As more people seeking asylum are left to sleep rough, it makes it even harder for them to access mental-health care they may need

Warning: This article mentions suicidal ideation and self-harm. If you or somebody you know might need help, Pieta House’s suicide prevention hotline can be contacted 24/7 at 1800 247 247 and the Samaritans’ at 116 123.

Samson Ogunniran perches on a concrete platform in front of the International Protection Office (IPO) on Merrion Square.

His fingers are intertwined, and their skin is flaking. He’s wearing a black beanie, a long, shabby jacket and black Adidas joggers.

At his feet, there’s a sleeping bag rolled up like a burrito on top of a big black suitcase tucked next to a grey backpack.

He got the sleeping bag at a homeless charity in the city centre and used it to sleep outside the IPO the night before, he said on Friday afternoon. “There’s nowhere to sleep.”

Ogunniran said he’d arrived in Ireland last Monday and had been sleeping rough since.

Earlier that day, staffers at O’Farrell House, a Department of Social Protection office in the city centre, had said they couldn’t help him get a bed at a homeless hostel, said Ogunniran.

“They said, you need to see someone here,” said Ogunniran, pointing at the IPO doors as they slid open and shut.

Finally, an IPO worker steps outside and starts asking him questions. Nearby, an Arabic interpreter is on a cigarette break.

Later, the staffer handed him a letter that said he had requested shelter from the International Protection Accommodation Services (IPAS).

“Did you fill in the vulnerability assessment?” the worker asked him before slipping back inside. He had, he said.

Staff at the Department of Children, Equality, Disability, Integration and Youth – which oversees IPAS – have worried about homeless asylum seekers’ access to health care for some time, show documents released under the Freedom of Information Act.

Getting people to complete vulnerability assessment forms at the IPO while they register their asylum claims and the government has in-person access to them, is part of efforts to offer better support, documents suggest.

The department had worked with the HSE to formulate a mental-health question for those forms, according to the documents.

Asylum seekers and refugees are more likely to carry traumas and grapple with post-traumatic stress disorder (PTSD) and depression than people born in Ireland or migrants who weren’t forced to move, says a 2013 study by researchers at University College Dublin’s (UCD) School of Psychology.

But in a healthcare system that’s under-resourced and in need of more psychiatrists for all kinds of people all over the country, access to treatment for all asylum seekers is also narrow.

For those homeless with mental illnesses, it’s even harder because they can only get booked with GPs through drop-in homeless day centres, says Dr Alva O’Dalaigh, a GP with Safetynet, a medical charity caring for marginalised patients.

People with mental-health problems can lead chaotic lives, she says, and they might not make it to those appointments. “So if a GP in the community says please come see me on Tuesday at 11 o’clock, they just won’t be able to manage that.”

Language barriers can compound the issue further, she said.

A spokesperson for the Department of Children and Equality said that IPAS works closely with the HSE to identify vulnerable homeless applicants with health issues when they turn up at the IPO to see if they need to be prioritised for accommodation.

Recurring concerns

Documents suggest past tensions between different government agencies around the services on offer for asylum seekers. In March, civil servants at IPAS had said it was getting trickier to work with the HSE to manage mental-health cases at its spaces.

“Engagement with HSE on acceptable resolutions for Mental Health cases within our accommodation settings is becoming more and more challenging,” they wrote in a departmental situation report dated 7 March.

The issue needs to be highlighted at an upcoming meeting with senior officials at the HSE and the Department of Health, they wrote.

In another report from 21 March, staffers were wondering how to manage eight cases of mental-health challenges among residents.

“Matters have been raised with HSE colleagues. Need to consider raising formally in writing with HSE,” they wrote.

Minutes of a meeting between HSE and IPAS officials from 22 March record concerns about the number of mental-health cases again.

“A Community Response Group at a national level has raised the issue of people going into homelessness due to mental health vulnerabilities/PTSD,” say minutes of another meeting on 10 May.

The HSE had offered to train centre managers to spot symptoms of mental illness among residents, it says.

The years of living precariously

For homeless asylum-seekers, lack of access to medical cards is another issue, says O’Dalaigh, the GP with Safetynet.

Homeless asylum seekers and those living in the Citywest transit hub don’t qualify for medical cards because they don’t have a permanent address, she said.

Refugees from Ukraine got blank medical cards without permanent addresses at one stage, said O’Dalaigh.

“But I’m not up to date on that because [Ukrainians] generally, they don’t stay in transit for long,” she said.

An HSE spokesperson also said that it “currently funds My Mind, which provides free counselling and psychotherapy services to Beneficiaries of Temporary Protection from Ukraine living in Ireland”.

However, asylum seekers, coming from other countries, have not been given these kinds of services.

Instead, they are left to scramble around trying to get a medical card, to help clear the cost barrier to getting health care.

Not having a permanent address, or even being homeless and sleeping rough, makes this process even more difficult.

A spokesperson for the HSE did not respond to a query asking if it would issue blank medical cards for homeless applicants.

A general shortage of GPs can stand in the way too sometimes, documents suggest.

During a meeting between officials at the HSE and IPAS on 20 April, a department staffer asked if asylum seekers with lengthy stays at Citywest can apply for medical cards, documents show.

But HSE officials say that people need a named GP for that. “And this would be difficult to do in the area for 626 people,” they said. They say there is healthcare on-site if needed.

