ICATA Journal
Working with Refugees: A CAT-Based Relational Perspective
Cite as: Melville, F., & O’Brien, J. (2017). Working with Refugees: A CAT-Based Relational Perspective.International Journal of Cognitive Analytic Therapy and Relational Mental Health, 1(1), 54–71. https://www.internationalcat.org/volume-1-2
Int. Journal of CAT & RMH Vol.1 No.1 March 2017/ISSN2059-9919
Abstract
In the context of the Syrian refugee crisis this paper explores how the relational framework of Cognitive Analytic Therapy (CAT) can be applied to working with refugees. Having a relational and contextual understanding of, and response to, the refugee experience is critical in responding humanely to the needs of refugees. This paper takes a look at an existing trauma recovery framework, utilising a relational perspective, focusing on four core adaptive systems that dominate the refugee experience: safety, attachment, meaning and identity, and justice. The narratives of survivors, professionals and services are drawn upon to illustrate the dominant reciprocal roles in each domain. The intention of this paper is to stimulate dialogue about how the CAT framework can enable services and professionals to feel more empowered when working with refugees.
Keywords: Refugee, Asylum-Seeker, CAT, Relational Mental Health
Introduction
The Syrian refugee crisis has highlighted how the public and political responses to the refugee phenomenon are often polarised. The tragedy is that these responses reinforce the themes already dominant in the narratives of refugees, that is, vulnerability, disconnection, discrimination, disempowerment and being devalued. Concomitantly, health and welfare sectors in countries of re-settlement struggle to engage and meet the complex set of psychiatric and psychosocial needs (Centre for Multicultural Youth (CMY), 2015; Colucci, Minas, Szwarc, et al., 2015; McColl, McKenzie, & Bhui, 2008). As a consequence services and professionals in countries of re-settlement often feel overwhelmed, pressured and powerless and refugees continue to feel misunderstood, alienated and disempowered and, as a consequence, may not seek help for their difficulties.
It is generally accepted that responses to refugees require an integrated approach that not only targets individuals but also the wider refugee communities (CMY, 2015; Miller & Rasmussen, 2010; Williams & Thompson, 2010). Traditional, conceptual frameworks and models of care, however, have focused on the psychiatric symptomatology of refugees, with an emphasis on post-traumatic stress disorder. These approaches have been widely criticised as being too reductionistic and neglectful of the importance of the relational and sociocultural context both in terms of the resilience to and recovery from traumatic experiences (Bhui & Bhugra, 2002; Eades, 2013; Kirmayer, 2005; Silove, 1999; Summerfield, 2000). Subsequent research highlighted the role of pre migration and post migration variables and the need to bridge the gap between psychiatric symptomatology, psychosocial and resilience frameworks (Eades, 2013; Miller & Rasmussen, 2010).
Most countries of re-settlement have a range of specialist and mainstream services. Mainstream services still tend to be dominated by the psychiatric paradigm. Concomitantly, critics highlight that while specialist services have made efforts to develop more holistic and integrated approaches they still tend to focus on interventions that are linked to individual recovery frameworks (Eades, 2013; Summerfield, 2000). These approaches do not adequately consider the socio-cultural context (and systems) or explore the relational aspects that reinforce (or protect from) the experience of trauma and themes of vulnerability, disconnection, discrimination and disempowerment (Eades, 2013). In the current political and economic climate the challenge is for professionals, services and indeed society to respond in ways that enable the inherent adaptive resilience of refugees and their communities; the relational context being critical to such.
In this paper we provide a preliminary exploration of how the CAT relational framework can be used when working with refugees. There is a growing literature describing the use and principles of Cognitive Analytic Therapy (CAT) with different populations including people with personality disorders (Kerr, 2006), psychosis (Kerr, Birkett, & Chanen, 2003) and learning disabilities (Lloyd, J & Clayton, P., 2013). While there is some literature on CAT and working cross-culturally (Brown & Msebele, 2011; Emilion, 2011; Toye, 2003) there is a scarcity of discussion on working with refugees (Brown, 2011).
