213-Refugee Families: Ethical, 213-Refugee Families: Ethical, Clinical, and Training PracticesClinical, and Training Practices

AAMFT 2008 MEMPHIS TN USAAAMFT 2008 MEMPHIS TN USAOctober 31, 2008October 31, 2008

Laurie L. CLaurie L. Charlésharlés Alisa S. BeaverAlisa S. Beaver

Gonzalo M. BacigalupeGonzalo M. BacigalupeUniversity of Massachusetts Boston*University of Massachusetts Boston*

www.familytherapy.umb.eduwww.familytherapy.umb.edu

http://http://refugeefamilies.wikispaces.comrefugeefamilies.wikispaces.com//

*Thanks to Paula Moebus for her help with this presentation!*Thanks to Paula Moebus for her help with this presentation!

Learning ObjectivesLearning Objectives

(1) Identifying core aspects of refugee (1) Identifying core aspects of refugee families assessment & interventionfamilies assessment & intervention

(2) Exploring person of the therapist and (2) Exploring person of the therapist and cultural competency criteria in work with cultural competency criteria in work with this populationthis population

(3) Utilizing a resilience framework to guide (3) Utilizing a resilience framework to guide ethical interventions with refugee familiesethical interventions with refugee families

Refugees & Asylum SeekersRefugees & Asylum SeekersIndividuals and families Individuals and families who have fled their who have fled their country because of a well country because of a well founded fear of founded fear of persecution for reasons of:persecution for reasons of:

• RaceRace• ReligionReligion• Membership in a Membership in a

particular social groupparticular social group• Political opinionPolitical opinion• NationalityNationality

(Photo: Florence Wilson, Liberian refugee Oakland, California, 2007 UNHCR World Refugee Day Photo Contest Winner). UNHCR

Recognizing Refugees & Torture Recognizing Refugees & Torture SurvivorsSurvivors

Country of origin Country of origin Immigration status Immigration status

(refugee, asylee, (refugee, asylee, asylum seeker)asylum seeker)

Politically active in Politically active in their countrytheir country

Member of a Member of a minority groupminority group

Fear of Fear of deportation and deportation and re-displacementre-displacement

NEW YORK—Refugees aboard a ship in New York Harbor, 1951.

© Dennis Stock / Magnum Photos

Family members Family members remain in country of remain in country of originorigin

Coming to the United StatesComing to the United States

Fleeing Country of Fleeing Country of OriginOrigin

Coming as a Coming as a RefugeeRefugee

Coming as an Coming as an Asylum SeekerAsylum Seeker

Photo: Roberto “Bear” Guerra for the IRC.A Somali Bantu family of ten arrives at Boston’s Logan Airport. They are greeted by their caseworker and their eldest son, who arrived in 2004.

Refugee Stages Refugee Stages (“Refugee Career”)(“Refugee Career”)Berry, (1991), and Prendes-Lintel, (2001)Berry, (1991), and Prendes-Lintel, (2001)

Pre-departurePre-departure

FlightFlight

First AsylumFirst Asylum

ClaimantClaimant

SettlementSettlement

Adaptation Adaptation

Global Context of Forced MigrationGlobal Context of Forced Migration

Internal conflicts the most prevalent Internal conflicts the most prevalent type of conflict resulting in type of conflict resulting in displacement (Marshall and Gurr, displacement (Marshall and Gurr, 2003 in Ingleby, 2005)2003 in Ingleby, 2005)

Internally displaced persons Internally displaced persons outnumber refugees who leave their outnumber refugees who leave their home countrieshome countries

Global Context of Forced MigrationGlobal Context of Forced Migration

35.5 million refugees at the end of 35.5 million refugees at the end of 20032003

23.6 million of these Internally 23.6 million of these Internally DisplacedDisplaced

11.9 million became international 11.9 million became international refugees (USCR, 2004).refugees (USCR, 2004).

