MIRI, Aug 15 — Based on case examples and interviews with mental health experts, it is evident that lack of citizenship status can impact one’s mental health, especially in the long run.

However, this topic remains under researched and underreported, especially in Malaysia.

This is especially true in Malaysia where past and current studies and research mainly focus on causes and consequences of statelessness and the gaps in the national law and policies, but very little studies look into the implication of lack of legal status towards mental health of the stateless persons.

Maalini Ramalo, who is director of social protection at Development of Human Resources for Rural Areas Malaysia (DHRRA Malaysia), is among those who have conducted research on statelessness. She said the lack of research into the implications of statelessness on the mental health of this community could be attributed to several interrelated factors.

"Firstly, it is a sensitive and politically charged issue. The government may be reluctant to support or facilitate research that could highlight its failures or controversial policies regarding stateless populations.

"This can deter researchers from pursuing this line of inquiry due to potential political backlash or legal challenges,” she told The Borneo Post.

Second is the lack of research funding and low priority placed on the issue, contributing to why the topic on mental health of stateless people is under-researched, she added.

Maalini also noted that the stigma and social attitudes surrounding mental health may lead to the lack of support for this area of research.

"In addition, as organisations and impacted individuals work towards addressing statelessness, the visible needs often overshadow the less visible but equally important mental health issues,” she said.

Mental health support

In the UK, Dr Francesca Brady, a senior clinical tutor at University College London and a clinical psychologist at the Central and North West London NHS Foundation Trust, said access to primary care, including mental healthcare, is theoretically available to everyone.

Asylum seekers who have been granted leave to remain in the UK, and stateless persons who have successfully been accepted under its Stateless Determination Procedures, can access primary care including psychological healthcare, for free.

"When it comes to more complex or specialist care, for example, I work in trauma services, technically that would not be open to people who do not have an active asylum claim (asylum claims that are currently being processed or have been refused by the Home Office, or stateless individuals with no active claim and no nationality).

"However, there are some caveats. If a person needs an emergency or lifesaving care and that can be provided, including acute mental health care, they will be exempted (irrespective of whether they have an active claim or not),” Dr Brady said in an interview.

On the other hand, Malaysia does not differentiate between foreigners, refugees, and stateless individuals; hence, stateless persons are charged the same fees as foreigners when accessing healthcare services in all government clinics and hospitals in the country.

The Fee Act (Medical) 1951 which was amended in January 2016 was meant to cut medical subsidies for foreigners.

However, it has also discouraged stateless persons from seeking healthcare services, including mental healthcare.

On the other hand, Malaysia does not differentiate between foreigners, refugees, and stateless individuals; hence, stateless persons are charged the same fees as foreigners when accessing healthcare services in all government clinics and hospitals in the country.

The Fee Act (Medical) 1951 which was amended in January 2016 was meant to cut medical subsidies for foreigners.

However, it has also discouraged stateless persons from seeking healthcare services, including mental healthcare.

Recognising the importance of the welfare of undocumented and stateless populations, non-governmental organisations (NGOs) like DHRRA Malaysia have initiated an effort to provide emotional and mental health support since 2007.

Maalini said the organisation targets the general Malaysian public, including stateless communities.

For stateless cases, she said DHRRA’s main focus is on in-situ statelessness rather than refugees and migrants, as it aims to make the Malaysian government responsible for its own people who are becoming stateless.

"That is the strategy we have taken and also along the side, how the public tends to alienate, you know, refugees and migrants from accessing our resources.”

Maalini emphasised that this approach is important to ensure the Malaysian government does not shift the focus away from Malaysians becoming stateless due to nationality laws by claiming that DHRRA is addressing issues related to immigrants and refugees.

She stressed that this, however, does not mean that DHRRA ignores immigrants or refugees seeking psychological and mental health support from it.

DHRRA, she said, has less experience with immigrants and refugees, and thus refers such cases to organisations that directly work with these groups.

"The very specific reason for this is like when somebody comes to you for mental health support, it also means that they are seeking a solution for the type of problems that they have.

"For example, if a stateless person is very suicidal or very depressed because of their status, usually because of a long waiting (period, for their application status). DHRRA, with its experience, will support and guide them in the right direction,” she said.

Among the cases DHRRA has handled over the years are issues such as divorce, abuse, separation, and child custody.

The organisation, Maalini pointed out, always tries its best to support them mentally and psychologically. But if they are unable, they will refer the individual elsewhere.

"So that is how we have sort of packaged our mental health and psychological support for the vulnerable communities that reach out to us.”

Despite its efforts to provide psychological and mental health support for stateless communities, Maalini said funding continues to be one of DHRRA’s main challenges.

She said the lack of recognition that statelessness impacts the country has, in a way, restricted attention, awareness and funding for DHRRA.

"These are individuals that would never be able to leave the country and have strong links to Malaysia, through Malaysian heritage and being born here in Malaysia. Their statelessness is caused by the inconsistent practices of policies as well as inequality in the law.

"I would say because of the lack of recognition of this, the attention, awareness, and funding allocation for this matter is extremely low,” she said.

In addition, she said DHRRA also faces restrictions regarding who it can receive funds from, to continue providing the services to the communities.

Availability of care

Deputy Health Minister Datuk Lukanisman Awang Sauni has said the Ministry of Health (MoH) provides healthcare services including mental health care to everyone in need regardless of their background.

He said this is because access to health care is fundamental in attaining good health, including mental health.

"However, due to certain barriers, such as legal restrictions, this vulnerable group might not be able to access mental health care.

"These barriers may include legal restrictions, undergoing process of deportation, lack of documentation, financial constraints, language barriers and stigma,” he said.

While stateless and undocumented individuals face barriers in accessing services, he said MoH provides a 50 per cent discount off the foreigners’ rate for refugees with the United Nations High Commissioner for Refugees (UNHCR) card who seek medical attention at public healthcare facilities.

In addition to public mental health clinics and services, he said undocumented or stateless individuals in Malaysia may access mental health support through various channels such as non-governmental organisations (NGOs).

"There are NGOs in Malaysia such as Tzu Chi that focus on providing mental health support to marginalised communities. These organisations may offer counselling, therapy and other forms of assistance to undocumented or stateless individuals,” he said.

He said that there are also community-based organisations (CBOs) which provide support to underserved populations, including undocumented and stateless individuals.

Lukanisman said these organisations conduct community outreach programmes, support groups and make referrals to mental health professionals.

Additionally, he said there are hotlines and helplines available to anyone in need of psychological and mental health support, such as Talian HEAL 15555 which is managed by registered counselors in the MoH.

"While these services may primarily target the general population, they are typically available to anyone in need, including undocumented or stateless individuals.

"There is also a helpline provided by NGOs such as Befrienders and Mercy Malaysia,” he said. — THE BORNEO POST