In this paper we focus on advocating for a better understanding of the socio-cultural context of the refugee experience and the incorporation of a relational perspective that takes into account the individual’s developmental narrative (and reciprocal role patterns) and patterns enacted by the refugee experience currently in the very core of intervention frameworks and recovery processes. In doing so we map a CAT relational framework onto an existing trauma-recovery framework (Silove, 1999; VFST, 1998) by providing a relational ‘mirror’, which highlights the dominant reciprocal role patterns in the refugee experience. It is the aim of this paper to stimulate further dialogue about using CAT to meet the needs of refugee populations.
The refugee experience and refugee trauma frameworks
In responding to the complex needs of refugees and their communities it is important to stop and reflect on the refugee experience and the existing field of literature. Refugees are forced to flee their country of origin due to war, mass trauma, torture, and other human rights injustices. Many have – individually or collectively – been subject to violence and persecution, lost support networks (family and socio-cultural), been subject to human rights abuses and lived in environments of deprivation. Refugees and asylum seekers make the perilous journey to new countries seeking refuge. If refuge is granted they have to contend with the challenges that arise from the process of re-settlement.
It is acknowledged that the experience of people from refugee backgrounds is heterogeneous and most are resilient and adjust ‘successfully’. Reports indicate, however, that there is a higher risk of psychological difficulties, such as depression, anxiety and somatoform disorders, substance misuse and social isolation compared to the general population (Burnett & Peel, 2001; Fazel, Wheeler, & Danesh, 2005; Reed, Fazel, Jones, et al., 2012).
The refugee experience brings to the fore the complex social, cultural, economic, political and familial context that influences distress, resilience, wellbeing and help seeking (Kirmayer, 2005; Summerfield, 2000). The distress for refugees is both personal and social; it is about displacement and disruption to these social, cultural, economic, political and familial realities. Central to the refugee experience is the erosion of interpersonal trust yet trust is fundamental to help-seeking, engagement and recovery. The rebuilding of positive relational and social contexts is pivotal.
The literature on the health and wellbeing of refugees indicates that post-migration factors clearly compound the difficulties experienced by refugees (Carswell, Blackburn & Barker, 2011; Porter & Haslem, 2005).
Table One Conceptual framework of understanding and working with the impact of trauma and torture in refugees (adapted from Silove, 1999; VFST, 1998)
Post migration challenges include socio-economic adversity, racism and discrimination, government policy (especially aspects of the asylum system), social isolation, language acquisition, negotiating new cultural, educational and employment systems and concern for absent family. Some groups are at greater risk, for example asylum seekers, and the literature clearly documents the long term psychological toll of chronic uncertainty, discrimination, socio-economic adversity, adverse government policies and detention on asylum seekers (Robjant, Hassan & Katona, 2009; Steel, Momartin, Silove et al., 2011). Another factor critical to the recovery process is the re-building of social networks; highlighting a process of ‘collective’ rather than just individual recovery (Eades, 2013).
The Victorian Foundation for Survivors of Torture (VFST, 1998) has developed the ‘Recovery Framework’ with the aim of providing a therapeutic intervention that attempts to integrate psychiatric and psychological approaches highlighting the impact of the refugee experience and implication of mass trauma on four fundamental systems of adaption: ‘safety’, ‘attachment’, ‘meaning and identity’, and ‘existential justice’ (Silove, 1999; VFST, 1998). This framework shifts from a purely psychiatric paradigm and highlights the complex psychological and social manifestations of the ‘refugee experience’ on individuals and communities. It assumes that individuals and communities have an inherent capacity to survive and adapt and that psychosocial recovery is a central goal.
The value of using CAT when responding to the needs of refugees
We argue that the CAT framework could be a valuable therapeutic and contextual framework when working with refugees. CAT provides a relational approach and, unlike other models, considers not only the ‘socio-psycho-developmental’ but also socio-cultural processes that are internalised and contribute to the formation of self – relational patterns, distress, vulnerability and resilience (Kerr, 2009). This allows the recognition of the socio-cultural, socio-economic and relational determinants of mental health and wellbeing and not just locating the ‘problem within the individual’. It provides tools to allow the exploration of a contextual reformulation of the refugee journey as well as the individual’s developmental narrative so that professionals and services can create a more informed understanding of the relational patterns that impact on (or enable) the refugee recovery journey. Furthermore, the framework and tools can also be used flexibly for individuals, communities and applied to the professionals and services that may also be impacted by the work.