Factors affecting ability to fleeFactors affecting ability to flee

Access to Access to transportationtransportation

Government policy of Government policy of host countries (1951 host countries (1951 Geneva Convention on Geneva Convention on Refugees attempted Refugees attempted to set policy, but to set policy, but adoption varies)adoption varies)

Individual/family Individual/family resourcesresources

State of State of Conflict/SafetyConflict/Safety

Consultation Room used by Mental Health Team working with those displaced by war; Boguila Hospital, Central African Republic. Picture by Laurie L. Charles, 2008

Most countries accepting refugees Most countries accepting refugees are non-Western countriesare non-Western countries

Total for US, Canada, Total for US, Canada, Australia and New Australia and New Zealand is only 3%Zealand is only 3%

Europe 7%Europe 7% Non-Western Non-Western

Continents accepting Continents accepting refugees:refugees:

Middle East 37%Middle East 37%

Africa 27%Africa 27%

Southern & Southern & Central Asia 16%Central Asia 16%

““Refugees to the West a Refugees to the West a select group…select group…

able to plan, pay for able to plan, pay for and undertake a and undertake a hazardous and hazardous and uncertain enterprise”uncertain enterprise”

(Ingleby, (Ingleby, 2005)2005)

The Refugee ExperienceThe Refugee Experience

Please take a moment and list 10 Please take a moment and list 10 things that are near and dear to you. things that are near and dear to you. This list might include the people in This list might include the people in your life, school or work, ideals and your life, school or work, ideals and beliefs, culture or material beliefs, culture or material possessions. possessions.

Learning Objective #1:Learning Objective #1:

Identifying Identifying core aspects core aspects of refugee of refugee families families assessment & assessment & interventionintervention

Art by Grace Huang, Amermann Elementary School, Northville, Michigan UNHCR World Refugee Poster Winner . UNHCR

Trauma AssumptionsTrauma Assumptions Refugees assumed to have traumaRefugees assumed to have trauma DSM PTSDDSM PTSD

• Life threatening event(s)Life threatening event(s)• hyper-arousalhyper-arousal• intrusive thoughts/imageryintrusive thoughts/imagery• avoidant thoughts/behavioravoidant thoughts/behavior

Assumed therapeutic goals: Processing, working Assumed therapeutic goals: Processing, working through, mourning, etc. through, mourning, etc.

Alternative PTSD ConstructAlternative PTSD Construct• Judith Herman’s Complex PTSDJudith Herman’s Complex PTSD• Emphasis on relationship, safety, coping along with Emphasis on relationship, safety, coping along with

mourningmourning

Rethinking Trauma Paradigms Rethinking Trauma Paradigms (Ingleby, 2005)(Ingleby, 2005)

““PTSD concept” pathologizes a normal PTSD concept” pathologizes a normal response to extreme eventsresponse to extreme events

DSM PTSD dx presupposes discrete DSM PTSD dx presupposes discrete traumatic events, not long series of traumatic events, not long series of experiences often experienced by experiences often experienced by refugeesrefugees

Exposure to events is not a reliable Exposure to events is not a reliable predictor of symptoms – other factors predictor of symptoms – other factors influence sequelaeinfluence sequelae

Confusion of cause and effectConfusion of cause and effect Confusion of event and situation; PTSD Confusion of event and situation; PTSD

ignores contextignores context

Trauma history assumptions should not Trauma history assumptions should not (necessarily) dictate therapeutic goals(necessarily) dictate therapeutic goals

Refugees may want/need more Refugees may want/need more attention to more immediate attention to more immediate concerns (housing, work, school, concerns (housing, work, school, reunification) (Summerfield, 2002, reunification) (Summerfield, 2002, Hays, 2007).Hays, 2007).

