or identified through proactive outreach interventions.
In addition to offering individualised psychosocial support, the MMHSP also strived to raise
mental health awareness among migrant communities. Four workshops were held with
members of the Somali and Libyan communities, raising awareness on different types of
mental health challenges, dealing with stigma, assisting interventions and useful contacts.
Theoretical elements were broken down and accompanied by visual materials as well as
practical activities. The workshops provided a safe space for discussion, questions and
answers, and allowed for shared experiences. An interpreter was present throughout the
sessions to ensure understanding and to facilitate interactions.
Finally, research was conducted to identify current systemic issues and best practices across
different agencies and departments relevant to migrants with mental health challenges, and
to present recommendations to policy makers, administrators and professionals on the
subject.

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Anticipated Outputs and Wider Relevance

This research project is part of a service project which aims at exploring some of the
underlying mechanisms that cause migrants with mental health problems to become stuck in
a readmission cycle. The research has identified good practices in relation to professional
work, cooperation among various stakeholders and policy solutions. These practices learnt
can plausibly be carried over to other marginalized communities in Malta. Equally, some of
the lessons may also be applicable for other services dealing with migrants.

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 LITERATURE REVIEW

Local Research

There is a fairly large national as well as international literature on migrants with mental
health disorders and the barriers they face accessing healthcare provision. However, this
literature is dominated by qualitative studies that may be highly particularistic and from which
it is difficult to draw generalisable inferences. Moreover, the majority of these studies focus
on the cases in the US or the larger economies in Europe, while there are few that cover
Malta. The present review will explore some relevant literature findings concerning migrants’
with mental health challenges in Malta.
An EC Commission funded study by Biffl and Altenburg (2012), looking at a range of European
countries, including Malta, noted a range of different barriers to mental health care
particularly for undocumented migrants. These include a lack of legal entitlements, fear of
being reported, unaffordable costs, lack of information, and discriminatory attitudes in
society towards migrants. These barriers, along with the uncertainties resulting from their
undocumented status, have a strong negative impact on the mental health of migrants, and
increase the risks of depression, anxiety and sleeping problems. In addition, Biffl and
Altenburg (2012) also maintain that undocumented migrants are highly susceptible to a
condition termed by psychologists as ‘Chronic and Multiple Stress Syndrome’, or ‘Ulysses
Syndrome’, which, if untreated, may lead to serious mental illnesses, such as psychosis (p.
190). The study additionally highlights shortcomings in mental health care provision in Malta,
such as the scarce availability and accessibility of counselling services to migrants within MCH
as well as in the community. Assessing whether these conclusions are still relevant, given the
change in the Maltese mental healthcare context brought by the new Mental Health Act, will
be an important component of the research project.
A comparative study on access to physical and mental healthcare across four European
countries by Collantes et al. (2011) surveyed 100 asylum seekers and undocumented migrants
in Malta, all of whom had been placed in detention on arrival and were from sub-Saharan
Africa. All but six were male. Snowball sampling was used to reach migrants receiving services
from Maltese NGOs. Consequently, there are two main potential sources for bias: (1) migrants
not receiving these services might be in a worse situation, (2) and/or migrants that are in a

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better situation might not seek NGO support services. However, the sample did have a high
level (70%) of self-reporting of poor to very poor psychological health. It also identified several
potential causes: trauma suffered due to detention procedures, the migration journey
experience, and the home country situation; precariousness of legal situation; poor housing
and working conditions; familial separation and absence of emotional support. Several
difficulties in accessing care were identified by respondents. 38% reported that waiting lists
were too long; a third reported suffering discrimination and feeling unwelcome when
accessing care; a quarter of respondents reported having communication difficulties due to
language, 17% lacked information about their rights and how to access care, and 16%
reported they lacked transport. There was also a range of other difficulties identified by
smaller proportions of the sample. It is a major concern that 44% of asylum seekers reported
that they were refused treatment by health professionals or administrative staff when
seeking treatment over the previous year.
A study by Rossi and Caruana (2014), and a briefing paper by Taylor-East et al. (2016), detail
the situation for detained asylum seekers with mental health problems. Both report that
being in a detention environment greatly increases risks to mental health. A key
recommendation of Taylor-East et al.’s report (2016) is that the focus of the services provided
should be shifted beyond treatment of acute conditions, towards prevention and early
intervention. Rossi and Caruana’s study (2014) surveyed detainees who had been admitted
to the then Asylum Seekers’ Unit (ASU, today ward 8B) of MCH over a six month period in
2014. Reportedly, there was an average of 1.7 admissions per patient, with 30% admitted
twice and 17% admitted three times or more. The majority of these patients (58%) had
attempted suicide while in the detention centre, which was often the reason for admittance
to MCH. The study highlighted problems of care in the detention centres, such as outsourced
healthcare provision that is not integrated with the National Health Service and with no access
to mental health care specialists as well as a lack of mental health care knowledge among
detention staff. In addition, the authors identified a lack of continuity of care when patients
were discharged from MCH back to the detention centre. Additionally, conditions on the ASU
ward were criticised by the patients as being a significant stressor, and considered to be no
better, and by some worse, than the conditions in detention.

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In light of the above, key bottlenecks seem to be the lack of awareness and resources for
addressing mental healthcare as a critical component of services in detention centres. Most
cases are only identified and referred when they are acute, while little or no attention is
placed on prevention or containment of mental health distress. In line with the mentioned
literature findings, the present FSM project has also identified that continuity of care is
lacking, especially when migrants leave hospitals and institutions where they are receiving
care. The continuity of care service has the potential to be successful in the long-term
recovery of migrants with mental health challenges.

International Literature and Implications for Research

There is a broader literature on migrant mental health in other countries, particularly in the
larger EU countries and in the US. However, a systematic review of 54 studies by Woodward
et al. (2014) found that few of these studies used systematic forms of sampling. The often
transient and difficult to reach nature of the population means that most studies are
therefore linked to services, rely on forms of snowball sampling, and tend to have small
samples. Despite the potential for a lack of generalisability, there are a number of shared
themes consistent cross-country and study. From this literature a number of major challenges
have been identified that affect both migrants’ recovery and integration as well as care
providers supporting them, for instance: document barrier, gatekeeper challenges, social
integration, cultural and language barriers, good practice, housing environment, and
employment.

Documentation.
A frequently noted barrier to mental health care stems from the uncertain status experienced
by many migrants (Woodward et al., 2014). Undocumented migrants often lack entitlements
for non-emergency care or avoid seeking the necessary care out of fear of being reported.
Even when migrants are entitled to support services and social benefits, they and/or medical
staff may be unaware of their rights. This seems likely to be an issue in Malta as there are
systematic inconsistencies over the legal entitlements of migrants, with some being able to
receive non-emergency care for free and some being charged.

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Gatekeeper challenges.
Mental health services are often accessed through referral from primary health care services,
which act as gatekeepers. This may be a barrier to vulnerable migrants. For instance, the
pathway to care is often distinct to that of other residents, with lower utilisation of primary
healthcare services by migrants. Winters et al. (2018) suggest that primary healthcare with
migrant specific outreach services would be an important alternative pathway to the access
of care. Furthermore, Giacco et al. (2017) argue that migrants often lack the knowledge of
how to navigate the health system and feel distrustful towards public organisations or their
representatives, either because of negative pre-migration experiences of authorities or their
fear of being reported if they are undocumented.

Social integration.
Upon relocation, migrants tend to experience a loss of social ties in their countries of origin,
while having to rebuild new social networks in the host country. It is suggested that the level
of social integration has an impact on the individual’s sense of wellbeing; a survey of Latin
American immigrants in Spain found that higher social integration was positively associated
with higher levels of subjective wellbeing (Herrero et al., 2011). Similarly, Giacco et al. (2017)
link poor social integration after resettlement with higher rates of depression and anxiety.
Where there is a sharper cultural gap between mother and host country, usually the barriers
to social integration are likely to be more difficult to overcome. In addition, the greater the
hostility to integration and discrimination in the host country, the greater the likelihood that
migrants will (a) find it difficult to form social networks and (b) the greater the likelihood that
this will create a distrustful and negative view of service practitioners, when viewed as
representatives of said hostile host country. In light of the above, it is plausible that the
absence of supportive social networks in the host country might be likely a determinant of
mental ill health and potentially enhance the risk of relapse.

Cultural and language barriers.

