Case Studies

Working with African refugees: An opportunity for reconnection

Most African refugees have fled war, famine and displacement from their home country, and many have experienced protracted stays in refugee camps in conditions of extreme deprivation without adequate medical care. Counselling psychologist Dr Jill Parris MAPS works at the Ecumenical Migration Centre where her work focuses on the family relationships of humanitarian entrants from the Horn of Africa. In this interview with InPsych she shares her insights into working with this population.

How did you come to be involved with the Horn of Africa communities and what is your role?

After retiring from working in management of counselling and welfare services at Relationships Australia and the Wesley Mission five years ago, I decided that I would love to give back to Africa, the continent of my birth from where I migrated 30 years ago. I still remember vividly what it was like to leave my birthplace and choose to make Australia my home, and sometimes I still miss Africa.

For many years I put aside my connection to Africa as I got on with building a new life in my adopted home, however when I returned to study the choice was clear: I needed to find a project that would support my fellow Africans whose settlement needs I could understand. I chose to work with people from the Horn of Africa because it offered me the opportunity to reconnect with people who shared some aspects of my life and culture and the experience of displacement that I, my parents and my parents’ parents had known.

Knowing that most African people relate strongly to their communities I decided to explore the possibilities of community cultural development as a method of intervention. As I was interested in comparing counselling with community development, I took up a position as a therapist working with the humanitarian entrants from Africa at the Ecumenical Migration Centre (EMC), which is part of the Brotherhood of St Lawrence.

People are usually referred to EMC to negotiate their transition into Australia. Relationships have often been severed by war and displacement and people seek help dealing with family reunification. Most Africans come from collective societies which have a very different cultural understanding of what family means. An example is that the oldest child often spends many childhood years with grandparents. When the relationship between grandparents and child is severed by migration this causes great difficulty to the new family unit in Australia, which now includes a child who had not been part of the family. When such issues come to the attention of the wider service network, they are often referred to the EMC for support.

What are some immediate and/or longer-term wellbeing and mental health issues confronting people settling in Australia from African countries?

The stresses of adapting to the expectations of Australian society, struggling with learning English and the difficulty of finding meaningful work makes assimilation difficult and can result in depression and strong feelings of alienation.

Many people arrive and simply wish to put trauma behind them and build new lives. It is important that we respect this and do not ‘medicalise’ settlement. On the other hand, several settlers have complex mental health issues (covering the full range of mental disorders) because of years of displacement or simply because such issues have not been diagnosed or treated before coming to Australia.

There is a strong perception that there is a persistent problem with violence among young Sudanese boys. The experience I have had of these youth is that they have faced issues of racism and misunderstanding in Australia. Because the issue was so pressing, I developed a game, ‘Sweet and sour settlement’, as a training tool to be used in schools and with people in the field.

What is your approach to working with these issues?

In general, working with settlers requires a capacity to offer a transitional space where practice, informed by western counselling theory, is translated, and combined with practical support for clients in negotiating mainstream Australian service systems. The aim is to help clients build towards stable and durable family relationships in the Australian context.

I see myself as a cultural anthropologist who understands counselling practice, the Australian service system and the transitional issues faced by newly arrived humanitarian entrants (ethnicity, trauma, dislocation, culture, family and community structure etc), and I employ flexible practices to help clients negotiate these.

What cultural differences are there in working with African settlers who have a mental illness?

When working with these people it is important to understand the cultural imperatives in relation to the illness. For most African settlers the family of the person with a mental illness needs to be fully involved in treatment. They expect to be told how to respond to the person and require clear simple advice about management. Do not expect the family to allow the person with a mental illness to live independently; rather encourage the family to support the person to take responsibility.

What has the experience of working with members of the African community meant for you as a person and as a psychologist?

The experiences of the past five years have been profound. Firstly, I have come to admire the resilience and tenacity of many of the people I have had the privilege of meeting. I have been horrified by the brutality man is capable of and I have come face to face with the ravages of trauma on the soul.

At a deep personal level, each person has brought to our relationship an expectation that I take time to show respect – respect for them and for my own place in society. This they have done by not engaging with the business at hand before enquiring about my family and their wellbeing. This formal process which begins each encounter has helped me to reconnect with what I hold important in terms of heritage, place and belonging. I find that I need to manage my personal boundaries with clients well. Clients often find it difficult to be on time, which makes setting and keeping appointments difficult. Supporting clients with settlement issues requires me to accompany them to meetings that I would not usually attend as a psychologist working in a western style practice. When I see people in their homes, I am careful to clarify my role, not as a friend but as offering a specific professional counselling service.