Culture may value “active forgetting” Culture may value “active forgetting” over “processing trauma” over “processing trauma” (Summerfield, 1999, Angel et al, (Summerfield, 1999, Angel et al, 2001, Ingleby, 2005) 2001, Ingleby, 2005)

Sense of Family and CommunityBefore Torture / War

family

stabilit

yhealth

sense of belonging

well being

control

safety

trust

power

self worth

dignity

faith

Sense of Family and CommunityReduced by Torture / War

ILLNESS

WOUNDS

TORTURE

LOSS OF LOVED ONES

WITNESSING ATROCITIESDISPLACEMENT

REFUGEE CAMPS

RAPE CONCENTRATION CAMPS

MISTRUST

Sense of Family and CommunityRe-Constituted Post-Migration

Negotiating U.S. Institutions & Systems Education?

LOSS OF LOVED ONES & new relationships

“American-ized” children/confusion about U.S. social norms

New Language

Outsider/

Insider WORK & LIVELIHOOD?

Experiential Exercise: Packing Your Experiential Exercise: Packing Your SuitcaseSuitcase

You are a journalist in the country of L who You are a journalist in the country of L who

runs a newspaper where controversial runs a newspaper where controversial political pieces are published. A fellow political pieces are published. A fellow journalist “disappears” and during the journalist “disappears” and during the next few months you receive several next few months you receive several threatening calls, and your name appears threatening calls, and your name appears in a government publication listing in a government publication listing suspected subversives. One night you suspected subversives. One night you arrive home to an anonymous letter arrive home to an anonymous letter threatening your life. You decide you must threatening your life. You decide you must flee and seek political asylum elsewhere. flee and seek political asylum elsewhere.

Packing Your SuitcasePacking Your Suitcase

You have 2 minutes to pack your You have 2 minutes to pack your bags. You may take only what is in bags. You may take only what is in your house at the moment and what your house at the moment and what you can carry with you. You don’t you can carry with you. You don’t want to obviously look like someone want to obviously look like someone leaving the country. You may choose leaving the country. You may choose 8 categories of things to bring (e.g. 8 categories of things to bring (e.g. clothing).clothing).

Factors that Affect Utilization of Services Factors that Affect Utilization of Services By SurvivorsBy Survivors

Lack of knowledge of resources availableLack of knowledge of resources available Limited access to insurance and lack of Limited access to insurance and lack of financial resourcesfinancial resources Lack of bilingual providers / interpretersLack of bilingual providers / interpreters Lack of culturally competent providersLack of culturally competent providers Lack of literature written in native languageLack of literature written in native language Mistrust of Western health systemMistrust of Western health system Stigma of mental illnessStigma of mental illness ShameShame

ORGANIZING A SYSTEMIC STANCEORGANIZING A SYSTEMIC STANCE

Develop your working knowledge of the Develop your working knowledge of the life experiences and resettlement issues life experiences and resettlement issues of refugees, asylum seekers and asylees of refugees, asylum seekers and asylees before, during, and after conflicts/violencebefore, during, and after conflicts/violence

Enhance your understanding of a refugee Enhance your understanding of a refugee survivor’s life before the trauma and survivor’s life before the trauma and uprooting, including knowledge of past uprooting, including knowledge of past resources, strengths, roles, status, and resources, strengths, roles, status, and other core aspects of identity and other core aspects of identity and meaning.meaning.

ORGANIZING A SYSTEMIC STANCE: Sources for ORGANIZING A SYSTEMIC STANCE: Sources for learning more about the history of a peoplelearning more about the history of a people

Oral & Written historiesOral & Written histories Country reports from governmental or (I) Country reports from governmental or (I)

NGO or human rights organizationsNGO or human rights organizations Accounts from cultural anthropology and Accounts from cultural anthropology and

sociologysociology The arts (drama, poetry, memoirs, visual The arts (drama, poetry, memoirs, visual

arts)arts) Web sites maintained by political or social Web sites maintained by political or social

justice organizations within the country as justice organizations within the country as well as outsidewell as outside

ASSESSMENT INFORMATIONASSESSMENT INFORMATION:: Important Things to Learn About the FamilyImportant Things to Learn About the Family

What was the family’s previous social, What was the family’s previous social, economic, educational or political status? economic, educational or political status?

