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ISP0010.1177/0020764014537236International Journal of Social PsychiatryMajumder et al.

E CAMDEN SCHIZOPH

Article

International Journal of

‘This doctor, I not trust him, I’m not Social Psychiatry

2015, Vol. 61(2) 129­–136
© The Author(s) 2014
safe’: The perceptions of mental health Reprints and permissions:
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and services by unaccompanied refugee DOI: 10.1177/0020764014537236

isp.sagepub.com

adolescents

Pallab Majumder, Michelle O’Reilly, Khalid Karim and Panos

Vostanis

Abstract
Background: Unaccompanied refugee adolescents are a small but clinically significant group. This group is vulnerable
with physical and psychiatric needs which are often not met. There are several barriers to providing care for this group,
originating with the refugees but also due to service provision.
Aims: The aim of this research is to appreciate the views and perceptions that unaccompanied minors hold about
mental health and services.
Method: Fifteen unaccompanied adolescents engaged with mental health services were interviewed, and thematic
analysis was employed to explore relevant issues.
Discussion: Their views reflected a range of opinions on mental health and the treatments they received, but many held
negative attitudes toward mental health and had a lack of trust in services. This could be explained by their descriptions
of their experiences within their home country of psychiatric care, their experiences of being a refugee/asylum-seeker
or cultural differences.
Conclusion: We argue it is important to engage this group in the development of policy and practice in child mental
health, and in developing services.

Keywords
Refugee adolescents, mental health, stigma, qualitative, perceptions

Introduction
Globally, there are approximately 12 million refugees and
asylum-seekers, and in 2012, there were 193,510 refugees
and 17,170 asylum-seekers in the United Kingdom
(United Nations High Commissioner for Refugees
(UNHCR, 2012)). It is recognised that approximately half
of the world’s refugees are adolescents, with unaccompa-
nied refugee/asylum-seeking adolescents being defined as
those under the age of 18 years, separated from parents
and attached to no significant adult (Thomas & Byford,
2003). In 2011, 6% of UK applications were from unac-
companied asylum-seeking adolescents (Refugee Council,
2012), with 11% being under the age of 14 years, 29%
aged 14–15 years and 60% aged 16–17 years (Home
Office, 2004). Hence, the majority of this group falls
within the adolescent range.
Our understanding of refugees and their service needs
remains fragmented due to a lack of evidence (Cox,
2011), but research suggests that this group is at high risk
of developing mental health problems due to their previ-
ous experiences (Fazel, Wheeler, & Danesh, 2005). They
are likely to need mental health services (Huemer &
Vostanis, 2010), but struggle to get their needs met (Ellis,
Miller, Baldwin, & Abdi, 2011). While the reasons are
unclear, several factors implicated include the communi-
ties’ stigma of mental health (Lustig et al., 2004), their
own attitudes and mistrust of authority (Ellis et al., 2011).
Additionally, appropriate services may be unavailable or
insufficient for their needs (Vostanis, 2010).
School of Medicine, Biological Sciences and Psychology, The Greenwood
Institute, University of Leicester, Leicester, UK
Corresponding author:
Michelle O’Reilly, The Greenwood Institute, University of Leicester,
Westcotes Drive, Leicester, LE3 0QU, UK.
Email: mjo14@le.ac.uk
130 International Journal of Social Psychiatry 61(2)

Table 1. Table of participants.