Importantly the work has connected me with what I believe in as a person – the right of every human to respect and dignity.

Lastly, this work has confronted me with my own prejudice and the need to take time to do more than practice empathy. I make judgments and then often need to rethink them. I have found that the communities with whom I work challenge me to rethink beliefs I was not aware I held. Now I know that the only certainty is change.

How would you advise APS members who might be considering working in a professional role in such a setting?

I would advise anyone wanting to work in this role to take time to consider his or her decision. This work is rewarding but it is also challenging on several levels. Working with people, many of whom have faced profound trauma, is of itself traumatising. It takes a courageous soul to support those facing their horrors and to keep smiling. Many families need help on the practical rather than, or as well as, the psychological level and it is difficult to do one part of the work without the other.

The work is complex as people negotiate all aspects of settlement. You may find yourself involved in practical issues such as a parent’s need to provide lunch for a child going to school. At the other end of the scale, you may need to assist with the difficult task of helping people renegotiating relationships in the light of the expectations of a new and very different culture.

Having said this, it is wonderful to see this country through the eyes of another and to travel with people who have a thirst for productive settlement. Sharing in the wealth of cultural difference is exhilarating and enriching.

Reflecting on your experiences of the strengths and difficulties of working as a psychologist with people who have experienced (and fled) war, conflict and trauma, is there a take-home message for us as psychologists here in Australia, and as global citizens?

This may sound trite, but my main message is to treat others as you would like to be treated. We live in a world where the powerful take from the powerless and then judge them for seeking asylum.

It is always important to think about what you might have done in similar circumstances. When working with trauma make sure that your client is psychologically safe before even beginning to think about talking about it. Always be ready to hold firm boundaries and ground experiences in the present. Take very great care of yourself.

Reference: Heather Gridley. (2012). InPsych, Vol 34, February, Issue 1.

Asha and Sahra’s US Experience

Asha was a 39-year-old woman from East Africa. She arrived in the United States as a refugee and lives with her three children. Her husband was killed during the war in Somalia. Asha’s teenage daughter, Sahra, was having trouble in school. She had many unexplained absences and seemed to be depressed when in school, often crying and refusing to participate in learning. Asha had gone through horrific experiences in Africa. Her village was attacked by militia. Her husband was killed, and the women, including Asha, were raped. Sahra was about four years old when these events took place. She spent most of her early childhood in refugee camps, and the family migrated when she was about 12 years old. Asha never sought help for her trauma even though she was having nightmares and constantly feared that she would be attacked again. She never considered that her children were affected by these horrific events as she believed they were too young to understand what had happened.

Asha herself was having problems with Sahra at home. Sahra often refused to help with chores, and she was violent toward her other siblings and even to her mother. Sahra also refused to speak the family’s native language and only spoke English. Since Asha did not speak much English, she and Sahra did not communicate much.

The school called Asha multiple times requesting that she come for a meeting to discuss her daughter’s school issues. The school counselor explained to Asha that they felt that her daughter needed to see a therapist, and they asked her to sign consent for a referral. Asha refused to sign the papers. She told the counselor that her daughter was not “crazy” so she did not want her to go to a therapist. Finally, the school became aware of the availability of a Trauma Systems Therapy for Refugees (TST-R) team in the school and referred Sahra to the team.

TST-R was specifically created to address the multiple barriers faced by migrant children in need of mental health interventions. It addresses the cultural and linguistic barriers, the stigma attached to mental health, and the primacy of concrete needs. Part of the TST-R team approach is to provide advocacy to support everyday hassles so that a family’s daily stressors are reduced and the potential for worsening of psychological symptoms is averted. The team uses a social-ecological based assessment to evaluate the child and family’s needs in multiple domains, which are identified as refugee core stressors… The TST-R clinical team includes a clinician and a cultural broker and expands to include other service providers as needed. For example, a family struggling with legal issues may be referred to a lawyer who works closely with the team. A cultural broker is a professional who combines cultural and clinical expertise and who acts as a bridge between the clinical team and the community. Cultural brokering is “the act of bridging, linking, or mediating between groups or persons of differing cultural backgrounds”

The first thing the TST-R team did was have a cultural broker go to the home and talk to the mother. The cultural broker was from a similar culture and understood the importance of using non-stigmatizing language to frame services. She used strength-based language focusing on the parent’s goals for the child:

“I know you want your daughter to succeed. Education is very important for a child’s success, but youth who are sad, angry, or stressed because of things that have happened to them in the past can have difficulties focusing on lessons, listening, and getting along with others. This can interfere with their learning and impact their future. I want to work with your child so that I can help her learn how to manage these feelings, memories and difficulties. I know how important your daughter’s future is to you. I know you crossed borders and walked miles, you sacrificed much to bring her to safety. I am committed to helping Sahra so that she can achieve the hopes and dreams you had for her.”