What are some of their beliefs, practices, What are some of their beliefs, practices, rituals, ceremonies, or significant rituals, ceremonies, or significant achievements or milestones?achievements or milestones?

What are the family, social, and What are the family, social, and community roles? community roles?

What can you learn about pre-migration What can you learn about pre-migration functioning? What was the highest functioning? What was the highest functioning level in home country?functioning level in home country?

Who Who was was this family before they were this family before they were displaced? displaced?

ASSESSMENT INFORMATIONASSESSMENT INFORMATION, con’t., con’t.:: Important Things to Learn About the FamilyImportant Things to Learn About the Family

How was daily life lived?How was daily life lived? What became of their homes? What are their ties What became of their homes? What are their ties

to the land?to the land? What are other aspects of the family’s status or What are other aspects of the family’s status or

resources? resources? What are the family’s beliefs and practices What are the family’s beliefs and practices

relevant to relevant to HealthHealth HealingHealing SufferingSuffering Sickness Sickness Loss Loss GriefGrief MourningMourning JoyJoy Well beingWell being Peace?Peace?

Learning Objective #2: Learning Objective #2: Exploring person of the therapist and Exploring person of the therapist and cultural competency criteria in work with the refugee populationcultural competency criteria in work with the refugee population

Photo by Gonzalo Bacigalupe, 2008

Cultural Competency-An Ethical Cultural Competency-An Ethical ImperativeImperative

AttitudesAttitudes – appreciation of multiple cultural – appreciation of multiple cultural perspectives; awareness of/safeguards against perspectives; awareness of/safeguards against ethnocentricity; openness; collaborative curiosity; ethnocentricity; openness; collaborative curiosity; all counseling as multi-culturalall counseling as multi-cultural

KnowledgeKnowledge – cultural practices/ information; – cultural practices/ information; cultural practices/information/intersection of cultural practices/information/intersection of identities, contexts, privileges, & oppressionsidentities, contexts, privileges, & oppressions

SkillsSkills – breadth, flexibility in clinical skills; – breadth, flexibility in clinical skills; shifting frameworksshifting frameworks

Knowledge: Re-evaluating Knowledge: Re-evaluating Therapeutic frameworksTherapeutic frameworks

Culturally specific interventionsCulturally specific interventionsmeditationmeditationreligious rituals/practicereligious rituals/practicecommunity art/action (AIDS community art/action (AIDS

quilt)quilt)Use/Modification of Western Use/Modification of Western interventionsinterventions

12 step principles re-written from a particular 12 step principles re-written from a particular cultural perspectivecultural perspective

Narrative therapy and story-tellingNarrative therapy and story-telling

Cultural Competency and Self of Cultural Competency and Self of the Therapistthe Therapist

Experiential exercises, Journals, Experiential exercises, Journals, Discussion re:Discussion re:

EmpathyEmpathyLossLossResilienceResilienceStrengthsStrengthsValues/World ViewValues/World ViewVarieties of cultural practiceVarieties of cultural practice

Cultural Competency and Self of Cultural Competency and Self of the Therapist, cont’d.the Therapist, cont’d.

Inter-disciplinary approach to Inter-disciplinary approach to learning/teaching:learning/teaching:• Self-ReflectionSelf-Reflection• Field ExperiencesField Experiences• InterviewsInterviews• Film, Literature, MemoirsFilm, Literature, Memoirs• Class FacilitationClass Facilitation

Cultural Competency and Self of Cultural Competency and Self of the Therapist, cont’d.the Therapist, cont’d.