A literature review by Giacco et al. (2014) highlights cultural and language barriers to mental
health care. Language is an obvious barrier to care, and even when an interpreter is available
it can present challenges to care. This is likely to be especially true for mental health
treatment, including the viability of talking therapy treatments. Another issue identified by

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Giacco et al. (2018) is that different cultural backgrounds may have different explanatory
models of illness; consequently, they stress the importance of cultural sensitivity training to
care providers as well as collaboration with and outreach to families and migrant
communities. In this regard, the authors cite a study indicating that culturally tailored
psychoeducation intervention to the families of Chinese-American patients with
schizophrenia could contribute to the improvement of symptom levels and quality of life. As
a result, it can be suggested that the availability of trained interpreters as well as cultural
training to care providers (or absence thereof) is likely to be an important determinant of
successful long term rehabilitation and integration.

Substance use.
Substance use disorders are frequently comorbid with other mental health problems (Regier
et al. 1990). PTSD, which has a higher prevalence among forcibly displaced individuals (Carta
et al., 2005), is in particular associated with a higher likelihood for substance use (Javidi and
Yadollahie, 2011), especially in open centers (McLeary et al., 2015). Subsequently, the
comorbidity of mental health distress, substance use and additional psychosocial challenges
typical of migrant populations has been linked with the likelihood for multiple hospitalisations
(Commissioner, 2017). According to the report, nurses claim that substance users are
particularly resource draining, accounting for 20 percent of admissions but 80 percent of
nursing time. This background suggests that substance use may be an important determinant
of individuals staying in a readmission cycle.

Good practice.
A survey of professionals in 14 European countries by Priebe et al. (2012) identified four
components of good practice for mental health care targeting socially marginalised groups:
community outreach, facilitating access to general health services, collaboration and
coordination of services, and high quality and available information. Outreach programmes
are important as there are often a number of barriers that prevent marginalised groups from
accessing mainstream mental health services. Facilitating access, by reducing administrative
and bureaucratic barriers, is important as marginalised groups often lack the capacity to
navigate the general mental health system. Collaboration and coordination of services,
through information sharing, is important for ensuring continuity of care and that individuals

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are not neglected by any service providers involved in the care plan. Compiling information
for professionals on available services and support relevant to migrant populations, including
community groups and other agencies that may be able to provide culturally sensitive advice,
as well as appropriate information delivery to the service users are also crucial for improving
psychosocial recovery outcomes.

Housing environment.
Poor housing conditions, such as open centres or homeless shelters, as well as homelessness
are considered to exacerbate or maintain mental health distress among migrants, thus
becoming a barrier to recovery. Press reports suggest that homeless shelters are seeing an
increasing proportion of homeless migrants (Schembri Orland, 2017, July 16). This is a cause
for concern as Krausz et al. (2013) found that homelessness presents a number of additional
barriers to accessing mental health care (Krausz et al., 2013).

Employment.
Many migrants in Malta work in so called “3D-jobs” (dirty, dangerous, demanding), meaning
often highly unstable, irregular and poorly paid occupations. Precarious or undocumented
status (ILO, 2014), low levels of education and illiteracy (Marfleet & Blustein 2011), language
barriers, as well as the lack of official recognition of migrants’ certified diplomas, make
migrants more susceptible to underemployment, unemployment and labour exploitation. On
the one hand, individuals who work illegally might refrain from utilising psychosocial care
services out of fear of being reported/deported. On the other hand, unemployed or
underpaid individuals might be unable to afford care expenses unless they are entitled to free
treatment. It is therefore plausible that poor working conditions associated with low quality
of life are likely to trigger as well as maintain mental health distress, while also creating
additional barriers to care access.

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 METHODOLOGY

The present study has employed an exploratory qualitative approach as the most suitable
research methodology for three main reasons.
Firstly, the aim of this research is to explore the idiosyncrasy and complexity of migrants’
mental health recovery challenges in Malta through the observations of care providers from
government institutions who provided services to migrants with mental health difficulties.
Secondly, since the literature on migrants with mental health problems and appropriate
interventions within the Maltese context is still very limited, qualitative research is more
suited to identifying barriers to successful interventions.
Finally, given the small size of participants, probabilistic methods are unlikely to be viable or
appropriate for this research, as representativeness and generalisability of the collected data
could not be guaranteed.

Participants’ Recruitment

Research respondents for this study were invited to participate voluntarily and anonymously
through an opt-in approach. An online survey was disseminated among professionals working
in different local, governmental agencies through a gatekeeper. Among the participating
agencies were MCH, CCF, Appogg, and Jobsplus.

Data Collection and Analysis

Research data was collected through 30 anonymous interviews held via an online survey,
which included quantitative as well as qualitative questions. The questionnaire was
disseminated among professionals working in different governmental agencies between
August and October 2018. The method of data analysis chosen is thematic analysis. The scope
of this method of analysis is to identify, analyse and report patterns within the collected data
(Braun & Clarke, 2006).
Additionally, data was collected by FSM psychosocial team through personal observation on
the field. Observations and reflections are described in a separate section.

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Methodological Limitations

A problem with surveys, and why they are not used very frequently for qualitative research,
is that, even if there are write-in answer spaces, it is not possible for the researcher to explore
topics that emerge in more depth.
This does mean that there are some limitations to the research. While plausible barriers to
recovery can be identified and their potential mechanisms discussed, it will not be possible to
determine with confidence the relative explanatory power of different determinants.
Additionally, claims cannot be made that conclusions drawn are necessarily generalisable.
Due to the small sample size, claims to representativeness and to the ‘typicality’ of the cases
are very difficult to make.
Finally, and perhaps most importantly, in order to preserve service users’ anonymity and
confidentiality, the research does not give voice to their personal stories. Instead, their
recovery challenges are re-narrated through the voices of care providers. This means, not only
that migrants’ voices are excluded but also that the data collected might not entirely
represent their experiences entirely.

Ethical Considerations

Research needs to be designed in a way that it causes no harm (Denzin, & Lincoln, 2011). This
means protecting the dignity, safety and anonymity of participants, service users and any
persons directly or indirectly involved in the research journey.
One of the most important ethical issues to be considered, especially due to the small size of
Malta and the research sample, is the issue of anonymity and confidentiality. For instance, in
order to anonymise the data as much as possible, it has been necessary to speak more
obliquely than in research with a larger population to make sure that both participants and
service users are not identifiable. In these lines, prior to participating in the survey,
interviewees have also been requested informed consent concerning the anonymous use of
quotations.
Furthermore, to safeguard the anonymity, confidentiality and right to informed consent of
vulnerable migrants (which might eventually be impaired by the mental illness) as well as to

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prevent the risk of retraumatisation, we have refrained from interviewing service users and
decided not to include their individual stories as part of the research. At the same time,
excluding the personal voices of migrant service users, which are of crucial importance to be
heard, poses an additional barrier to ethical research. For instance, it gives rise to issues such
as power imbalance, disempowerment and a possibly deficient or filtered representation of
service users’ perspectives (Denzin & Lincoln, 2011). In light of this, we have strived to
maintain maximum respect and carefulness throughout the research, especially when
reporting migrants’ experiences through the eyes of professionals.

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 FINDINGS AND ANALYSIS

The research findings are presented in the following five sections:

• Services and Referral System

• Challenges Faced by Migrant Service Users
• Challenges Faced by Helping Professionals
• Good Practices
• Recommendations

Services and Referral System

Types of services and response rates.

The research questionnaire was sent to several institutions that provide professional services.
Some institutions focused primarily on mental health, while others provided other social
services, but collaborated with mental health services in cross referral of clients. Some
services were generic in reaching all types of clients. Correctional services were considered as
a separate category.
The research generated 30 responses, which came from the following service type of
institutions:

a) Services focusing primarily on mental health – 41%

b) Services focusing on social issues, other than mental health – 38%
c) Services focusing on social issues, including mental health – 8%
d) Generic services – 3%
e) Correctional services – 10%

The percentages show that there is a balance between responses from mental health services,
and other social services that do not focus primarily on mental health. This gives a good
balance between perspectives of those who work in mental health institutions, and those
who attend to clients who often have left such institutions but still face social challenges, or

13
those who have social and mental health challenges but have not been hospitalised in such
institutions. Because the research is considering the ‘revolving door’ phenomenon where
people are often re-admitted several times to various services, a well-balanced response rate
from these various institutions is considered beneficial.

Referral types and referral system.

The research finds that most professionals received referrals from other professionals (77%),
while the rest approached service providers themselves (23%).
The reasons for referrals as received by professionals vary, with employment, housing,
finances and mental illness being the primary reasons, as shown below:

Reasons for Referral

Caring of children

Substance abuse

Disability

Social benefits/ financial problems

Mental illness

Unemployment

Housing/accommodation

0 1 2 3 4 5 6 7 8

The referral system largely depends on the service providers themselves, and the
professionals who work with service users. In correctional facilities it is mostly professionals
and correctional officers who refer clients, especially some months before they leave prison.
One of the major reasons for referral is the need to secure housing and employment for
clients, so that when they leave prison they would have a smooth process of inclusion in the
community, which increases the chances of prevention of crime and readmission to prison.
Some referrals are also made when clients decide to start a drug rehabilitation programme.