Several core tenets of the CAT framework are, in our opinion, particularly useful when working with refugees. In particular the explicit use of a relational lens, the focus on a collaborative shared reformulation and the concepts of the ‘observing eye’ and zone of proximal development.
While the importance of the sociocultural and relational context may be implicit within the psychosocial literature, this is not necessarily fait accompli among services and professionals within the broader health and welfare sectors (Chowdhury, 2012; Kirmayer, 2005). In fact, one of the core critiques of conventional psychiatric models is the neglect of socio-cultural (and historical) context and values when working with anyone from a different cultural background (Ben Ezer, 2012; Bhui & Bhugra, 2002; Bracken, Giller, Summerfield, 2000; Chowdhury, 2012; Kirmayer, 2005). A lack of awareness or capacity to reflect on the sociocultural background and refugee experience in countries of re-settlement lead to stereotypical assumptions and misunderstanding that can undermine appropriate and effective responses (Brown, 2011; Brown & Mseble, 2011; Ruiz & Bhugra, 2010).
The creation of a collaborative, shared reformulation is a specific process in CAT, which, is about recognising the impact of the sociocultural and historical context (Ryle, 2010; Ryle & Kerr, 2002). The socio-cultural context is a critical determinant of the formation of self, identity and meaning-making, both from a macro level (institutional and social patterns of country of origin and resettlement) and in terms of the psychosocial development of individuals. The socio-cultural context and refugee experience is crucial in developing an adequate understanding of individuals from refugee backgrounds, their needs, and potential reciprocal role procedures.
The CAT relational perspective, through contextual reformulation, can enable one to explore and understand how pre-existing childhood reciprocal role patterns and the patterns enacted throughout the refugee journey can interrelate and co-occur. Developmental narratives and pre-existing reciprocal roles can contribute to our vulnerability and resilience and longer term mental health. Many refugees come from communities that have been discriminated and been displaced for generations and it is important to consider not just familial realities but the broader historical socio-cultural-political context when understanding and identifying the ‘sources’ of an individual’s reformulation and subsequent reciprocal role patterns. The themes identified in this model may reflect both formative and contextual reciprocal role patterns.
Inherent in the function of torture, the impact of mass trauma and the refugee experience as a whole is the breakdown of positive reciprocal relationships. We also know that positive relationships are protective factors in the process of resilience (Eades, 2013, Reed et al., 2012). Incorporating a relational lens (both individual and collective) at the core of the recovery process, therefore, can allow the survivor to recognise, reformulate and create new relational processes empowering them to successfully integrate pre and post migration experiences. It also allows professionals and services to develop a greater depth and understanding of how potential unhelpful reciprocal roles and procedural patterns play a role in pre-disposing, precipitating and perpetuating the survivor’s current functioning.
At the core of the recovery process is the shift from enactments that perpetuate the destructive reciprocal relationship of ‘powerful, superior to powerless, inferior, worthless’, which dominates the refugee experience. The emphasis of the recovery process should be that of ‘accepting, welcoming to accepted, belonging’. At the core of intervention frameworks, therefore, is the need to involve the experiential modelling of alternative reciprocal role relationships, which take an observing eye from the physical environment, to survivors, communities and service responses.