Number Gender Age in Nature of the mental health problem Country of Immigration
years origin status
1 M 18 Depression, Self-harm Afghanistan Refugee
2 M 15 PTSD, Anxiety Iran Asylum seeking
3 M 17 PTSD, Depression, Anxiety Afghanistan Asylum seeking
4 M 17 Self-harm, Adjustment reaction Afghanistan Refugee
5 (Declined) F 18 PTSD, Substance misuse Somalia Refugee
6 F 17 PTSD, Depression, Self-harm Eritrea Asylum seeking
7 M 15 Learning difficulties, Dissociative disorder, PTSD Afghanistan Asylum seeking
8 M 17 Psychosis Somalia Refugee
9 M 16 Self-harm, PTSD, Anxiety Afghanistan Asylum seeking
10 M 17 PTSD, Depression Afghanistan Refugee
11 M 16 Self-harm, Adjustment reaction Iran Refugee
12 M 17 Self-harm Afghanistan Asylum seeking
13 M 18 Depression, Adjustment reaction Afghanistan Asylum seeking
14 M 15 Depression, Self-harm, Substance misuse Afghanistan Asylum seeking
15 M 18 PTSD, Self-harm Afghanistan Refugee
16 M 18 PTSD, Impaired sleep Afghanistan Refugee

PTSD: posttraumatic stress disorder.

Unaccompanied asylum-seeking/refugee adolescents 2001). Therefore, refugee/asylum-seeking adolescents can