14
When asked about the effectiveness/efficiency of the referral system, professionals gave
diverse responses, some noting that the referral system was typically effective, others
explaining why it was not, and others remarking that it varied, depending on factors which
usually complicated the processes of helping. A major difficulty are the restrictions in
eligibility to services for migrants with rejected status, which greatly limit professionals.
Long waiting lists were mentioned by five respondents as barriers to clients’ progress which
make referral unfeasible. One respondent noted that:

“Referral to mainstream services is lengthy and complex, and often for nothing.”

Other professional respondents shared similar frustrations. Limited resources and

bureaucratic systems are seen as a major barrier, with the result that migrants find services
“confusing” and “not always attractive.” These factors limit access to services for migrants.

“Other agencies are usually reluctant to accept migrants as clients mainly due to lack of
knowledge on migrants in general.”

“Some services just ask us to tell client to go as a drop in however they are not necessarily
attended to when they do or else, they have to wait for hours”.

The lack of resources often makes professionals feel ‘helpless’.

“I think there is a general feeling of helplessness when it comes to dealing with migrants
because so many barriers are found by professionals working with them that when you have
a new migrant client you immediately think of the long and difficult road you have ahead of
you.”

The lack of training is also mentioned as a factor that hinders the quality of referral services.
Professionals need to be trained on migration issues, and also to deal with their own
prejudices:

“I believe other services do give importance to migrants however I do believe that more
training needs to be provided since even professionals can be judgmental.”

15
Some respondents wrote that NGOs, such as JRS and FSM, were very helpful to their referred
clients, although they did not mention how.

Rating services.
Respondents were asked to rate public housing, rehabilitation, social support and psychiatric
services. As the results show below, the majority of respondents believe that public housing
services need significant improvement on all aspects of accessibility, efficiency and
effectiveness. The majority also believe that rehabilitation programmes on substance abuse
and psychiatric hospital services also need to improve, although to a lesser extent. Social work
services need small improvements to increase their accessibility and efficiency, although
significant improvement is needed to make services more ‘effective’.

16
17
Keeping appointments.
Respondents were asked to compare the attendance of migrants to appointments between
Maltese/EU nationals and other migrant groups. Half of the respondents choose the
statement that there is no difference, while more than a third select the statements that non-
EU migrants rarely attend, attend less frequently or irregularly, when compared to Maltese
and EU migrants. One needs to note however that these facts are not based on statistics, but
rather on the perception and experience of the respondents.

18
Challenges Faced by Migrant Service Users

Factors limiting post discharge recovery for migrants.

A number of different challenges that hinder mental health recovery of migrants after
discharge from hospital were presented to respondents. They were asked to choose three
factors they think have the most impact. The graph below shows the response rate for each
factor.

Factors limiting recovery post discharge

Post Traumatic stress Disorder

Racism

Stigma

Resistance to medicine and treatment

Difficulty accessing social benefits

Difficulty accessing social services

Unemployment

Employment exploitation

Lack of decent housing

Lack of support- social networks

Precarious legal status

0 2 4 6 8 10 12 14 16 18 20

Having a precarious legal status and having no access to decent housing are seen as the most
limiting challenges inhibiting recovery post discharge. Resistance to medicine and treatment
regimes is also a strong inhibitor. Unemployment also has a high rate of response, as well as
the lack of supportive social networks. The challenges of Post-Traumatic Stress Disorders,
stigma and racism were additionally mentioned by respondents themselves.

Reasons for rehospitalisation/reincarceration.

Respondents were asked to state reasons why migrants would be re-hospitalised or even
reincarcerated after being discharged/released from hospital or the correctional facility.

19
 Reasons for Rehospitalisation/ Reincarceration

Failure to follow a long term plan

Mental illness

Poor income

Drugs and alcohol consumption

Stop treatment/Non compliance to…

Unemployment

Poor social/community support

Homelessness/Poor housing facility

0 1 2 3 4 5 6 7 8

Major factors contributing to relapse are homelessness/poor housing, the lack of social and
community support, and unemployment. Other reasons are the lack of compliance to
treatment, poor income, mental illness and the abuse of drugs and alcohol. Failure to follow
a long-term plan is also mentioned as one of the reasons, as well as the failure of clients to
attend appointments.
Other reasons mentioned by single respondents include:

§ Not having an address

§ A time of crises
§ Racism
§ Re-traumatisation
§ Undiagnosed conditions for which client takes medication
§ Health deterioration
§ Dealing with cultural differences
§ Having nothing to lose

These are reasons for relapse as presented by some respondents:

“If social problems remained unsolved, one has a greater chance of relapse and is re-
hospitalised.”

20
“If their social needs are not met when they leave the prison, they are bound to return. A stable
job, and reliable accommodation are a must, as is a long-term care plan.”

“Lack of housing, employment and social support lead to recidivism/relapse due to the fact
that clients start to view CCF or other institutions as an alternative to the streets.”

Barriers for migrants to following a care plan.

Migrants can experience a number of barriers when they are following a care plan, and as a
result, their contact with service providers may be interrupted. This can put them at risk of
health deterioration and social exclusion, decrease their confidence in their own progress and
make them distrustful of professionals and service providers. Respondents were given a list
of factors to choose from, as well as the possibility of listing down their own factors.

Factors preventing migrants from following care plan

Unrealistic expectations and poor insight on mental…
Poor follow up in the community
Clients' feeling of helplessness

Clients move to another country

Poor transport access
Clients' experiences of discrimination

No accompanying service when needed

Distrust

Lack of advocacy in securing services

Lack of cultural competence by professionals
Language barriers

Lack of interest due to different priorities

Lack of coordination between services
Clients' poor understanding of the service

0 2 4 6 8 10 12 14 16 18

The most salient factors chosen from the list were those of clients’ poor understanding of the
service as well as the lack of coordination between services. It is interesting because these
two may also be related, since the lack of coordination between services often confuses
clients who may appeal to all services, indiscriminately, hoping to access needed support.

21
Language barriers also rate high, as well as the lack of interest of clients who may have
priorities that are different to the professionals working with them. The lack of cultural
competence is mentioned here, as well as the poor advocacy in securing services and the
distrust of clients towards service providers.
Three other factors were presented by respondents: poor community follow up, clients’
feeling of helplessness, as well as clients’ unrealistic expectations and limited insight on
mental illness.
While some of these factors are common to migrant groups, such as language barriers, others
are related to the lack of education and awareness on mental health. Cross cutting factors
such as poor education background, which may also be more common in certain migrant
groups, place clients at further risk of mental illness and social exclusion due to the lack of
access to opportunities that can improve one’s wellbeing and quality of life.

Individuals and groups at high risk of mental illness.

An open question was presented to respondents, to list the migrant individuals or groups that
they feel are most at risk of mental illness and relapse.

Migrants most at risk of mental illness and relapse

Those whose expectations prior to arrival are not met

Single parents
Those who have poor coping skills
Those who have a history of mental illness
Those with no family/social support in rehabilitation
Those who have no access to benefits
Those who are unemployed
Those who abuse of substances
Those who have PTSD
Asylum seekers
Persons with a criminal record
Undocumented/rejected/limited protection
African migrants
Past trauma

0 1 2 3 4 5 6 7 8

22
Some respondents listed one type of individuals or groups; others mentioned several groups.
Each group was listed in a category, and each category plotted against the rate of response.
The results show that respondents give the highest priority to individuals with past traumas,
and those who are undocumented, rejected or even have limited protection. Respondents
comments:

“Individuals who have not been given a refugee status/subsidiary protection can access near
to no services to my knowledge and this puts them at increased risk
of poverty and unemployment, and poor mental health.”

“Individuals who have symptoms of post-traumatic stress disorder due to witnessing

war/harrowing experiences are also at increased risk, particularly of substance abuse.”

“Those experiencing additional and exceptional trauma in journey, eg. rape during voyage.”

The lack of family support and social networks was also mentioned by several respondents as
a major hurdle to mental health and mental health rehabilitation. Single parents were
mentioned as a group at risk; one respondent pointed out the difficulties of:

“Single mothers with children with no support and no status – thus implying limited or no
access to certain services and benefits.”

African migrants as well as persons with poor coping skills were seen as particularly at risk:

“Poor coping skills especially when they find themselves in a different cultural environment
that makes it harder for them to feel understood.”

Racism and/or discrimination in support system.

Although most professionals working in support services can identify racism and
discrimination in the support system, they often are not aware of these attitudes and
behaviours within the helping professions. In this survey, respondents were asked whether
they are aware of incidents of racism or discrimination of migrants in the provision of support

23
services. Although some did not answer either way, there were 13 affirmative and 3 negative
answers.