CAT’s emphasis on maintaining a reflective, dialogic observational position is critical in creating the capacity to step out of these unhelpful patterns (the ‘observing eye’, Ryle & Kerr 2002). This also applies to professionals and services who, in a fragmented and under-resourced health and welfare system, often feel overwhelmed and disempowered when working with refugees, characterised by a sense of hopelessness, cynicism and powerlessness and some describe increased experiences of vicarious trauma (Ruiz & Bhugra, 2010). As a way of coping, professionals and services appear to oscillate between either ‘backing off’, minimising care efforts (even discriminating against) or entering into such patterns as ‘rescuing and striving’ (see the ‘Helper’s Dance’; Potter, 2015). Vygotsky’s, ‘zone of proximal development’ (ZPD) is another central tenet of CAT and concept that reinforces the idea of being person-oriented and increases the likelihood of maintaining an awareness of context (Ryle & Kerr, 2002). When working with refugees, for example, it is important to consider the role of socio-cultural values regarding disclosure, the sociocultural manifestations of distress and expectations about ‘intervention’ (BenEzer, 2012; Brown, 2011). Critically, it is important to assess when it is safe to work on trauma related symptoms or to consider if an inpatient psychiatric setting is going to be ‘therapeutic’.
The remainder of the paper will describe the four core adaptive systems, which form the basis of the Recovery Model with examples of the reciprocal roles that dominate each adaptive system (see Figure One for a diagrammatic representation of this relational framework).
Figure One: Diagramatic Reformulation
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Conclusion
CAT provides a relational framework that allows services and professionals to hold the intrapersonal, interpersonal and social contextual dynamics that shape the experience of refugees. Compared to other models this allows a shift in focus of ‘responsibility’ from the individual to the relational context and having a shared responsibility. CAT is also explicit in not only advocating for the importance of socio-cultural context (past, present and future) but it is also part of the very structure of the approach enabled by use of various tools such as contextual reformulation. The CAT approach and tools can also be used to work collectively as well as individually and draws attention to the power of relational positions in the recovery process for survivors and their communities.
Survivor quote (‘welcoming, accepting to accepted, belonging’): ‘soldiers don’t smile. . . the local people didn’t smile at us. . . When we re-settled here. . . it was like. . . people smiled at you. . . it was like. . . yes I am a person worth smiling at. . .’ This survivor was then able to internalise the ‘accepting to belong’ reciprocal role and in turn began to feel that they could accept that this could be their new home.
Adaptive system: Safety (Threatening to Threatened)
One of the core strategies used by persecutory regimes in oppressing and destroying individuals and communities is to ‘create a state of terror’ and insecurity (VFST, 1998: 29). This domain is well recognised in the trauma and anxiety literature and in the very definition of post traumatic stress disorder (DSM-IV, American Psychiatric Association, 2000). In the refugee literature, however, there is emphasis on the broader definitions of ‘threat’ to include threats of mass violence, incarceration, displacement and general intimidation in order to oppress and create a sense of ‘not being safe’ (Silove, 1999; VFST, 1998). It keeps individuals and communities in a state of precariousness, focused on maintaining safety, existing in the present rather than re-directing attention to the future.
These acts of oppression and terror can be described in relational terms as a reciprocal role of ‘threatening to threatened, vulnerable’. Individuals, families and communities exist in a state of anxiety, vulnerability and uncertainty regarding their safety and future. It reduces their sense of control over the present and future.
The impact of such may be internalised (by individual and community systems) and manifest in various survival patterns (reciprocal role procedures) ranging from anxiety-fear responses, a pervasive mistrust and paranoia and withdrawal and avoidance. There are ethno-cultural variations in psychosocial responses and coping patterns, including psychosomatic presentations and dissociative-like experiences (BenEzer 2013, Chowdhury, 2012; Kirmayer, 2005). This state of anxiety, insecurity and vulnerability regarding safety can persist for a long time after the trauma and can be reinforced by post migration stressors in countries of resettlement.
Survivor story (‘threatening to threatened, vulnerable, no control’): A man was a survivor of detention and torture in his home country. He is now detained by the country from which he seeks protection. He feels powerless, threatened, criminalised and humiliated. When others put their hands on his shoulders this triggers flashbacks; windowless interview rooms create a threatening environment that remind him of being trapped and powerless; lack of information leaves him feeling precarious. He feels fearful and withdraws from professionals. He is plagued by tightness of chest, headaches and ‘tension’ and hopelessness. He doesn’t want to engage with the services available to him.
An alternative reciprocal role that services and professionals can enhance is ‘protecting to safe’. This can be enhanced through measures ranging from physical environment, system processes, modelling predictability and continuity and by being a ‘witness to’ to the narrative .