Cultural competency, like Cultural competency, like ‘collaborative supervision’ or ‘joining’ ‘collaborative supervision’ or ‘joining’ refers to categories of behavior that refers to categories of behavior that occur only in relationship with an occur only in relationship with an audience. audience. L. Charles, 2007, Qualitative InquiryL. Charles, 2007, Qualitative Inquiry

• It is a performance achieved in the It is a performance achieved in the moment-to-moment interaction (Gale, moment-to-moment interaction (Gale, 2007, JMFT) between one’s self and 2007, JMFT) between one’s self and othersothers

Performing Culturally Competent Performing Culturally Competent Work with RefugeesWork with Refugees

Re-think the language you use to Re-think the language you use to describe therapydescribe therapy

Try using language & metaphors Try using language & metaphors provided by client, even it if means provided by client, even it if means giving up your favoritesgiving up your favorites

Find ways to question your cultural Find ways to question your cultural assumptions at every stage of the assumptions at every stage of the workwork

Learning Objective #3 Learning Objective #3 Utilizing a resilience Utilizing a resilience framework to guide ethical interventions with refugee framework to guide ethical interventions with refugee

familiesfamilies

What principles and What principles and tools are emerging as tools are emerging as useful in the work with useful in the work with refugee families?refugee families?

Advancing a Advancing a collaborative collaborative relational clinical relational clinical approach: The IIB approach: The IIB and UMB Projectand UMB Project

IVORY COAST—Liberian refugees, 1995.IVORY COAST—Liberian refugees, 1995.© Leonard Freed / Magnum Photos© Leonard Freed / Magnum Photos

Working Model PrinciplesWorking Model PrinciplesCollaborative workCollaborative work

• The patient as a content expertThe patient as a content expert• Conversation process is continuously Conversation process is continuously

negotiatednegotiated• Intra-institutional and inter-institutional trust Intra-institutional and inter-institutional trust

relationsrelations Conversations are the therapeutic toolConversations are the therapeutic tool1.1. Language as constitutive rather than Language as constitutive rather than

representingrepresenting2.2. The assessment and intervention are The assessment and intervention are

iterative processesiterative processes

Working Model PrinciplesWorking Model Principles

Therapy is not always the Therapy is not always the preferred routepreferred route

Therapists facilitate assessment by Therapists facilitate assessment by working with family to see what their working with family to see what their needs are: Utilityneeds are: Utility

The power of the storyThe power of the storyWitnessing: Documentation of Witnessing: Documentation of

testimonytestimonyThe story-making context is core (the The story-making context is core (the telling occurs in context)telling occurs in context)

Working Model ToolsWorking Model Tools

Co-therapy and team workCo-therapy and team workLearning toolLearning tool

Heighten accountabilityHeighten accountability

Develops shared languageDevelops shared language

Supports and sustain therapist’s Supports and sustain therapist’s listening of traumatic storieslistening of traumatic stories

Working Model ToolsWorking Model Tools "Case management" & advocacy "Case management" & advocacy

are complementary practicesare complementary practices

Outreach workOutreach workSafetySafetyConfidentialityConfidentialityTrustTrust

Appreciative inquiry Appreciative inquiry Inquiry into assetsInquiry into assetsEnvisioning a futureEnvisioning a futureAccessing resources Accessing resources

Negotiating the First InterviewNegotiating the First Interview

• What do federal and state agencies expect? What do federal and state agencies expect? What do institutions believe is core?What do institutions believe is core?

• The intake as an opportunity for engagementThe intake as an opportunity for engagement• Appointments are a cultural artifact: An Appointments are a cultural artifact: An

opportunity to design it anew opportunity to design it anew • What forms encourage a family to attend the What forms encourage a family to attend the

first session?first session?• Videotape: Distinguishing it from torture and Videotape: Distinguishing it from torture and

surveillancesurveillance• Documenting: balancing accountability and Documenting: balancing accountability and

confidentialityconfidentiality

Immigration and refugee Immigration and refugee experiences intersectexperiences intersect