Direct/indirect racism or discrimination in

provision of support services

Yes No

Negative answers included the following comment:

“No... however some people have unrealistic expectations which can be mis-interpreted as
discrimination.”

This comment is important because it points out to difficulties in how professionals may
define ‘discrimination’ and ‘racism’, and whether they are actually able to identify related
incidents when they occur. Affirmative answers included such comments:

“Witnessed professionals passing discriminatory comments.”

“I do hear of incidents reflecting racism in some of the individuals providing the services.”

“Yes, certain disrespectful comments need to be challenged by seniors as they continue

spreading hate.”

“Yes I am aware of such incidents. It effects clients by becoming hopeless and helpless and
therefore lose all trust in the system that it is going to help them.”

24
“Yes. Certain professionals discriminate against migrant clients. The clients always realise this
which makes them distrust the service and resist treatment. After discharge, most clients
disappear and do not come for follow up appointments as a result.”

“Yes of course. It affects them a lot as they lose their trust of our services. Sometimes I tend to
accompany them to certain public services to make sure that they are not discriminated.”

Some respondents explained how discrimination works in the larger system, which makes it
difficult for migrants to access certain services, rights and provisions. Examples included
renting discrimination, and bureaucratic procedures migrant parents face when registering a
child at school. It is recommended that more awareness and training is given to improve
empathy and quality of services when dealing with diverse cultures. More sanctions need to
be developed and enforced with respect to racism and discrimination within support services.
Organizations providing specialized services for migrants can monitor clients, being present
during ward rounds and facilitating communication, treatment plans and monitoring before
and after discharge.

Failed asylum seekers and migrants with protection obtained in other EU countries.
Failed asylum seekers and migrants with humanitarian protection obtained in other EU
countries may be more at risk of social exclusion and mental health illnesses. 18 out of 23
respondents agreed with this statement, explaining the limitations of resources and services
for migrants in general, and failed asylum seekers or those with protection coming from other
EU countries in particular. Professionals often deal with this reality by explaining to clients
about policy limitations which restrict their access to certain services. Professionals helping
clients to work towards independence often try to explore resources for persons who face
high risks of social exclusion. They sometimes request the support and advice of NGOs. They
also raise awareness of the needs of migrants at risk among policymakers as well as
authorities in their own agencies and public institutions. One respondent remarks:

“I tried hard to increase awareness of this issue with management, but although I was heard
on several occasions, no action was taken.”

25
These remarks indicate that professionals may face struggles with their own management, or
even with other authorities and systems, in order to promote social justice. This reality
contrasts with expectations of reporting migrants, which may contradict professionals’
principles, as one respondent remarks:

“Yes, in fact we are ordered to inform about migrants to explore the possibility of deporting
them back.”

Additionally, migrants may face restrictions in accessing important medication, rendering

them in danger of continuous relapse and mental health deterioration:

“Yes, it is true, and their situation becomes further complicated by the fact that free
medication is not provided to them. Those deemed to be vulnerable and in need of long-term
treatment/care should be given a particular status in order for them to receive treatment and
services without interruption.”

26
Challenges Faced by Helping Professionals

A general view of challenges for professionals.

Professionals were given a list of challenges they may be facing while helping migrant clients.
The most common challenges selected were related to language barriers and insufficient
resources available for helping clients. Half of the respondents feel that the low
responsiveness of other authorities or agencies is a challenge to their work, and almost half
of the respondents find that discriminatory policies, bureaucratic requirements and
complexity of migrants’ needs also limit their work with migrant clients. In the section for
open responses one respondent wrote that there is a difficulty in making contact with clients
by phone.

Professionals' challenges

Difficulty contacting by phone

Insecurity of status of clients

Complexity of psychosocial needs limiting professional work

Bureaucratic and administrative requirements

Discriminatory policies limiting access to support

Insufficient resources available to help

Long waiting lists

Lack of responsiveness from other authorities/agencies

Insufficient diversity training

Cultural barriers

Language barriers

0 2 4 6 8 10 12 14 16 18 20

27
Knowledge about services and entitlements of migrants.
Knowledge about legal statuses, rights and entitlements of migrants is very important for
professionals to understand the barriers and limitations that migrants face in accessing
services, education and employment opportunities. This knowledge helps professionals to
forecast in developing care plans with their clients, and to understand the reasons why certain
persons may face additional barriers to others.
In this survey, the majority of respondents felt they do not have enough knowledge (63.3%),
while others felt they did (30%). One respondent felt they were unsure, and another
respondent felt they need to know more about this subject.

Professionals' self evaluation: Do you feel you

have enough knowledge on the legal statuses,
rights and entitlements of migrants?
70.00%
No
60.00%

50.00%

40.00%
Yes
30.00%

20.00%
Need
10.00% Unsure more
0.00%

Respondents were also asked whether they felt they had enough information about services
available for migrants at risk, so that they would be able to inform their clients or refer them
to these services. Most respondents (73%) felt they did not have sufficient information.

28
 Professionals self-rating on whether they have sufficient information
about services supporting migrants at risk

Translation and interpretation services.

Translation and interpretation services are extremely important for professionals to address
language and cultural barriers and manage effective communication with clients. Less than a
third of respondents in this survey have readily available translation which they regard to be
effective and available and has a positive impact on their work. 40% of respondents do not
have any access to translation services, while almost a third of respondents have limited
access to translation, or regard translation as limited in relation to its effectiveness in their
work with clients.

AVAILIBITY AND IMPACT OF TRANSLATION

Available & effective No translation Limited

28%
32%

40%

29
The lack of availability of translators and interpreters is a major problem for professionals to
work with their clients, develop care plans, and support clients to commit to these plans.
Respondents regards the cultural work of interpreters as very important:

“I had situations where the interpreter was instrumental in intervention. Also, a cultural
interpreter could explain certain concepts in the client's context. eg what it means to have a
mental health issue in certain cultures or even certain symptoms might be interpreted
differently.”

Sometimes translators and interpreters were only partly available, for example, during ward
rounds, but not available during the respondents’ individual work with clients. This made it
hard for professionals to establish and work on goals together with the client, and to
communicate effectively:

“Interpreters are not available during sessions in my case since they are only present during
doctor visits. It impacts my work greatly since language barrier is a huge boundary in service
provision and it’s hard to establish therapeutic rapport in this case and formulate a rehab
programme.”

Additionally, it was stated that in the case of drop-in services it is difficult to plan the
recruitment of translators and interpreters ahead of time.
On the other hand, the respondents also mentioned the limitations of translation and
interpretation. A major problem in using translation services is that of confidentiality. At times
clients may not trust interpreters and translators provided, especially when they need to
disclose sensitive information, and some prefer to bring a close friend to translate for them
instead.

Client’s distrust.
Respondents were asked whether they have faced the distrust of a client, and how they
responded to this. While some respondents did not answer ‘yes’ or ‘no’, there were 12
affirmative and 4 negative answers. This shows that distrust is a major issue in the worker-
client relationship.

30
 Experience of client's distrust

Yes No

Some respondents explained the reasons why clients may feel distrustful of professionals and
services:

“Sometimes it's not easy as some inmates doesn't accept the female professional role.”

“Continuous rejection from services results in distrust. If client sees that you are trying to help
them, they will eventually trust you.”

“When we had clients who were very resistant to medication...”

“To think I could report him for following suggestions…”

31
Collaboration with other professionals and agencies.
Respondents were asked to write about the major challenges professionals face in
collaborating with other professionals in other agencies and organizations, and what they do
to overcome these challenges. The challenges listed have been grouped and mapped in the
following chart:

Communication & Poor leadership

information and diverse
barriers agendas

Limited resources
require prioritization Data Protection
of clients in crisis and client consent

Poor
Eligibility barriers collaboration Lack of efficiency
and selective between and continuity
services between services
professionals
and services

The diagram above shows various factors that limit the collaboration with other professionals.
One of these factors, mentioned by several respondents, are limited resources. Limited
resources, including staff shortage, cause long waiting lists and create several inefficiencies
especially in accessing timely support for ensuring continuity of care. Limited resources lead
to time restrictions which limit professionals in the monitoring of clients, especially in their
long-term care. As a result, professionals are restricted to dealing with crises interventions,
and limited in ensuring that their clients are progressing to achieve medium to long-term
goals of independence and wellbeing:

“Lack of staff, huge caseloads and lack of resources, to overcome these challenges I try to
prioritize cases and deal with crisis first.”