are an especially vulnerable group due to their social/per-
sonal circumstances and the lack of responsible adults
safeguarding their interests (Thomas & Byford, 2003).
Unaccompanied refugee adolescents, in particular, have
greater psychiatric morbidity than the general population
(Huemer et al., 2009), and up to 47% suffer severe symp-
toms of anxiety, depression and posttraumatic stress
(Derluyn & Broekaert, 2007). This is important as the
cumulative exposure to traumatic events is associated with
a range of negative psychological outcomes (Fazel, Reed,
Panter-Brick, & Stein, 2012; Thabet, Karim, & Vostanis,
2006), but despite this, the mental health trajectories of
this group remain diverse (Ellis et al., 2011).
The stress faced by these young people includes invol-
untary displacement from their home (Ellis, Kia-Keating,
Yusef, Lincoln, & Nur, 2007) and can also be a conse-
quence of discrimination and resettlement (Montgomery
& Foldspang, 2008). A ‘triple stigma’ can arise from (1)
associations with their refugee/asylum-seeking status, (2)
mental health problems and (3) resultant from their unac-
companied situation.
Understanding the perspective of unaccompanied refu-
gee/asylum-seeking adolescents with regard to services is
essential so that they can be tailored to meet their specific
needs (Rutter, 2003). In contemporary practice, these
young people may receive the appropriate treatments, but
there are concerns that there is sometimes a failure to con-
sider the distress experienced and the adversities encoun-
tered (Ehnholt & Yule, 2006). Even within available
services, treatments such as psychological therapies need
to be adapted, as application of an unaltered Western
model of treatment can be meaningless for them (Lynch,
affect service design and delivery, and this article seeks to
explore their perspectives.
Methods
Participants
The adolescents and their carers were referred to a special-
ist child and adolescent mental health service (CAMHS)
for ‘looked-after’ children following problems encoun-
tered at ‘home’ or school. They were recruited through
Local Authorities from Central England (Table 1). A total
of 15 adolescents aged 15–18 years and their carers con-
sented (carers’ data represented elsewhere). Participants
were mostly male, typically from Afghanistan, but also
from Iran, Somalia and Eritrea. All had English as a sec-
ond language, and while an interpreter was available for
all, most chose to speak for themselves.
Data collection
Face-to-face semi-structured interviews were audio-
recorded to allow an exploration of issues from the partici-
pant’s perspective. Interviewing continued until data
saturation was achieved (O’Reilly & Parker, 2013a).
Data analysis
Data were analysed using thematic analysis, allowing
meaning to be drawn from data through the emergence of
patterns (Boyatzis, 1998). Data were transcribed verbatim
and independently coded to improve reliability. Categories
Majumder et al.
were examined systematically to identify core issues to
address the aims of the research. Due to the language dif-
ficulties, some questions required rephrasing, and some
answers initially lacked coherence or were fragmented.
Therefore, the representation of these answers as direct
quotations is fragmented in places.
Ethics
Ethical approval was obtained through the National
Research Ethics Service (NRES, UK).
Analysis
In relation to mental health, four themes emerged: descrip-
tions of mental health, mental health and asylum-seeking/
refugee status, experiences of using services and opinions
of treatments.
Theme 1: Descriptions of mental health
Adolescents’ definitions of mental health were variable.
Some were able to describe mental health along classical
Western lines; however, others defined it differently, deny-
ing any problems, using a physical explanation of their
symptoms or using fairly negative/pejorative language:
1. 
Mental health, means when some people’s not happy.
(Respondent 6)
2. I think I was before going mental very in mind, my brain
wasn’t working seriously. (Respondent 13)
Although there were language difficulties, some respond-
ents were able to relate their mental health directly to their
emotions, ‘not happy’. These descriptions were fairly clear
and would enable services to understand them. While
some were able to clearly articulate their problems, others
described their problems in more abstract ways. This may
have been simply due to linguistic issues or may reflect
particular cultural views. Attributing the condition to the
‘mind’ or ‘brain’ allowed them make sense of their experi-
ences and demonstrates a significant degree of insight.
Many of the adolescents denied having mental health
problems, even on direct questioning, despite engagement
with services. These participants tended to describe physi-
cal symptoms as the cause:
3. He says I’m not (.) I am ill because I’ve got a headache and
my eyes hurt. (Respondent 7: interpreter)
4. I don’t have any (.)uh (.) I mean I’m not um (.) mental
problem (.) I go (.) I saw the bad dream I didn’t sleep then
sometimes. (Respondent 6)
These respondents are using alternative descriptions for
their mental state. For example, Respondent 7 attributed
131
their ill health to parts of their body, rather than directly to
emotions. The interviewer sought clarification, but he was
clear that he had no mental health problem. This denial of
mental health problems was also shared by Respondent 6:
‘I’m not mental problem’.
In addition to using physical descriptions or denial,