Professional Story (‘protecting to safety, control’): ‘In order to help create a sense of safety and control I leave the doors open for him and let him know he can sit in reception and come when he is ready. The stance of staff at reception is a core intervention in providing a ‘welcoming – protecting’ position. When he withdraws I don’t press or push rather I let him know that I am available and I will often just sit alongside him until he is ready. This allows him to again feel some control, respect and be in an environment that feels safe.
Adaptive system: Attachment (Isolating to Disconnected)
Another strategy used by persecutory regimes is the ‘systematic disruption of basic and core attachments to families, friends, religious and cultural systems’ (VFST, 1998: 30). Disruptions to attachment systems include forced disappearance, destroying connections to the land or to ancestors, banning cultural traditions and language and systematically inducing a climate of mistrust within communities (Silove, 1999). The destruction of attachment systems aims to destroy the sense of self and identity (individual and community) and reduce any sense of individual or collective connectedness and therefore empowerment.
These acts, the loss of meaningful attachments, can be described as ‘isolating, marginalising to marginalised, disconnected’. This disconnection threatens not only the sense of attachment and belonging with others but also a sense of identity and can endure for years (VFST, 1998). The sense of disconnection can be perpetuated in countries of re-settlement, for example, through government policy restrictions on family migration, detention, restrictions on the right to work and racism and discrimination (McColl et al., 2008). There is ample evidence that a sense of disconnection is one of the core risk factors in perpetuating mental health difficulties (Burnet & Peel, 2001; Miller & Rasmussen, 2010; Williams & Thompson, 2011). This reciprocal relationship can result in numerous responses that vary from being passive through to rebellion and substance misuse. The following is a quote from a young man who arrived in a country of resettlement when he was an adolescent.
Survivor story (‘isolating, marginalising to isolated, disconnected’): ‘. . . I am always struggling, always an outsider-misunderstood, inferior. . . my community has always been outsiders. . . but now my community excludes and looks down on me because I don’t conform. . . no one understands me… where do I fit in?. . . I have my ‘bros’. . . we hang out, and we will fight for each other. . . that’s what my history has taught me. . .’
The adolescent describes feeling as if he isn’t accepted by his cultural community or by the country in which he has resettled. As a consequence he rejects both cultures, which perpetuates the reciprocal role of ‘isolating to disconnected’. An alternative reciprocal role, ‘belonging to connected’, can be promoted by professionals, services and systems. A participatory, inclusive framework both by services and professionals can enhance resilience, acceptance, belonging and sense of empowerment, for example, advisory groups, consumer representatives and support for community initiatives (CMY, 2015).
Professional story (‘connecting to connected’): ‘. . . talking to some disengaged young men they described feeling misunderstood and disconnected. The young men acknowledged they wanted to reconnect with their community but also wanted to have their ‘new’ identities accepted. The goal of our community programme was to provide opportunities for community elders, church-goers and disengaged young men to re-connect. We helped the community organise a range of inclusive activities, including fishing trips (an activity that was important traditionally). As one elder said: ‘When I got to know them (young men) more they weren’t as bad as I thought’. This community program provided a bridge between the young people and the elders allowing a safe place for participants to practice enacting the reciprocal role of ‘connecting to connected, accepted’.
Adaptive system: Meaning and Identity (Destroying to Disempowered)
Acts of mass violence and death, incarceration, torture and indoctrination erodes away at the ‘central values of human existence’ (VFST, 1998: 30). The aim is to erode an individual’s (and community’s) sense of identity, agency, trust, faith and meaning in self and the world (Silove, 1999). This can leave individuals feeling inferior, worthless, helpless and disempowered. The re-settlement process can perpetuate this relational experience as individuals and communities negotiate new systems, language and expectations that challenge the sense of self, identity and mastery.
The impact of these acts on the systems of meaning and identity could be described in relational terms as ‘destroying, disempowering to worthless, disempowered’. Policies such as temporary protection visas, detention, denial of access to work and health care leave asylum seekers disempowered, powerless and feeling ‘less worthy’ than other citizens. Discrimination in the country of resettlement is also destructive to sense of identity and meaning. There is a greater sense of powerlessness, which can result in increased passivity, patterns of absence of care and neglect or resistance and aggression.