32
At times professionals might not distinguish between problems of limited resources, and
those related to ineligibility of services, since both lead to the same barriers. Clearly
professionals face frustration when they cannot access resources for their clients, and most
tend to regard restrictive policies as a barrier to the work they need to do in public
institutions:

“The major challenge is the limited resources available across welfare, example, no
placements for homeless persons, no allocations available from the Housing Authority, no
placements in Smart Kids for children to attend, not able to apply for free child care without
having job first, no Klabb 3-16 in some localities… one needs to be very creative and
collaborate closely to try and come up with the best way of how to better support clients. Also,
one needs to advocate and try to influence policies when possible.”

Another factor mentioned several times, was that of communication and information
barriers. Professionals have extremely busy schedules which restrict their time for meeting,
communicating and discussing continuity of care in the case of referred or followed clients.
At times communication is also impeded because it is difficult to obtain the client’s consent,
or the client refuses to do so. Time limitations often restrict professionals’ interaction with
information sharing sources, which can increase knowledge among professionals about links
and networks that they can access for client support. Network meetings might not be held
often enough to share updated information about other services and programmes available
for clients.
Professionals try to deal with these challenges by referring clients to NGOs and public services
where they can be helped in their specific needs. They also try to make an early referral so
that clients would have an appointment in time. Some mentioned their role in advocating for
policy change and for their clients’ access to services, as well as making effort to have more
frequent meetings with other professionals.

33
Good Practices

Continuity of care.
Respondents were asked to give examples of good practices for the continuity of care.
The examples of respondents included the effective collaboration between stakeholders,
such as CCF, Jobsplus, and LEAP services, as well as agreements between public services and
NGOs. Focused, or ‘specialized’ services were also mentioned as a good example, as well as
good communication and coordination between professionals within the same agency or
working with different stakeholders. Namely, continuity of care can be more effective when
there are key workers assigned to every client and where there is a multidisciplinary approach
to following a single, coordinated care plan. Finally, it is considered good practice to invest in
preparation of clients before they leave any institution or programme. A long-term plan needs
to be developed and needs to include a responsible person who will monitor the client. In
light of this, improving monitoring in the community will support clients towards
independence, preventing relapse, re-hospitalisation or re-incarceration.
However, a respondent comment:

“I don't think there is continuity of care as most migrants end up staying at MCH (Mount
Carmel Hospital) for long periods of time due to lack of resources and autonomy in other
service providers and organisations.”

Practices that promote long-term recovery.

Respondents were asked to write down practices that contribute positively to long-term
recovery in mental health for migrants. All factors mentioned were plotted on a graph, as
indicated below. The graph shows that continuous, focused support is a priority for ensuring
long-term care, as well as collaboration between services and kinship/ethnic communities.
Monitoring and follow up, multidisciplinary teams and adequate housing are somehow
important, although less important than the facilitation of direct client support:

34
Building trust with clients.
Respondents also gave examples of how they build trust with their clients:

“By explaining to them what my work entails.”

“I find that the only way to build trust is by offering unconditional positive regard over a long
period of time.”

“Working at the client's own pace and showing him that you are only there to help him.”

“Trust is built by empathising with the client and by listening to his/her experiences in order
to understand the client better. Also trying to put the client at ease.”

“A Person-centred approach continued by meaningful, solution-focused strategies.”

“By being respectful, patient, honest and open-minded.”

“By making sure that I am supporting the client in the best possible way.”

“By time they see you have their best interest if you are consistent.”

35
“Trying to increase contact, empathise with their situation.”

“By getting to listen and understand person's concerns and work on what the person would
like to accomplish in his recovery. Showing positive regard and respecting boundaries.”

“I explain everything to them and make sure they understand what is going on.”

“Building a therapeutic relationship.”

“I invest in the professional relationship and do my best to treat client as a partner. Also, I do
not take the expert position and I am genuinely interested in their culture.”

“Listen and give time.”

“Keep trying to instil trust.”

These responses indicate that the majority of respondents regard trust as something which
you can build, ‘instil’, and work towards using the right type of approach, attitude and
communication.

36
Recommendations

Resources to improve services.

Respondents were presented an open question asking them about which resources would
they invest to improve public services, if they were to focus on the prevention of
rehospitalisation/reincarceration of clients with mental health challenges. Some respondents
listed a single intervention, while others described a number of interventions. All
interventions were grouped and plotted in the graph below.

Which resources can best improve public services to prevent

rehospitalisation/reincarceration?

Cultural sensitivity

More social workers

Awareness of migrants on available services

Mental health outreach department

Improve legal system

Interpretors

Coaches and mentors for monitoring clients

Support long term inclusion

Housing/shelter with services

Community outreach and follow up

0 2 4 6 8 10 12

As shown, community outreach and follow up was the most mentioned intervention,
followed by housing/shelter with support services, including those that promote long-term
inclusion. Responses indicate that support services need to be improved in order to ensure
that clients continue their long-term plan in the community, and to prevent relapse by
engaging with clients immediately and effectively in the community when they are in need of
support.
One respondent explains that translation/interpretation is critical in the assessment of mental
conditions:

37
“More interpreters are required. I have been to many ward rounds where if I did not arrange
for an interpreter myself, the client would have been assessed without the ability to
understand the main issues.”

Improving continuity of care.

Respondents were then given a list to choose from, in relation to which efforts would best
help to improve care continuity for the target group selected in this survey. The list included
factors such as improved coordination among professionals, having a common online
database system (for effective monitoring of clients), better access to accommodation
centres for those discharged, and others, as listed below.

Which of these would most help improve care continuity?

Establishing a fixed lodging for migrants and community

service

More resources that offer specialized services for

migrants

Responsive/ongoing communication among professionals

More autonomy for professionals and support staff to

refer and communicate across agencies

Updated knowledge about diverse service providers

available

Easier access to closed/open centres for discharged

clients

Have a common online database system

Multidisciplinary care plan coordination among the

involved professionals

0 2 4 6 8 10 12

The majority of respondents regard the multidisciplinary, coordinated approach as a top

priority for the continuity of care, followed by the facilitation of information through a
common online database system. The third highest response relates to better access to
accommodation for discharged clients.

38
Enhancing professionals’ effectiveness and capacity.
Respondents were asked to comment about what can be done to enhance their capacity and
effectiveness in their work. Their contributions were grouped in four categories:

• Residential facilities

Clients who leave institutions and do not have an address are particularly at risk. They
often cannot access certain treatments or services and their continuity of care is
interrupted, jeopardising their progress and reducing the effectiveness of prior work and
time that professionals have invested in them. The provision of temporary, subsidised
housing for a period of time until clients can rent their own place is critical for promoting
effective independence. However, it is also important to consider that some clients
leaving hospitals need long-term care which might not be accessible to them. Therefore,
special homes and hostels for this type of care need to be considered. One idea is to have
a facility which specialises on the care of persons with substance abuse as well as mental
health difficulties.

• Community outreach and support

Community outreach and support is mentioned several times in other sections of this
research and has also been mentioned by respondents in this section. Outreach to
migrants needs to be improved and increased, made more available and accessible
through effective marketing strategies. It also needs to include focused strategies based
on the specific needs of target groups. This will indirectly improve the follow up and social
inclusion of individuals leaving hospitals and other institutions of care.
More specifically, community outreach needs to improve the awareness of migrant
communities on the importance of mental wellbeing and mental health care. Outreach
needs to be more proactive, targeting specific communities with information on mental
health services. One suggestion is to have a small psychiatric team providing services in
the community, thus supporting the community services team.
Effective community programmes rely on referral systems which facilitate the continuity
of care of individuals between institutions and services. At times referral procedures may

39
 be restricted to medical or other specific professionals, who may not be aware of the
importance of these services to migrant clients:

“I work in community mental health and we rarely get referrals of migrants to our services
and this is concerning as our services are very accessible but for some reason there are
very few referrals. For this reason, I could not answer various questions in the survey.”

• Social inclusion – policies and services

The Integration Policy needs to improve in implementation, with responsible authorities

ensuring that this policy is “working”, promoting the rights of migrants for basic needs
and services. One of the challenges that need to be addressed is the lack of human
resources in community services, especially those specifically targeting migrant
communities.
Access to legal services, as well as access to interpretation and translation services need
to be improved, especially within institutions, support services and in community work.
Some services need to be more focused on the specific needs of migrants. For example,
in hospitals there can be small service teams that focus on migrants, establishing and
making contact, and supporting workers and clients to reach their care plan goals.
The situation of migrants at risk who are not eligible for social support services cannot be
ignored. The lack of support measures for such clients renders clients more dependent on
institutions of care, less likely to become independent in the community, and more
difficult for professionals to maintain motivation and confidence in the effectiveness of
their working relationship with the clients. Better access to employment, housing,
childcare services and medication needs to be considered. These benefits can be made
conditional, depending on clients’ efforts towards social inclusion. In this way mental
health services can be much more effective in reaching both short, medium, and long-
term goals.
Often clients’ experience of services is a fragmented one:

“A one stop shop for the advocacy for migrants with these difficulties is required. Many of
our clients are experiencing gaps in services and remain unassisted. Specific attention
needs to be given to housing/addresses, control cards for medications, assistance to apply

40
 for identification, awareness of services and outreach, support within the community,
support to find employment (maybe a specific branch within Jobsplus), support with
training/courses to improve or compile a CV, awareness of social rights and benefits (social
security).”