Distinct dimensionsDistinct dimensions• Unique historical narratives (family, community)Unique historical narratives (family, community)• Less frequent experiences of severe trauma at a Less frequent experiences of severe trauma at a

community levelcommunity level• Unique resources available to refugeesUnique resources available to refugees• Potential for more individual family experiences, Potential for more individual family experiences,

rather than whole community experiencerather than whole community experience Parallel dimensionsParallel dimensions

• Process of negotiating new language, cultureProcess of negotiating new language, culture• Choices of how to balance/maintain historical and Choices of how to balance/maintain historical and

future language/culturefuture language/culture• Challenge of prejudice/racism from the new cultureChallenge of prejudice/racism from the new culture

Negotiating Larger SystemsNegotiating Larger Systems

Dilemmas in schools negotiating the special Dilemmas in schools negotiating the special education system:education system:• Avoiding inappropriate diagnoses and Avoiding inappropriate diagnoses and

obtaining needed servicesobtaining needed services• Culturally competent assessment of learning Culturally competent assessment of learning

and cognitive abilityand cognitive ability• Activating resources and avoiding conflict Activating resources and avoiding conflict

among administrators, teachers, advocates, among administrators, teachers, advocates, families, etc.families, etc.

• Negotiating obstacles of within group diversity Negotiating obstacles of within group diversity - when the interpreter/teacher is seen as the - when the interpreter/teacher is seen as the enemyenemy

• Advocacy and Community ActionAdvocacy and Community Action

Negotiating Larger Systems: Negotiating Larger Systems: Schools - Schools - a case examplea case example

Ali is a 13 year old student whose family are Ali is a 13 year old student whose family are refugees from Somalia, but who was born, along refugees from Somalia, but who was born, along with his brothers and sister in a camp in Kenya. with his brothers and sister in a camp in Kenya. He learned to recite parts of the Qur’an, and He learned to recite parts of the Qur’an, and knows the English alphabet, but has never been knows the English alphabet, but has never been instructed in any written language. He’s had instructed in any written language. He’s had some interpersonal difficulties related to different some interpersonal difficulties related to different expectations about male/female relations in expectations about male/female relations in school. His teachers suggest to the educational school. His teachers suggest to the educational advocate to refer him for evaluation for Special advocate to refer him for evaluation for Special Education. His school has a Somali para-Education. His school has a Somali para-professional who is Christian, from a different professional who is Christian, from a different tribe and socio-economic status.tribe and socio-economic status.

Questions to Think About:Questions to Think About:

1.1. What might your role be as a helper What might your role be as a helper to Ali and his family? to Ali and his family?

2.2. To qualify for Special Education Ali To qualify for Special Education Ali must have a disability – does he? must have a disability – does he? How will you assist Ali’s family to How will you assist Ali’s family to navigate the educational systems?navigate the educational systems?

3.3. What systems within schools allow What systems within schools allow for development of services to a for development of services to a group, rather than an individual?group, rather than an individual?

Collaborative Therapy: A Table of Relationships

Photo By Gonzalo Bacigalupe

Contact InformationContact Information

Laurie L. Charles: laurie.lopez_charles@umb.eduLaurie L. Charles: laurie.lopez_charles@umb.edu Alisa S. Beaver: alisa.beaver@umb.eduAlisa S. Beaver: alisa.beaver@umb.edu Gonzalo M. Bacigalupe: gonzalo.bacigalupe@umb.eduGonzalo M. Bacigalupe: gonzalo.bacigalupe@umb.edu

University of Massachusetts Boston University of Massachusetts Boston M.S. in Family Therapy ProgramM.S. in Family Therapy ProgramDept. of Counseling & School PsychologyDept. of Counseling & School Psychology100 Morrissey Blvd100 Morrissey BlvdBoston, MA 02125Boston, MA 02125

www.familytherapy.umb.eduwww.familytherapy.umb.edu

http://refugeefamilies.wikispaces.com/http://refugeefamilies.wikispaces.com/