some used terminology that would be considered politi-
cally incorrect in Western culture:
5. I don’t want anyone say [A] is crazy. And I was very crazy
actually because I try twice kill myself, I try hung myself.
I cut myself, I really was crazy. (Respondent 11)
6. I say no I don’t want to go hospital to be with the mentals
or that kind of people. (Respondent 1)
7. My friend tell me they can give you an injection and they
send you in the crazy hospital. (Respondent 9)
Even when they acknowledged they had mental health
problems, they still expressed negative attitudes towards
mental health, both for themselves and others. It is not
unusual for young people to use negative concepts to
describe mental health (O’Reilly, Taylor, & Vostanis,
2009). This is demonstrated by the phrases ‘mentals’,
‘crazy’ or ‘that kind of people’, which together with the
concept of a ‘crazy hospital’ positions those with mental
illnesses as a socially excluded group. Evidently, the
labelling of mental health problems from their perspective
is synonymous with being removed from society and
incarcerated.
Theme 2: Mental health associated with
asylum-seeking/refugee status
Commonly, mental health problems were associated with
their experiences of being asylum-seekers/refugees. These
experiences tended to be grouped into their own personal
encounters, fears for their families’ welfare and worries
about immigration status:
8. Cuz I had a difficult journey and you know for me it was
difficult to cope or live alone. (Respondent 10)
9. I’m seventeen, I’m alone, I’m scared. (Respondent 14)
It is well documented that many asylum-seeking/refugee
young people encounter further trauma or abuse during
their journey, as well as fears of deportation (Huemer &
Vostanis, 2010). This has potential to impact on mental
health which is oriented to by the respondents who report
that they are ‘alone’. In addition to these stresses, some
respondents report having considerable anxiety about the
welfare of their families/communities left behind:
10. I’m here I don’t know my family about (.) worry about
my family. (Respondent 3)
132
11. I was thinking about my family so that’s why I was sad.
(Respondent 14)
These responses are entirely appropriate to being unac-
companied minors who have been separated from their
homes. Other respondents describe the hostile environ-
ments in the countries of origin, which contrasts with their
experience of those in the host country:
12. And my mum feel now died, I feel she died, now is (?),
now my mum is live ….. My brother died. He got gunshot,
someone kill him, my uncle dead. And my uncle dead,
three uncle dead, my father died. (Respondent 8)
13. I see lots of problems in my age when I was in Afghanistan
so from age ten I been seeing people die in front of me
I’ve seen people killing each other in front of me (.) dead
bodies in front of me. (Respondent 1)
Although the experiences of these respondents have been
extreme, it is difficult to ascertain the relative impact of
these events on their mental health or whether the subse-
quent dislocation and integration into a new environment
may have been more significant. Potentially, it is a cumu-
lative effect and therefore care needs to be taken when
interpreting multiple layers of events. Most individuals
described multiple traumas which could have contributed
to their problems. Obviously, in addition to the dislocation
from their home country, there remains uncertainty around
the immigration process which may affect their mental
health.
Theme 3: Experiences of using services
The respondents talked about their experiences of services
in the United Kingdom, but also care provided in their
home country. Despite this engagement with UK services,
there was a general distrust of them. Some of this appears
to have a cultural element feeling different from the host
population:
14. English people and doctor people, you don’t understand
me anything at all for me. (Respondent 8)
15. Because in here everything is different in England. It’s
like England is very healthy for everybody, like hospitals,
doctor, family, anyone but, no, in Iran I don’t think is like
someone like, if I have problem, I don’t think it’s like
someone like help me, is only my parent or someone else.
(Respondent 11)
Both respondents felt that the cultural differences
impacted on services’ understanding of them, which
may have implications in creating an optimal environ-
ment for any service delivery. Complicating matters fur-
ther appear to be a more fundamental distrust of health
services:
International Journal of Social Psychiatry 61(2)
16. This doctor, I not trust him, I’m not safe. (Respondent 8)
17. I didn’t say to anything about my problem, I didn’t tell it
to anybody, you know, because I don’t trust anybody.
(Respondent 9)
Considering the traumatic events and possible exploitation
of these young people, mistrust is entirely understandable
and continues to act as a protective mechanism. However,
this is another barrier for the adequate engagement with
services. This mistrust can translate into feeling ‘not safe’.
Mental health services perceive themselves as trustworthy,
but trust is clearly an important issue for these young peo-
ple, and Respondent 16 reports that this is necessary if they
are to receive the help they need:
18. Trust is the most important thing, so what I would suggest
to [names service] is, I really appreciated their help, at
that time I did really needed help to be honest with you,
’cos I was in a very big mess …………… If you keep
