Resilience, Suffering and Creativity: The Work of the Refugee Therapy Centre

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The trauma of refugee status is particularly corrosive. It does the usual harm of devastating our own self-image and sense of permanence in the world, but it does more. It is a dislocation from our familiar domestic geography and culture, and that must wrench from our grasp all the external markers by which we know ourselves and our worth. The threat of persecution, torture, and death is aimed at a complete destabilization. The result is a complex of anxieties that add up to far more than simple suffering. If therapy is primarily aimed at the gentle exposure of one's worst fears, then what purchase can it have on this most ungentle process of becoming a refugee?

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CHAPTER ONE: Trauma, resilience, and creativity

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Aida Alayarian

“Resilient: adj. 1 able to recoil or spring back into shape after bending, stretching or being compressed. 2 able to recover quickly after difficult conditions”

(Oxford English Dictionary, 2001)

Introduction

Resilience has been defined as the ability to experience severe R trauma or neglect without a collapse of psychological functioning or evidence of post traumatic stress disorder. It differs from well-being or positive mental health, which assumes an acceptable environment and effective psychological functioning. Such positive mental health requires, as well as resilient qualities, the creation of a protected inner space.

The ideas in this and the following chapter derive from two principal sources: my own personal experience and my experience of working with refugees who, in my view, possess the art of living, who have suffered traumatic events such as death camps or labour camps, imprisonment, torture, hiding, fleeing, leaving behind everything familiar in order to stay alive. I am focusing on people who have been able to move on in life after their traumatic experiences, to re-create a reasonably happy atmosphere for their family to integrate into a new society to work effectively in their profession or occupation, and to love and contribute to the life of the community they live in.

 

CHAPTER TWO: Resilience: a case illustration

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Aida Alayarian

This chap ter s how s some phases in th e treatment of a young woman, and the place of resilienc e in her therapy.

In presenting the case of Mariana, we see how the therapy enabled her to reconnect with the original basis of resilience that later experiences had jeopardized and almost destroyed. We shall see her alternating between relatively aggressive responses and stable defences.

Mariana, a Middle-Eastern woman in her thirties, referred herself for therapy. Her parents are both in their seventies and living in her county of origin. Her father was a successful businessman. He had problems with drink and drugs. She described her mother as a depressed, irresponsible, angry, and uncaring teacher and mother. Mariana is the eldest of three, with brothers two and seven years younger. She had a normal birth and had been a happy baby and developed well. She described her childhood as peculiar and her family as a dysfunctional one. She remembered repeated physical and emotional abuse by her father. Her difficulties began when her father began to exercise irrational strictness that made her fearful and defensive. Her mother had not had the strength to help her during those periods of her life and she left feeling unprotected. She finished her high school at the age of eighteen and achieved a National Diploma.

 

CHAPTER THREE: Memory for trauma

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Stuart Turner

Introduction

There is no simple description of the dilemmas facing refugees. Legally, refugees are people who have an experi-T ence of fear—a well-founded fear of arbitrary persecution in their own country (UN Convention on Refugees, 1951). It is a fear of what may happen in the future, although typically it is based on what has already transpired. Some refugees become generally fearful, perceiving even safe or neutral situations as threatening, attributing dangers where none exists. This aspect of their experience is discussed in this chapter, taking account of theoretical aspects of traumatic memory. However, this topic needs to be placed in a much broader framework.

Refugees may have faced exceptional circumstances such as torture, state violence, sexual assault, persecution, displacement, ethnic cleansing, civil war, arbitrary arrest, and they may have witnessed or heard about serious injury, murder, and massacre. There may be particular issues affecting some refugee communities that are irrelevant to others; this work demands a good knowledge of history, geography, religious and cultural variation.

 

CHAPTER FOUR: The therapeutic needs of those fleeing persecution and violence, now and in the future

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Lennox K. Thomas

Introduction

The maxim of “a stitch in time saves nine” needs to be borne in mind when thinking about and planning therapeutic T work with refugees. For all the experiences of persecution and torture in their country and the estrangement in their place of refuge, some sense has to be made of the experiences. Greater planning needs to take place in order to ensure better mental health services for refugees and asylum seekers. This is not just important at the point of arrival but for the future, particularly for children and young people. Many professionals could be helpful in that process, among them general medical practitioners as the first line of contact, then schools, and psychotherapists. Therapists are more likely to attend to people who are experiencing psychological and emotional problems, but there are others involved in hospitalization, religious counselling, or other assistance who might also need to be able to understand the cultural context of the psychological presentation. In that regard, the planning of services might require the input of social and medical anthropologists, whose understanding of culture and symptomatology will be helpful. Because being a refugee is not a normal part of life and is therefore something that most people will be unlikely to experience, some asylum seekers will need help with the process of resettlement. While for some the move from one country culture, and language might be relatively unproblematic and taken on as one of life's challenges, others might want help for a variety of reasons. For many, there may be needs as a result of the trauma they experienced, as well as a call for legal support with their asylum claim. Not everyone who is referred for therapy will need it at that time, or at any other time for that matter.

