Aims This study assesses the Somali community ’s perceptions of mental health and explores their challenges and difficulties when accessing and utilising services in Camden. The findings of the study are contextualised within the existing structures and organisations in the mental health system and aim to add to the existing knowledge base around good practice and service delivery. Methodology A multi-method or triangulation approach was used. Most of the data were collected via in-depth semi-structured interviews with seven [three male and four female] Somali users of the St. Pancras Refugee Centre. All participants lived in Camden and were unemployed. Language and education levels varied and the mean age was 34. A second interviewer, an experienced community worker in Camden, was involved to accommodate the need for cultural and linguistic interpretation. Interviews with eight Somali groups in Camden explored the relationships between refugee community organisations [RCOs] and the provision of mental health. Data from these interviews were analysed using the "framework method". Finally, quantitative data from users of St. Pancras Refugee Centre were used to provide a context and for an analysis of the probable extent of issues raised during the qualitative research phase. Users ’ personal data were analysed during the six month period between April and September 2005. A conference paper by the author offers similar findings. Key Findings Somalis make up the largest number of users [37%] at the St. Pancras Refugee Centre yet in the period from April to September 2005, only five users were receiving treatment from secondary mental health services. More common amongst users of the St. Pancras Refugee Centre were mild and moderate depression. Of those accessing primary or secondary health care, the majority were living in insecure or temporary housing conditions. Service users and community groups mentioned barriers to accessing mental health services including fear and mistrust of the system, insufficient language, anxieties and pre-occupation about immigration status, housing and income. Interviewees identified the need for practical solutions to social, legal and economic problems. They also noted lack of support from their own community including a problem of denial whereby sufferers hide their problems due to fear of humiliation or stigma. With a lack of Somali community support, refugee communities and voluntary organisations that work across all communities become a crucial support service. Users identified religion and traditional means as coping mechanisms. Cultural interpretations of distress must be taken into account or else communities will not access services, misdiagnosis can occur or mental distress may be interpreted as mental pathology. Many Somalis experienced distress in the pre-migration phase which caused a breakdown in their ability to trust others. Institutional racism is one of the largest challenges facing Somali refugees. Users who try and access mental health establishments confront vast and complex institutions where the "Western biomedical model" dominates and clinical providers who lack understanding about the migratory experience resort to "box ticking" to find diagnoses. This article suggests that mental health services need to take a holistic approach towards mental health whereby psychosocial issues are understood by looking at economic, social, environmental and cultural factors. Practical issues such as housing, immigration and training opportunities can serve as crucial supportive interventions when dealing with a group faced with the pressures and anxieties of exile. Conclusions and recommendations Mental health services need to have an inclusive multicultural strategy which addresses cultural and linguistic needs and also a clear understanding of the migration process. Service providers must engage with refugee communities, community organisations and Somali community groups to establish an appropriate approach and delivery of services. St. Pancras Refugee Centre has responded to the lack of cultural understanding of health professionals by offering training focusing specifically on the needs of refugees and by encouraging user involvement. This approach should be used by other established services to make sure the needs of refugee clients are being met. An essential precondition for Somali refugee service user participation in Camden is effective training in transcultural awareness for mental health professionals and community groups. The myriad of barriers and challenges facing Somali refugees [including cultural traditions, perceptions of mental health, narrow Western definitions and treatment scenarios, the issue of trust and the practical implications of language difference] requires the acknowledgement that there are many different potential pathways Somali refugees in Camden may take into the mental health system. Unfortunately, evidence suggests that mainstream services fail to acknowledge the implications of pre- and post-migration. Transcultural psychiatry has begun to influence policy in this area but much work continues to be necessary in order to provide a bridge between Somali users in Camden and traditional established practices within the mental health system.

This paper is the second in a two-part series dedicated to mental health needs of refugees and asylum seekers. Against a background of selective review of literature and context in paper 1, this paper describes practical steps in meeting the mental health needs of refugees and asylum seekers. Nurses see refugees and asylum seekers at the very point of their distress—often outside of or external to immigration detention facilities. Practical strategies are presented for the generation of trust and supportive counselling with implications drawn for nurses working across a range of practice settings, such as in accident and emergency departments, psychiatric clinics, community-health centres and as general practice nurses. Continuity and integration of mental health care is achieved by bridging discrete elements in the asylum seeker journey through legal reviews, news from home and ongoing psychosocial stressors, in the context of different episodes, interventions by different providers or changes in illness status. Also important will be actions that build resilience intrinsically over time, such as the asylum seeker ’s values, sustained supportive interpersonal relationships and therapeutic care plans.

Building on their previous works about cultural competency in clinical areas and in psychotherapy, the editors have created in this volume an exceptional and entirely new approach to understanding and acquiring cultural competency. Instead of examining populations of different ethnic groups, particularly minority groups (as is typical in the literature), this illuminating volume examines cultural issues as applied to the practice of virtually every psychiatric service (e.g., inpatient, outpatient, consultation-liaison, pain management, and emergency) and specialty (e.g., child and adolescent, geriatric, addiction, and forensic psychiatry). Concluding chapters discuss cultural factors in psychopharmacology and psychotherapy. Thirteen distinguished contributors bring these issues to life with numerous case vignettes in all 11 chapters. The foundation for this breakthrough approach rests on •Culture—The unique behavior patterns and lifestyle that encompass a set of views, beliefs, values, and attitudes shared by a group of people that distinguish it from other groups. Culture and people influence each other reciprocally and interactionally—on a conscious or unconscious level. •Cultural competence—Clinicians need to master cultural sensitivity, knowledge, and empathy; they need to be flexible, and they need to be skilled in culturally relevant doctor-patient relationships and interactions and to know how to use these elements therapeutically. •The critical importance of cultural competence—Clinicians typically work in multiethnic-cultural societies, providing care for patients of diverse backgrounds. For this reason, virtually all clinical practice can be seen as transcultural. Even when clinicians treat patients who share cultural backgrounds similar to their own, it is inevitable that some differences exist. Further, in the medical setting, three types of culture are present: the culture of the patient, the culture of the physician, and the medical culture in which the clinical work is practiced. Understanding these three cultural dimensions is essential to comprehending and carrying out culturally competent clinical work. This practical and innovative guide—designed to help mental health care professionals meet the new requirements for cultural competence in clinical work—will find a welcoming audience among students, residents, educators, and clinicians everywhere.