things to yourself obviously it will never ever help you.
(Respondent 16)
It is perhaps unsurprising therefore that the general per-
spective of mental health services was negative with many
children reporting that they did not like attending their
appointments and that the interventions were unhelpful:
19. When I’m in the meeting I’m like one minute is one hour
(.) I don’t like (laughs). (Respondent 3)
20. I lost my family I had a lot of problem (.) ….. I was telling
her a lot of things ……… but she didn’t help me.
(Respondent 6)
21. They ask you one question, they ask you one word like
ten times, they keep asking. They know everything but
she just keep asking, I said I can’t do this. If you are keep
doing this … end of 2012 you’re going to kill me, I said
I’m going to do it. (Respondent 2)
It is not uncommon for children generally to disengage
with interventions or show some form of resistance to
mental healthcare (O’Reilly & Parker, 2013b). This can be
problematic for service providers who are charged with
safeguarding and promoting mental well-being in these
populations. This is further compounded by the feeling
that services fail in their duty to provide help for these
individuals. Obviously, care needs to be taken when work-
ing with these young people, as their views about mental
health services may only worsen if they feel their problems
are becoming more intense. These young people have
responded in a negative way to what is seen in contempo-
rary practice which includes a full assessment and clarifi-
cation of the problems in detail. This by definition requires
a great deal of questioning and characterises psychiatric
practice. Although the respondents typically were negative
Majumder et al.
about engaging with services and tended to dislike attend-
ing, some were able to see benefits:
22. Well coming here the doctor helped me and the doctor tell
me the reason (.) I was happy about the reason that is the
most important thing for me. (Respondent 9)
23. He says I’ve seen Doctor [X] twice (.) he has been very
helpful (.) he always help us (.) he’s thanking him.
(Respondent 7: interpreter)
This does, however, have to be contextualised against the
rest of the narratives in these interviews where the indi-
viduals, particularly Respondent 7, denied having any
mental health difficulties but appears thankful that he has
been helped. There are clearly some contradictions in their
accounts of their involvement with services. To contextu-
alise the experiences within a Western health service, it is
useful to explore their experiences of services in the coun-
try of origin.
The respondents were able to describe what their expe-
riences or perceptions of mental health services were in
their home countries. In general, the adolescents described
health services as limited or absent. There was also distrust
of the professionals involved in these services, which may
partially account for the limited trust of refugee services:
24. They different yeah (.) they is different (.) no-one like a
feel sick or something in my country give a tablet or
something. (Respondent 4)
25. No CAMHS there (.) there is a hospital if he there is a you
know some people trust that some people not trust that.
(Respondent 9)
The sample represents different countries of origin with
different notions of mental health and treatments. In addi-
tion to not trusting services or experiencing treatment lack-
ing in any psychological support, one respondent described
an unpalatable view of their experience of a mental health
hospital, and another talked about the limited knowledge
that appears to exist about mental health:
26. I went to see one hospital in Afghanistan I was really
young (.) I was (.) they’re usually kids going to see
mentals problem (.) mental people (.) there’s just like a
prison they put in there and they’re just inside the cage
fighting with others (.) they’re just like making fun of
people. (Respondent 1)
27. Yeah, in Afghanistan in winter if you got money, you go
to hospital, if you don’t have money then go on street,
sleep on street. Sleep on street and go crazy, innit.
(Respondent 4)
28. But there’s one thing is good about Afghanistan is the
service is good if you’ve got the money, everything will
133
go through, you know, straight away but in England you
don’t pay. (Respondent 12)
The descriptions of the hospital being ‘like a prison’ and
the comparison of the environment to ‘cage fighting’ is an
unpleasant visual image. The experience is that the label of
mental illness invites mockery or incarceration. It is unsur-
prising, therefore, that young people feel uncomfortable
admitting they have mental health issues or engaging with
treatments. The State-funded services available in the
United Kingdom contrast considerably with the descrip-
tions of healthcare in Afghanistan. The economic aspects
of healthcare limit what available resources are accessible
by the population, with health declining when it cannot be
afforded: ‘sleep on the street and go crazy’. Even if initial
treatment is possible, the ongoing costs become unviable.
Theme 4: Opinions of treatments
In addition to the views expressed regarding the cultural
background and services provided within the United
Kingdom, the unaccompanied adolescents did have views
on the actual treatments that they received. The general
treatment modality within CAMHS is psychotherapeutic
in nature relying on talk, with medication utilised when
this approach has failed, the symptoms are severe or when