 

CHAPTER FIVE: Does it matter how much can be put into words? Complexities of speech and the place of other forms of communication in therapeutic work with refugees

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Dorothy Daniell

Introduction

These reflections come from three years of work at the Refugee Therapy Centre.

My previous experience has been as a traditionally trained psychotherapist in private practice. I am particularly interested in how these two areas of work relate to, and inform, each other. I am focusing on the situation where client and therapist do not share a common language and an interpreter takes a dynamic part in the work.

Freud's theory and technique in relation to the role of speech in psychoanalysis

Common sense tells us that it matters intensely what can be spoken—in terms of the self being able to recognize its thoughts and feelings, and to share its experience with others.

Behind the naïve question “Does it matter how much can be put into words?” and the common-sense response, “Of course we know that it does!”, we can trace Freud's struggle to develop theory about the centrality of speech in psychoanalysis. He gave his patients a basic rule: that they should say directly whatever came into their minds, while on the couch, without holding anything back. This work of free association, and the analyst's interpretation, had the aim of lifting repression and extending the patient's area of consciousness. Freud also developed his aim of strengthening the patient's ego, by means of the analytic work. A note on the development of Freud's thinking concerning the role of speech related to mental functioning, is placed at the end of this chapter.

 

CHAPTER SIX: Loss of network support piled on trauma: thinking more broadly about the context of refugees

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Tirril Harris

It is understandable that the endurance of trauma is always the first issue to feature in any discussion of the refugee experience. I But other aspects are equally important in their impact upon refugee well-being. As Burnett and Thompson (2005) have argued, the experience of exile involves such substantial change that any intervention should be at a more holistic level rather than the simple focus on trauma, and that one of the priorities should be to recognize the importance of rebuilding the social world.

However, they are realistic about the enormity of the task, even for those who have fled with other family members, pinpointing the difficulty of forming a new network without the usual security provided by an established set of close ties on which to build. In this chapter I shall explore ideas concerning the fulfilment of this task, building on my experience both at the Refugee Therapy Centre and with participants in social psychiatry research projects with which I have been involved (Brown &Harris, 1978; Brown, Andrews, Harris, Adler, &Bridge, 1988; Harris, Brown, &Robinson, 1999; see also Brown, Adler, &Bifulco, 1986; Brown, Bifulco, Veiel, &Andrews, 1990). I shall start by looking at the theories and evidence concerning the manner in which different aspects of “social support” promote both physical and mental health, then consider what I have learnt about other aspects of the support networks developed in other cultures from talking with clients, and finally address the ways in which expectations of UK therapists and counsellors need to be adapted because of these other aspects.

 

CHAPTER SEVEN: Hearing the unhearable, speaking the unspeakable: original wounds, trauma, and the asylum seeker

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Bernadette Hawkes

“A woman like her should bear many children so she can afford to have one or two die”

(Ama Ata Aidoo, 1970)

Introduction

W hen I first began working with refugees and asylum seekers, I knew that they would have some sort of psychological problems. To leave behind a home, family members, become stateless, and in many cases to lose all one's possessions would be a large burden for anyone to bear. What I did not know and found it hard to imagine was that refugees often witnessed the rape and murder of their loved ones, that they would be forced to watch their homes being razed to the ground. I could not visualize the pain and physical damage they suffered at the hands of torturers, that they would walk hundreds of miles seeking a place of safety, or, if they had any money at all, they would use it to pay (often) unscrupulous people to arrange papers and a passage to another country that was apparently safer than the one they were leaving behind. What I have learned is that many people do survive, but their experiences leave scars that run deep and these are both physical and psychological. I have also come to know that the scars cover old wounds that are embedded so deeply that they affect the mind as well as the body. The wounds of the recent past re-stimulate the wounds from long ago. It seems that once the asylum seeker feels relatively safe, the mind is opened up and they “rememory” past traumas that have not been resolved. The concept of “rememory” is a useful notion that I came across in Toni Morrison's novel Beloved (1987).