O’Dalaigh says there are nurses visiting Citywest. “Because there’s like 650 residents there.”

They can book people with a GP at Safetynet or any GPs they can find for them, she said.

Tell me again

Even if people qualify for medical cards, it can take a while to get them sometimes.

Cynthia Lebuli first applied for a medical card while living in Crowne Plaza Hotel in Santry back in 2021, she says.

The hotel is an IPAS emergency shelter, but living there counts as having a permanent address.

But at the time, she says, there was a steep backlog for getting PPS numbers and asylum ID cards, known as blue cards because of their colour. She couldn’t apply for a medical card without them.

“I’ve got my blue card after three months, and I got my PPS number after four months.”

Then there was a series of bureaucratic hiccups and miscommunications around her medical card application, and she had to apply again and again, she said.

By the time it came through, she had the right to work and a job, and so it doesn’t cover her medical expenses in full, said Lebuli.

Before she got it, she saw GPs at Safetynet about looping suicidal thoughts. “I feel shameful to say it,” she said, sitting at a Starbucks in East Wall.

The doctors were kind, she says, but she had to see a different one every time and relaying what gnawed away at her over and over again took a toll. “I just felt so frustrated.”

One time, she unravelled while retelling, and shouted during an appointment, she says.

They put her on different anti-depressants, Lebuli says, and she stuck with one that keeps her the most alert to function at work and in college.

Lebuli has a history of mental illness and used to self-harm, she said.

In her country of birth, she was prescribed some meds that worked for her. But she’d tapered off them and was doing fine for a while.

Soon, her depression began ramping up again. “My mum had to reach out and get the name of my medication,” she says.

But her GPs here said that only a psychiatrist could prescribe that medication, says Lebuli. “That’s when they referred me to a mental health hospital.”

That was last year. She’s still waiting to see a psychiatrist. Some days, Lebuli says, she doesn’t feel like waking up.

Sharing the Vision

Ireland’s health care system is strained, and waiting lists can be long.

Refugees from Ukraine had been returning to the country for medical treatments and had seven days to come back and reclaim their beds in accommodation, show minutes of a meeting between IPAS and HSE officials from 10 May.

But asylum seekers can’t go back while their claims are being processed. Those escaping political persecution can’t go back at all while the regime that had oppressed them is still in charge.

A spokesperson for the HSE said that through its Sharing the Vision roadmap, it’s working to ease access here in Ireland to mental-health and primary-care services for asylum seekers and refugees.

“This work is being progressed by a Social Inclusion Workstream, which was established in February 2023,” they said.

It’s hoping to offer more culturally appropriate mental-health care as part of that strategy, they said.

Some resources are already available through its primary-care migrant health teams, the spokesperson said. “Interpretation services are also available.”

In parallel to those efforts, they said, it has sketched a “service delivery model” for refugees and asylum seekers.

Different charities are offering counselling support, but they have their limits too, said O’Dalaigh, the GP.

For victims of torture, there is Spirasi. “I think their wait time has gone to about 10 months now, with the increased numbers.”

Contours of trauma

O’Dalaigh, the GP at Safetynet, says symptoms of Post Traumatic Stress Disorder (PTSD) are very common among her asylum-seeking patients. “There is an awful lot of stress, and anxiety and PTSD.”

A study by researchers at University College Dublin’s School of Psychology, published in 2013, found that asylum seekers and refugees showed higher degrees of PTSD than people who had migrated by choice and those born in Ireland.

“With over 50% experiencing torture prior to arrival in Ireland”, the study says.

Still, it is deeply underresearched, it says. Asylum-seekers and refugees have  “remained virtually invisible in trauma research and thus, likely to be misunderstood and ineffectively treated”.

On top of traumatic experiences that would scar most people, O’Dalaigh the GP with Safetynet said some had perilous journeys out. Along the way, they may have been physically assaulted or raped, she said.

Sometimes, when they escape, authorities or militias in their country of birth take away or harm a family member as punishment, leaving them to reckon with agonising guilt, says O’Dalaigh. “Because you feel you might have been responsible for that.”

She’s seen the scenario unfold for her Afghan and Somali patients before, said O’Dalaigh.

Their traumas are compounded by environmental triggers here, she said, like homelessness, isolation and poor living conditions. “Sometimes the accommodation is very remote, maybe 14 kilometres to walk from any kind of urban centre where the bus transit is.”

Minutes of a meeting on 20 April between the HSE and IPAS staffers note the toll of living conditions on the mental health of asylum seekers.

Some are flagging mental-health concerns. “When further detail is sought, there do not appear to be clinical mental health issues, but environmental issues that are impacting on the person’s mental health,” it says.

Things like isolation and lack of internet connection at the centres, says the document.

Lebuli, who now lives at the old ESB office block in East Wall, says the stress of living in cramped quarters plus frequent anti-immigration protests outside their centre deepen her sadness.

“It does something to you, you know you’re unwanted,” she says.

The reality of now

Back outside the IPO, Ogunniran says he wants to keep mentally and physically fit as much as possible.

He’d read about anti-immigrant riots in the city and feels unwanted and ashamed, he said. “I don’t blame them, I blame myself,” he said. “Why couldn’t I live in my country?”

But if he can get a bed and settle in, he’d go to school here and try to become a police officer, he said.

For now, he will stay put outside the IPO, said Ogunniran on Friday, shaking his cold and dry hands.