What the cultural broker is doing is aligning with the parent’s priorities, thus developing a common goal or vision for the child so that the parent feels that the provider is helping them achieve what is important to them. Often refugee parents feel that outside experts come to them and act like they know the children better than the parents do. For parents struggling to maintain their parental authority in the face of an alien and often challenging environment, it is important for them to feel that what we are doing with their children is driven by their goals and dreams for them.

The mother told the cultural broker that the family was overwhelmed by multiple resettlement stressors such as lack of adequate housing, unemployment, and fear of losing benefits. She also was afraid she was losing her children, who were no longer acting the way children acted in her native culture. Sahra was already refusing to speak her native language. The family was currently homeless, and Sahra had to change schools four times in the previous year due to the family moving from shelter to shelter. Asha also explained that she felt overwhelmed and had not been sleeping or eating well. She expected life would be easy once she arrived in the United States, but it seemed as though things were getting even worse. She was still reexperiencing some of the previous trauma as well as struggling with new stressors. She asked for help with getting better housing, which she felt would help Sahra who now has to share a room with two younger siblings and had no privacy.

The cultural broker also met with Sahra who told her that she was being harassed at school by other kids who made fun of the way she dresses and tried to pull off her hijab. She said she hated school and did not want to come to class anymore. She also said that she was feeling sad because her mother is always crying and yelling. Sahra told the clinical team that she wished that she had died in the attack on her village because she hated her life.

The TST-R team assessed Sahra in the four refugee core stressors and found that she was facing difficulties in all four. She was facing discrimination and alienation at school; she was struggling with acculturative issues; Sahra had a history of trauma and had not been assessed for PTSD or other mental health symptoms, and she and her family faced resettlement hassles due to unstable housing and limited financial resources to pay rent.

The cultural broker invited Sahra to a group attended by many refugee and immigrant youth. She explained to the mother that these groups would help her daughter adjust to school and provide support for her. It was also important that the groups were led by a co-ethnic who would be able to help the mother communicate with the school if there were other issues. These non-clinical groups were focused on supporting migrant youth like Sahra in learning social skills such as communications and conflict resolutions. The groups provided support for those youth and also taught young people how to identify and manage emotion. Through group participation, Sahra was able to connect with her peers, share her feelings, and learn that others have gone through similar experiences. She was able to do this in a safe and supportive space. The groups were also in place for youth to identify issues such as being harassed by other students and to ensure that the school attended to these issues.

In TST-R, the home-based clinical team works with the whole family by providing family therapy and also by connecting the family to resources and support services. This home-based team was able to address resettlement issues such as helping the family secure permanent housing. They also provided therapy around acculturative stressors within the family, focusing on identifying triggers and developing better child-parent communication skills. The presence of the home-based team also reduced the family’s isolation and addressed the discrimination faced by Sahra at school. Finally, through psychoeducation and individual and family therapy, the clinical team was able to address the trauma and its impact on both family and individuals in the family.

Because the team was focusing holistically on multiple stressors, including acute housing and educational needs, the family was welcoming of the therapy as part of a comprehensive care that addressed priority issues for the family. They saw the psychological therapy as supporting all their problems rather than something alien that was being brought to them by outsiders. Stigma was no longer an issue since the family saw the team as a support system to advance success rather than address a deficit. The cultural broker who continued to be a key part of the home-based team acted as a bridge to other services and helped maintain this holistic and culturally relevant aspect of the intervention.

Sahra responded well to the treatment. She started attending school regularly and she reported better relationships with her mother and siblings. The mother’s symptoms also diminished, and she was able to access additional support through an ethnic-based agency where staff spoke her native language. Services were terminated after six months although the family stayed connected to the program. Sahra became a mentor for other youth who were going through similar experiences in her school.

Reference: Abdi, Saida. (2018). Mental Health of Migrant Children: Oxford Research Encyclopedias, Global Public Health. Department of Social Work, Boston University and Department of Psychiatry, Children’s Hospital Boston. Pages 11 – 13.