Special efforts need to be made to support migrants in accessing legal employment as

well as their employment rights under the Laws of Malta. If migrants are excluded from
accessing legal employment, while industries are hiring them outside legal procedures
due to labour shortage, then authorities are responsible to find effective solutions for
both workers and employers. One suggestion is that migrants are assisted in accessing
training and employment through a migrant cooperative. This will prevent exploitation of
migrants, promote regular employment, and include migrants in a protective social
security system.
There needs to be a plan for the inclusion of failed asylum seekers who are residing and
working in Malta. One respondent states:

“Granting of citizenship for those who have resided locally for over 5 years, learnt one of
the 2 official languages, become well integrated in the community, with the chance of
family reunification, and have been gainfully employed for over 3 years.”

Other suggestions included the improvement of access to medical-legal reporting, and the
addressing of stigmatising and prejudiced media reports, which often fuel further
discrimination and racism towards migrants.

• Empowering professionals

As in other questions, respondents referred to their own empowerment, both in terms of

professional capacity, as well as the improvement of structures and systems which
facilitate professionals in their work.
More training is required for professionals to understand the socio-cultural context of
migrants, including knowledge of different cultures and ethnic groups. This training needs
to increase the awareness and competence of professionals to work with migrants.
Professionals need to be more aware on how to respect and facilitate the individuality

41
and autonomy of migrants to control the process of their own progress. In addition,
professionals need to be informed on available entities, services and programmes which
their clients can access, and that they need to be updated when this information changes.
Collaboration and cooperation between professionals and agencies needs to be facilitated
and improved. There needs to be more open communication between professionals,
which can be aided through online systems that aim to facilitate coordination between
service providers in housing, employment, education and other services. The
multidisciplinary approach needs to be promoted in all services by agencies and service
providers by facilitating better communication and working relationships between
different professionals. This type of relationship however needs to be developed between
agencies, departments and non-profit organizations working in social support service
provision. It is pointed out that within services all professionals, including helping and
medical professionals, need to work together. Often helping professions are restricted in
their work when other professions do not consult them, or do not respect their opinion.
One respondent remarks:

“Adopting a mental health care and wellbeing policies instead of psychiatric care only”.

42
 THE FIELD EXPERIENCE OF FSM PSYCHOSOCIAL TEAM

Challenges Faced by Migrant Service Users

Based on our work experience in the field, migrants released or in the process of being
released from MCH or CCF often have challenges in meeting their basic needs due to several
systemic barriers. This includes poverty, insufficient positive support from peers or
community, limited access to stable housing and gainful employment, as well as several
challenges when applying for documents, social assistance and free medication (if eligible).
Substance use and the lack of sufficient rehabilitative resources seem to significantly hinder
migrants’ successful recovery and reintegration, while eventually exacerbating their
psychosocial vulnerability.
It is important to keep in mind that basic needs fulfilment and systemic or environmental
barriers are intrinsically interrelated, thus inevitably shaping the person’s recovery and
reintegration trajectory. The present section will highlight and explore some of the most
important challenges faced by our service users during the duration of the project.

Basic needs.
Basic needs are crucial for successful reintegration and long-term recovery. If people cannot
meet these needs, this will dramatically increase distress, vulnerability, helplessness,
hopelessness, as well as the risk of mental health deterioration or relapse. During our
programme, service users struggled to meet fundamental basic needs such as dignified
housing, financial welfare, updated documentation, stable legal status and adequate social
support.

● Housing

Press reports suggest that homeless shelters are seeing an increasing proportion of
homeless migrants (Schembri Orland, 2017, July 16), which is a cause for concern. Krausz
et al. (2013) found that homelessness presents a number of additional barriers to
accessing mental health care (Krausz et al., 2013). The majority of FSM service users, who
were released or in the process of being released from MCH or CCF, were/are homeless

43
and thus struggling to find stable, dignified and affordable accommodation. The dramatic
space saturation at governmental open centres for migrants, homeless shelters such as
Dar Leopoldo and YMCA, or Richmond Foundation supported housing for individuals with
mental ill-health, is no secret to professionals working in the social field. The majority of
migrant service users in our project have mostly been accommodated in temporary
emergency shelters like Dar Papa Frangisku, with a high risk of return to homelessness
after the maximum accommodation period of 6-8 weeks. Alternatively, they have
remained at MCH out of humanitarian goodwill of care providers, despite the high risk of
institutionalisation. Only a minority of service users could stay with peers or be placed at
AWAS open centres, provided that they had not previously resided there for over a year.
Although for many, emergency and temporary shelters are often the only available option
at discharge point, these cannot adequately cater for individuals with significant
psychosocial needs and vulnerabilities. The precarious living situation may even
significantly increase the risk of mental health deterioration and relapse, while presenting
individuals with additional barriers to accessing services and rights. For instance,
individuals residing at the temporary emergency shelter, Dar Papa Frangisku, or remaining
at MCH to prevent homelessness, cannot make use of the property address. This impairs
access to relevant rehabilitation services such as those provided by Sedqa, or to basic
rights and services such as the e-residence facility or having a work permit. These
restrictions then limit the service users’ ability to recover, reintegrate and thrive
successfully.
A question that emerged during our workshops with the migrant communities is whether
migrant community organisations have the capacity to offer housing support to
vulnerable peers. The discussions indicated there is often a lack of capacity of
organisations and individuals to offer accommodation, as well as stigma and fear towards
mental ill-health, especially if associated with substance use. Participants expressed
concern for personal and family safety in such situations.

44
● Entitlements and benefits

Before being hospitalised due to mental ill-health, MMHSP service users were usually
working, often in stable jobs, and living in the community or in governmental open
centres.
In the case of long hospitalisations, individuals often lose their jobs, housing and
belongings. Protection beneficiaries have also reported the loss of documents such as
protection cards, e-residence cards or work permits. While there might be a
misperception among professionals that these documents are not needed while a person
is hospitalised, migrants do have a right to these documents, and they are also
indispensable for applying for different benefits and services, such as unemployment
benefits and employment support services. If service users are given timely support with
obtaining and caring for necessary documentation while still inpatients – also by utilising
the hospital address to apply for such documents - they could finally obtain some sort of
financial assistance (for those eligible) or apply for relevant support services prior to
discharge, thus facilitating their independent living. Even service users who are allowed
to start working ‘on leave’, that is, while still an inpatient, could do so only if the necessary
documentation and applications are put in place with the help of care professionals,
taking into consideration the often long administrative processes. This support is
particularly needed in situations where individuals are required to apply for the renewal
of their protection, such as in the case of renewing THP.
Facilitating the right conditions for individuals to have a form of income during and after
their stay at MCH is also paramount in view of their recovery and reintegration in the
community. In this regards, two categories of migrants are highly vulnereable - failed
asylum seekers, and beneficiaries of humanitarian protection from other EU member
states who often arrive in Malta because they cannot find a job in their host country. In
the latter group, persons have no legal right to work, and no access to any benefits or
support services. After discharge, they may choose to go back back to their host country
or find a way to thrive in Malta, often taking precarious jobs and facing high risks of
homelessness.
Failed asylum seekers whose application is processed in Malta, on the other hand, can
apply for a work permit only if they find an employer who is willing to employ them on a

45
 legal basis, under certain conditions. Despite the demand for work in Malta, many
employers are still reluctant to issue a work permit. Additionally, migrants with rejected
status are also excluded from main employment support services, although they are
entitled to access the Jobs Brokerage Office, which can provide temporary jobs on an
occasional basis. This is an unsustainable solution for individuals who are struggling to
survive and create stability. Migrants in these two categories may end up unemployed for
a long period of time, or may find that their only option is to work in exploitative jobs
which may be dangerous to their health, inhibiting their recovery. The lack of support in
identifying, initiating and keeping a decent job also contributes to the increased risks
mentioned earlier. Often service providers can offer valuable support in communicating
with employers, assessing their values and expectations, and matching persons to
appropriate jobs where the employment relationship can be sustainable. This support
can avoid situations of exploitation, where migrants are underpaid, and continue to
struggle to meet their basic needs. FSM met with service users who often could not afford
to pay for food, rent, costly documents, and public transport. Poor work conditions are
associated with poor quality of life, which can easily trigger mental health distress and
relapse, while also creating additional barriers to care access.