the condition responds only to medication. This therapeu-
tic approach appeared very different to the a priori expec-
tations of the young people. Three broad issues emerged:
views on talking therapies, risks of re-traumatisation and
medication:
29. CAMHS is somebody talking to you on that, now I know
what it is, somebody talking to you, if you have any
problem, you can talk to the doctor. (Respondent 9)
30. 
That doesn’t helps me (.) that makes me more hard
because um the all the time I was talking about the past (.)
so every time I went there (.) reminding me after I went
home again (.) same depression and same problems.
(Respondent 1)
Opinions on talking therapies were mixed with some
appreciating the value of therapy, while others are more
negative about this modality. These negative views are
particularly relevant as many of the adolescents reported
that reliving the experiences during treatment opened them
to re-traumatisation, making their problems feel worse.
Although this may be distressing for the young people,
sometimes this is part of the therapeutic process which is
something that needs explaining to them. However, in
addition to this, it should be appreciated that their immi-
gration status and unaccompanied position may reinforce
their feelings of distress, thus affecting the therapy.
Given their viewpoints on mental health problems, it is
common for the respondents to request medication for
134
psychiatric conditions. Some respondents saw the drug
treatments as a positive aspect of their care:
31. I have medication, not medication that time, when you
have medication get better. (Respondent 8)
32. Giving me some medicines to keep my low up so that was
a bit helping me (.) ……….. so I went back home (.) take
the medicines and took it and I felt back normal.
(Respondent 1)
The full quotation from Respondent 1 described an inci-
dent where he forgot to take medication for a week and
the subsequent negative effects. This illustrated a positive
view of medication as it made him ‘normal’. However,
many adolescents failed to understand the reasons for
medication, and others sought it as treatment, particularly
if they thought their symptoms had a physical origin. This
lack of clarity does raise issues of informed consent which
needs to be considered carefully in practice.
Discussion
Conflict in many parts of the world has led to an increase
in refugees. Increased recognition that refugees have sig-
nificant physical health, social and mental health needs
has meant a development of services for them. Services
need to be appropriate to the requirements of this popula-
tion and recognise their specific requirements. The voices
of unaccompanied minors need to be acknowledged in
these developments as they are a particularly vulnerable
group.
An understanding of the concept of mental health is
often essential in ensuring engagement with treatment.
These concepts were unfamiliar to some of these adoles-
cents, and many reported negative views of mental health.
Nonetheless, their negative perceptions of mental health
are not entirely different from adolescents living in
Western cultures (O’Reilly et al., 2009). These adoles-
cents either denied them or reconstituted them as physical
problems. The participant’s understanding did appear to
be concomitant with their age; however, there were a
number of influences upon this. This may be a reflection
of their language difficulties (Lustig et al., 2004), may be
an echo of the cultural attitudes of their home environ-
ment (Lynch, 2001) or their experiences of services back
home. Describing mental health is notoriously difficult,
and most adolescents typically think in terms of mental
illness, rather than being mentally healthy (Svirydzenka,
Bone, & Dogra, 2014).
While there were reported positive experiences, there
was general mistrust of services, particularly doctors.
These adolescents appeared cautious of services for sev-
eral reasons, including professionals identified as repre-
sentatives of the state, and/or fear of deportation (Ellis
International Journal of Social Psychiatry 61(2)
et al., 2011). Consequently, mental health and legal issues
can be perceived as intertwined, despite the differences
being explained to them. In our sample, the level of trust
did not appear dependent upon their immigration status.
However, this was a limited cross-section of this popula-
tion. Thus, the mistrust of strangers could be viewed as
protective, originating from their adverse experiences or
culture. Trust is inherently a relational concept, which lies
between people and events, people and organisations, and
people (Gilson, 2003). Ultimately, therefore, trust involves
a degree of risk derived from the individual’s uncertainty
of the intentions, motives and future actions of others on
whom they are dependent (Kramer, 1999). Our respond-
ents reported finding the host country unfamiliar, which
can affect trust, thus creating a further impediment to
engagement. Furthermore, the unfamiliar language and
limited independent communication may have had some
effect. In many cultures, there is a mistrust of people out-
side of the family unit, and their current situation pre-
cludes them from accessing the support of their families,
which they may have accessed if distressed in their home
country. Although not universal, some adolescents in
Western cultures have also been shown to lack trust in
services which would support or enhance their mental
health (Flisher et al., 1997; Wilson & Deane, 2001). The