 

CHAPTER EIGHT: How I became a psychoanalyst

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Darlene Bregman Ehrenberg

In responding to the question of how I became a psychoanalyst, in America, outside the classical tradition, my thoughts go in I several directions. The first has to do with what in my personal history led to my choosing to become a psychoanalyst. The second has to do with what I then encountered and the choices I made professionally. Another has to do with the issue of being “inside” versus “outside” the classical tradition. Although it is obviously not possible to address all these issues in depth here, I share some thoughts about each.

My experience growing up first-generation American, in the Bronx, in New York City, in a family that had been devastated by Russian1 pogroms and persecution and later by the Holocaust, was that surviving trauma was the condition of being alive.

One year before I was born, my father's sisters, their husbands, and their children and infant grandchildren were buried alive by the Nazis in their town, David Horodok, a shtetl six miles from Pinsk in what is now Belarus and then was Poland but had been part of Russia when my father was growing up. The one Jew who had escaped, and who later wrote a book about what happened (a yizkor, “remembrance”, book), described how the ground over the mass grave was still moving three days afterward. My father, who gave me a copy of that book when I was an adult, told me, when he was well into his nineties, that there was never a day in his life after their deaths that he did not wake up thinking about his sisters, who had raised him, and about their families. (His mother had died when he was two years old.) And, until the day he died, a few days before his ninety-seventh birthday, he always carried in his pocket the last letter he received from his niece Mania. She had received a scholarship to Oxford before the massacre in which she and virtually the entire Jewish population of their town were so brutally murdered.

 

CHAPTER NINE: My experience of clinical work with refugees and asylum seekers

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Aida Alayarian

It is well established that mental illness often results from, or is worsened by, other social stresses such as bereavement, home-I lessness, discrimination, and poverty, particularly if two or more stresses happen together. In the acute phase of traumatic experience, the initial response is shock, arising from the sudden loss of balance in the individual's ego when the object is lost forever. There may be motor retardation, even complete collapse. In the face of an acute and massive loss of a valued object the first reaction is a peculiar state of the ego which Grinberg (1992) refers to as “shock or stupor”.

People become more stable with sympathetic listening. The experience of loss and its associated feelings can be faced with acceptance, and even psychotic conditions can evaporate when the ring of isolation is broken. Refugees have a higher risk of mental illness than others, showing depression, anxiety, or post traumatic stress disorder. They are frequently diagnosed as being in paranoid states, with paranoid schizophrenia. They may also present suicidal ideation or behaviour, outbursts of anger, restlessness, withdrawal, and psychosomatic symptoms. Some refugees may be in good spirits on arrival but a short while later, stress may show in their lives.

 

CHAPTER TEN: Boundary problems and compassion

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Aida Alayarian

When I think about supervision and its constraints, especially with the population we are serving with trauma and resilience, compassion comes to my mind. The definition of the word trauma, in a psychological sense, combines internal experience and external events: it suggests helplessness, and an event that confronted us with a realistic threat to our life or personal integrity.

For most of my career, I carried a caseload of patients with the severe character pathology of so-called post traumatic stress disorder. I have spent much of my professional life as a consultant or supervisor to therapists working with this client group.

I have noted with growing concern how often some of our most disturbed patients have had to suffer from boundary violations. It is easy to criticize colleagues who have lost their way in the treatment of severely traumatized patients so, as an alternative, in this chapter I present for our learning, in as much detail as confidentiality allows, a case I became involved in.

 

CHAPTER ELEVEN: Reflections on alternative organizational structures for charitable agencies

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Josephine Klein

This book is about the Refugee Therapy Centre, and this chapter came into being because of the Centre. It could not have T been thought about without my experience of the Centre, but it does not describe the Centre, except where I have said so explicitly. The Centre's employment policies and strategies are those considered normal in contemporary society, except in this single respect, that we prefer appointing refugees and asylum seekers.

Can we solve an old problem …

In a previous paper, “Why, as nearly as we can, we want our Refugee Therapy Centre to be run by people who have known enforced migration” (Klein, 2005), I cast an eye over the history of organizations of fortunate people whose compassion and/or guilt and/or sense of justice led them to help less fortunate others who were suffering from poverty, ignorance, oppression, or other hardships. I came to a conclusion:

In all these accounts we have to recognize at least one common factor: there are likely to be failures of understanding when a more favoured person helps a less favoured one, and this often generates a second problem, namely that the help offered will be imperfectly focused … . Learning from books, lectures, placements, even from friends, comes a poor second to having it happen to you. [Klein, 2005, p. 24]

 

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