● Documentation

As mentioned throughout the research personal documentation is a basic need and right
that needs timely attention for individuals to access their entitlements as soon as possible.
Below is a summary of the main barriers and challenges encountered by our service users:

a. Service users with protection in Malta who are homeless, residing in a temporary
emergency shelter or still at MCH cannot apply for their e-residence permit and work
permit until they have a fixed address.

b. Service users who are still inpatients at MCH may also remain without their protection
card or immigration certificate (if they have rejected status) for months or years if
accompaniment and guidance is not provided by professionals.

c. Undocumented migrants lack entitlements for non-emergency care and free

treatment after hospitalisation. At the same time, unless they are hospitalised during

46
 an acute phase, they tend to avoid seeking the necessary care out of fear of being
reported to the police and deported.

d. Individuals with rejected status and mental ill-health might be eligible to apply for THP
on mental health grounds, the granting of which depends on the final decision of the
Refugee Commissioner. It is only when the medical condition persists that this form
of protection is renewed, and it does not grant any access to social benefits. However,
it can help greatly to enhance quality of life, independent living and recovery while
giving access to some support services, such as employment support for vulnerable
individuals. Nevertheless, work in this field has shown that both service users and
professionals are often not aware of this option, and more information is needed on
how to support clients in applying for this protection.

● Legal status

Vulnerable migrants with less secure legal status, such as failed asylum seekers or
migrants with no legal status in Malta, are at higher risk of relapse and psychosocial
deterioration.
Particularly, migrants without legal status in Malta, such as beneficiaries of humanitarian
protection from a different host country, are denied free non-emergency treatment post
hospitalisation, which is very necessary for rehabilitation. They often cannot access any
support services designed for vulnerable individuals and targeting successful recovery and
reintegration. As mentioned earlier, the lack of status and documentation make such
persons more likely to refrain from seeking the needed medical care, except in acute
cases, out of fear of being reported and deported.
Other migrants who a more stable legal status might also face the risk of relapse or
deterioration if they, or their care professionals are unaware of their rights and
entitlements. During the project, this has been namely one of the major barriers to
successful recovery and reintegration encountered by service users.

● Social support

The majority of our service users seemed to have a very restricted network of peer
support, if any. Very often the links are lost during long-term hospitalisation, or due to the

47
 stigma and fear towards mental ill-health and substance use. Sometimes, peer support
can have a negative influence on the person’s general wellbeing and recovery. In the
MMHSP project, community support was, unfortunately, rather inexistent. Nevertheless,
attempts have been made by particularly sensitive representatives from the Somali and
Libyan community to get in touch with persons from their community at MCH and CCF,
and occasionally support some of the service users, either emotionally or with a donation
for basic needs.
Some of the reasons for the lack of peer and community support that were mentioned
during FSM’s mental health awareness workshops, as well as by some service users, were:

a. Stigma and fear;

b. Not knowing how to help, and what support services, as well as entitlements, are
available to people with mental health or substance abuse challenges;

c. Communities and peers might themselves experience struggles, such as poor living
and working conditions, and therefore be limited in offering adequate support,
especially to individuals with mental ill-health.

These realities emphasize the fact that the recovery and reintegration of vulnerable
migrants with fewer social links in Malta (friend and family networks) is undoubtedly
much more difficult due to the lack of positive social support.

Systemic challenges and barriers.

The FSM field experience has proved that the underlying presence of systemic gaps has often
caused the intervention and recovery process to slow down, stall, or even regress at the
expense of service users’ general wellbeing. The following account refers to those systemic
barriers and challenges encountered:

● Discriminatory practices and policies

Systemic discrimination is a major factor in preventing migrants from accessing relevant

support services. When legal status and types of protection are denied, those with

48
 psychosocial challenges are subject to various measures that restrict their support to
assistance and services. Discriminatory policies combined with hostile attitudes of
authorities or professionals (including care professionals) often discourage vulnerable
individuals from seeking service providers’ help. Therefore, distrust towards healthcare
providers often becomes an heir additional barrier to accessing the necessary care.

● Lengthy and exhausting procedures to access basic rights

When it comes to obtaining or renewing documents, and other services, many times
migrants have to endure exhausting bureaucratic, administrative and confusing
procedures as well as long processing times. Waiting for an e-residence permit, the yellow
book or social assistance are just few, but real, examples. Individuals perceive situations
like these as a major stressor, even more so if they are psychologically vulnerable and with
no supportive guidance or accompaniment from professionals. This not only hinders
prompt access to entitlements but is also more likely lead to distrust in the system and to
the neglect of one’s own rights, with severe repercussions on the person’s quality of life
and mental health.

● Personnel shortage within governmental institutions

The lack of staff in governmental institutions means that professionals can handle only
selected or severe cases. The vast majority of vulnerable individuals remain unnoticed,
are left out or feel they are not adequately supported by the assigned care professionals.
As witnessed in the past months, this systemic neglect can lead not only to the
deterioration of individuals, but also to rehospitalisation or reincarceration. In the worst
case scenarios, systemic neglect can lead to premature death or abuse of vulnerable
persons – an outcome that could, and should, be prevented with appropriate and timely
support.

49
● Scarcity of resources and services in the community

There is a lack of shelters for homeless and mentally vulnerable individuals, including
migrants. Rehabilitation, social work and other support services in the community are also
scarcely available. This means that there are long waiting lists, and selective criteria, for
accessing shelters and relevant recovery/reintegration services.

● Lack of continuity of care

Many clients are ‘being factually dropped’ from one system to another, once their term
within an institution has come to an end. The absence of consistent coordination and
communication among the different service providers following the same client amounts
to vulnerable individuals getting lost within systems.
Undoubtedly, the pervasive fragmentation between services and the lack of any agency
taking the overall coordination of cases presents a barrier to the continuity of care.

● Lack of cultural sensitivity

Within services in general there is a lack of cultural sensitivity and a lack of skills that are
necessary for in helping diverse clients. There is also a lack of knowledge and awareness
of advocacy-oriented approaches. The lack of trained cultural mediators within
mainstream services is one of the main causes of clients being misunderstood and
misdiagnosed and missing effective treatment.

● A culture of blame

Despite the increasing awareness of systemic gaps in the area of mental health, there is a
tendency to blame the victim and withdraw support when it is most needed. For instance,
the system often labels as ‘difficult’, ‘not motivated’, ‘not in need’, ‘non-compliant’
individuals who grow silent, isolated, or refrain from accepting support, often before any
relationship with the service provider is even established. Support is then withdrawn by
care providers without investigating the real causes behind the person’s resistant

50
 behaviour. When explored, resistant behaviour was often caused by mistrust of the
system, fear due to prior experiences of abuse, heightened levels of vulnerability,
experience of neglect by service providers, and culturally different help seeking
behaviours, among others. Needless to say, the effects of support withdrawal on the
individual or family is devastating. Such persons often are, and feel, abandoned by the
system.

Substance misuse treated separately.

Substance misuse can be a trigger as well as a consequence of mental illness, and in both
cases appears to be a key factor in maintaining or even aggravating the clients’ psychosocial
issues. Comorbidity of substance misuse and mental ill-health is generally associated with
increased risk of recidivism, readmission and/or reincarceration, which was also witnessed
during the project. Despite this strong correlation, substance use is often considered, even by
care providers, as an independent matter which should be treated separately. It is also
regarded as a personal responsibility, relying exclusively on one’s willpower to stop the
misuse by attending a rehabilitation programme.
Such perspectives are stigmatising on service users, and often lead to premature discharge
from hospital, especially if there are experiences of discrimination and prejudice by
professionals who blame the person for their vulnerability.
Stigma and fear towards persons who misuse substances often lead to social exclusion and
isolation from community, peers and family members, while presenting additional challenges
in accessing relevant social support.
Additionally, if substance abuse rehabilitation are not culturally sensitive to migrants, this
leads to low take up of such programmes by migrants and reduced responsiveness to
treatment.

51
Challenges Faced by Helping Professionals

Cultural and language barriers.

The availability of trained cultural mediators, and the use of cultural sensitivity, are two
critical factors for understanding the service users and their needs, and for providing effective
services. Although professionals are often aware about the importance of these factors, they
express their difficulties in working effectively with migrants, due to language and cultural
barriers, and the lack of respective resources. Such barriers can lead the misinterpretation of
symptoms or behaviours, and misdiagnosis of conditions.
Care providers also raise concerns about tendencies of migrants towards repeated lack of
attendance or punctuality to individual appointments, and non-compliance to treatment.
They raise questions as to whether these behaviours are caused by different cultural views
about time and treatment, or by language barriers, or both. They express their struggles in
their attempt to understand and overcome these barriers, which are perceived as major
barriers to migrant clients’ recovery.