views of the unaccompanied minors should be seen in this
context; however, their mistrust does seem to be of a
greater degree.
In child mental health, the predominant modality of
treatment remains the ‘talking’ therapies, and alongside
these modalities has been an increased use of medication,
despite their effectiveness not being fully evaluated
(Lustig et al., 2004). Many of the respondents found
engaging with talking treatment difficult, and they deemed
pharmacological treatments more acceptable. This may
reflect cultural experiences, where mental healthcare was
limited or absent and treatment was different or a different
understanding of illness. Explanatory models of illness
have a very strong cultural basis, and while talking thera-
pies have a well-established framework within a
Westernised healthcare system, this is not universal glob-
ally. Talking therapies can also be challenging, due to lin-
guistic limitations (even when using interpreters) due to
the loss of the subtle nuances of communication.
Consequently, psychiatric intervention may be deferred
until their language has improved (Huemer & Vostanis,
2010). This is a decision that needs to be balanced against
the risk. Even with appropriate medication, some respond-
ents lacked clarity regarding their treatment. This does
raise concerns around informed consent as they should
understand their treatments.
Although the unaccompanied adolescents were either
of refugee status or asylum-seeking, they had been within
the United Kingdom for different lengths of time, but they
had all been under a specialist mental health service for at
Majumder et al.
least 6 months. It is difficult to quantify the effects of
acculturation (the process of cultural change), assimilation
(adaption of cultural attitudes of the prevailing group) and
peer group influences on these young people and therefore
whether this process had influenced their understanding of
the Western health model. This variability does obviously
pose challenges for services, which supports the need for
specialist clinicians who understand these needs.
Fortunately, in this situation, the assessments and therapies
were provided by such professionals.
The findings from this study have implications for eth-
ics and services. Services should have the flexibility and
accessibility to engage the child, and mental health input
should always be integrated with welfare, education and
physical health services, thus encouraging consistency
and acknowledging the ‘therapeutic’ role of those
involved. Their access and engagement can be also
improved by utilising the mediation of people who have
already gained their trust (Davies & Webb, 2000).
Importantly, in addition to history of trauma, the impact of
the current psychosocial adjustment and uncertainty over
the future are also considerations. Ideally, foster carers
would need specific training on the issues facing these
adolescents or if possible have a shared cultural back-
ground; however, finding foster placements or group
accommodation which can meet these needs is difficult,
and this was reflected in our sample.
Ultimately, professionals still have the power to decide
what services will be accessible particularly for those who
actively choose to decline treatment. Young people can
feel that their voice is not given due credence (LeFrançois,
2007), and this is particularly problematic for unaccompa-
nied asylum-seeking/refugee adolescents. They may pre-
fer to resist the indigenous pathways to care and decline
treatments, or may view the service as intrinsic to their
refugee application, rather than as a mental health inter-
vention. It is important to strike a balance between respect-
ing their rights to make decisions and protecting them
from long-term health consequences.
This population remains under-represented in research,
and there are inherent difficulties in accessing them. The
sample itself is ostensibly small but is nonetheless repre-
sentative of the population and reflects the quality criteria
for sampling adequacy for the method (O’Reilly & Parker,
2013a). The representative group is in the 15- to 18-years
range and is potentially self-selected by the group mem-
bers’ ability to endure the refugee process unaccompanied.
Although there were linguistic difficulties, the adolescents
were able to express pertinent views from which to draw
conclusions. Future research may focus on younger chil-
dren or consider a wider range of countries of origin as
many of the adolescents in our study were from
Afghanistan, to obtain a broader range of perspectives and
understanding. It may also be useful to obtain data from
other localities within the United Kingdom, but our data
135
has transferability. At present, there is limited published
literature on the perceptions of mental health services in
British adolescence, particularly in relation to issues such
as trust, and further work would be beneficial. Larger
quantitative studies may help to inform service design or
government policy with the aim of developing interven-
tions which will facilitate care.
Acknowledgements
We would like to thank the young people who consented to par-
ticipate in this study. We also extend thanks to the social workers
and clinical professionals who made access possible. Finally, we
thank Claire Bone for her comments on earlier drafts.
Funding
This research received no specific grant from any funding agency
in the public, commercial or not-for-profit sectors.
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