Discouragement and frustration.

Professionals often feel overwhelmed, frustrated and dismayed by the shortage of staff and
limiting working conditions that do not allow for a comprehensive non-discriminatory
approach to service provision. Many care providers additionally express their lack of
knowledge and certainty about migrants’ service entitlements, and about community
organisations and NGOs that can provide relevant support after hospitalisation.

Limited availability and accessibility to community services and resources.

Professionals struggle in effectively supporting migrants with complex psychosocial needs,
such as homelessness and substance, due to the scarcity and inadequacy of community
resources. They often feel helpless with migrants with rejected or no legal status, as their
access to community services is extremely restricted.

52
Good Practices and Recommendations

Collaboration and coordination.

Close collaboration among service providers involved in each person’s recovery plan has
proven to be beneficial for both service users and professionals. Service users benefit from
the sense of continuity and holism of tailored care provision, as well as the genuine support
from different agencies, which eventually increase their trust in service providers and their
hope in their own rehabilitation.
Professionals can also benefit from this collaboration, acquiring new knowledge, insight, and
other resources, avoiding duplication, and benefiting from achievement of common goals.
The coordination of care plans among service providers allows for more thorough monitoring
of progress in recovery and reintegration, and easier
“Collaboration among
detection of new challenges. Based on this approach, professionals and
stakeholders must continue
care plans are revised and adjusted regularly according to be encouraged and
to the service user’s priorities. FSM’s field experience intensified to increase these
benefits to both service users
shows that such collaboration is a major key to the and professionals”

successful provision of care.

It is therefore recommended that collaboration among
professionals and stakeholders continues to be encouraged and intensified to increase these
benefits to both service users and professionals

Accompaniment.
Vulnerable persons often appreciate and benefit from accompaniment to services and
authorities, as they grow in their confidence and self-efficacy to navigate the system on their
own. This is especially important for persons leaving institutions, who may lack trust in the
system and feel overwhelmed by the multitude of people and tasks involved in the care plan.
It is also important for persons with poor coping skills or low motivation. Our experience has
shown that the presence of a trusted professionals at medical, legal or administrative
appointments can significantly improve the individual’s motivation, hope, trust,
understanding and utilisation of services. Such assistance can be used to support clients to
understand their own circumstances and requirements, and to learn about services and how
they work.

53
Accompaniment is extremely important in relieving
feelings of distress related to the fear of
“Pprofessionals
misunderstanding, exhausting or confusing procedures, accompaniment to be
included in the care plan of
hostile attitudes and systemic barriers. It is crucial when
psychosocially vulnerable
advocacy is needed so that the client’s voice is migrants, whenever this is
needed.”
represented and defended, and accessibility to
entitlements or services promoted. Unfortunately, due to
personnel shortage, scarcity of time, or an underestimation of the value of accompaniment,
vulnerable clients are often left on their own to navigate the system, facing delays and
misunderstandings, and sometimes discrimination, prejudice and blame.
It is therefore highly recommended that professionals’ accompaniment is included in the care
plan of psychosocially vulnerable migrants, whenever this is needed.

Advocacy.
On the micro-level, advocacy is key to defending migrants’ rights and helping them access
entitlements and services. On the macro-level, systemic advocacy is an even more powerful
tool for the development of just practices and policies
“Advocacy should be promoted,
encouraged and used by care in care provision and other services. This
providers, professionals, and improvement is of great value, not only to migrants,
policy makers, for ensuring quality
and justice in service provision.” but the whole society.
Advocacy should therefore be promoted, encouraged
and used by care providers, professionals, and policy makers, for ensuring quality and justice
in service provision.

A monitoring and reporting system.

Throughout the project, the FSM team has
“An effective reporting and witnessed and received several reports of repeated
monitoring system is imperative
for ensuring that service users’ episodes of neglect, discrimination, psychological
rights are protected through
detection and prevention of abuse, abuse and injustice from service providers at
and for professionals to work in a
governmental institutions towards migrant clients.
safe and just environment.”
Unfortunately, there appears to be no efficient and
safe reporting system that would take appropriate action against these circumstances

54
without the risk of endangering the service user. Such reports, however, do taint the efforts
of serious professionals, carers and policy makers who work to ensure care services based on
quality and justice. They also create an environment of frustration to both professionals and
clients, as they may feel as though they are working against the system and lose their
confidence and motivation as a result.
An effective reporting and monitoring system is imperative for ensuring that service users’
rights are protected through detection and prevention of abuse, and for professionals to work
in a safe and just environment.

Cultural mediators.
In order to provide service users with the appropriate support and enable professionals to
intervene in the best interest of their clients, it is paramount that interactions are free of
language barriers. This means that trained cultural mediators/interpreters need to be
engaged as much as possible, ideally during every interaction between professionals and
service users. If such services are unavailable
and inaccessible, professionals and service “Trained cultural mediators/interpreters
providers may decide to depend on untrained are critical to quality services and need
to be made available and accessible to
persons, who may not convey the right professionals and clients when needed.”

information or understand the goal of their

involvement. This may lead to several negative consequences and may also jeopardise trust
between the client and the professional. It may also lead to a breach of confidentiality if the
person helping in translation does not understand or appreciate the importance of
confidentiality.
Therefore, trained cultural mediators/interpreters are critical to quality services and need to
be made available and accessible to professionals and clients when needed.

55
Cultural sensitivity.
Cultural sensitivity is paramount when working with service users coming from different
cultural backgrounds. Lack of cultural sensitivity can lead to prejudice, misunderstanding,
ineffective treatment, poor provision of care, and
“Care providers should provide
cultural sensitivity training to increased risk of danger to health. This can be
everyone involved in the care of prevented through regular provision of training,
clients, through continuous
professional development.” monitoring and mentoring to professionals.
Therefore, care providers should provide cultural
sensitivity training to everyone involved in the care of clients, through continuous
professional development.

Outreach programmes.
Outreach programmes are necessary for raising awareness on mental health, identifying
mental health issues, and connecting people the services they need, and identifying those
who have dropped out from services they still need.
Outreach programmes are also important for “Outreach programmes are
important for raising
sensitising care/service providers about migrants’ awareness among migrants and
care providers about the
psychosocial challenges, as well as to encourage importance of mental health
collaboration and advocacy. and the relevance of quality
services, and for identifying
Outreach programmes are important for raising persons in need and connecting
them to relevant services.”
awareness among migrants and care providers about
the importance of mental health and the relevance of quality services, and for identifying
persons in need and connecting them to relevant services.

Resources.
The past year has seen a positive increase of projects targeting the integration and support
of vulnerable migrants in the community. Nevertheless, the worrying scarcity of resources
such as shelters for the homeless, specialised and culturally sensitive supported housing and
rehabilitation programs for persons with mental ill-health, as well as care personnel in
governmental institutions is taking a significant toll on both migrants, who are hindered in
their recovery and reintegration, and professionals, who are not enabled to support their

56
clients effectively. The lack of relevant community resources is a major predictor of
deterioration and mental health relapse.
“Increasing the availability of
Increasing the availability of resources is paramount to resources is paramount to the
successful recovery and
the successful recovery and reintegration of migrants
reintegration of migrants with
with mental ill-health, and to the prevention of relapse. mental ill-health, and to the
prevention of relapse.”

Inclusive policies and services.

While there have been ongoing discussions and improvements on improving the inclusivity
and accessibility of services and policies for migrants at several levels, the most vulnerable
groups are still predominantly excluded. Failed asylum seekers and beneficiaries of protection
coming from other EU member states have very restricted access to support services. This
automatically inhibits their chances of successful recovery and reintegration in the
community, and this inhibition often leads to deterioration and relapse. The impact of this
deterioration and relapse cannot be ignored, especially when it contributes to the increase of
homelessness, substance abuse and readmission. The impact on professionals is also
important, especially taking into
“Policy makers can improve and develop policies
consideration that they may see the
and services that meet the needs of various
groups, supporting the employment of persons same clients being readmitted. The
who provide important services in the Maltese
economy, and giving with particular attention to impact on the system is also one to
those who show higher levels of psychosocial
vulnerability.” appreciate, since readmissions
increase institutions’ costs for
maintaining persons and providing them with various services. This situation can be
prevented by offering some services to this population, who often find jobs in Malta but
cannot apply for a work permit. Policies can make it possible for such persons to work
regularly in Malta, even if this is based on job opportunities which are not being taken by EU
nationals or persons resident in Malta.
Policy makers can improve and develop policies and services that meet the needs of various
groups, supporting the employment of persons who provide important services in the
Maltese economy, and giving with particular attention to those who show higher levels of
psychosocial vulnerability.

57
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