Survivor story (‘destroying, disempowering to disempowered, worthless’): ‘. . . I have been separated from my children because I had to seek safety from the regime. Now government policy won’t let me reunite with my wife and children. This is tearing at my heart. How can I help and protect them when I’m not there? I feel guilt, anger at the world. Who am I without my children? I contact them over Skype. . . but it is difficult to feel close to them.’
This father attempts to remain connected with his children. He feels disempowered and questions his role as a parent. He becomes unmotivated, depressed, begins to give up and reduces his contact with the family. He is left feeling disempowered and worthless.
The alternative reciprocal role that can be drawn upon when working on improving meaning and identity is ‘recognising, participating to recognised, empowered’. Re-establishing socio-cultural structures and systems is an important source of creating connections, belonging, identity, meaning and empowerment for refugee communities. Taking a curious stance, and providing experiential interventions, allow the individual to find experiences that develop their own personal meaning. Community based interventions from socio-cultural projects to mental health provision have been proven to be of value (Williams & Thompson, 2011).
Professional story (‘recognising, participating to recognised, empowered’): ‘As part of our school support program we wanted to develop a resource to support schools to strengthen their engagement with families. We established a parent advisory group (PAG) comprised of refugee-background parents. We realised that if we were to be genuine about participation and empowerment then we would have to relinquish some control. The PAG process allowed an opportunity for parents to give direct feedback to the school and so feel more involved with the school, and their children’s education. The parents felt they were heard and both the school and the parents reported that parental engagement had been strengthened’.
Adaptive system: Sense of justice (Discriminating to Devalued)
Torture, rape, violence and the witnessing of such are not only about threats to safety or identity but are also examples of human rights violations. A denial of human rights is an active strategy to humiliate and dehumanise that destroys any sense of justice (Silove, 1999). Persecutory regimes also induce guilt and shame by leaving individuals and communities with ‘impossible choices’, for example, being put in the position of ‘passive witnesses’ or being left with the belief that ‘you could have acted differently’ (VFST, 1998).
These acts can be described in relational terms as ‘humiliating, devaluing to humiliated, devalued’. Loss of dignity, humiliation, shame, guilt, sense of weakness and betrayal are all associated experiences of extreme injustice: the act of being devalued. As highlighted by those who work with the impact of interpersonal trauma, the shame, the sensitivity to injustice, betrayal and feeling ‘let down’ may result in self destructive patterns or an underlying sense of ‘rage’ (VFST, 1998; Herman, 1997). Some describe feeling caught in a struggle either trying to suppress their emotions or losing control and ‘angrily exploding’ when confronted with perceptions of injustice and shame, for example;
Survivor story (‘discriminating to humiliated, devalued’): ‘My worker gave me a food voucher. I went to the supermarket but they told me it was for another shop. I felt humiliated, ashamed, stupid. I called the worker and was angry at them. They were out to get me, humiliate me, just like everyone else. . . me a poor black guy, they tricked me’. The professional felt abused and frustrated and a ‘dismissing, blaming to blamed, dismissed’ relationship pattern was enacted. The man disengaged from the service. The professional was not assertive in follow up. The young man later ended up in an inpatient psychiatric unit with untreated psychosis.
The above example highlights the need for services and professionals to find ways to enhance the ‘participating, valuing, empowering’ reciprocal roles of both survivors and professionals. Support and collaboration, such as, supervision and reflective processes can enhance the empowerment of professionals (Gardner, 2009; Robinson, 2013; Ruiz & Bhugra, 2010).
Future Implications
This is an exploratory article only and it would be of value to further develop and refine the CAT-relational model for working with refugees. A key limitation is that there has not been a process of evaluating the framework’s application, and feedback thus far is limited to qualitative and anecdotal accounts. It will be critical to evaluate which CAT tools and processes are of most value when working with refugees and, the adaptations required when working with anyone from a different cultural and linguistic background. Another area to explore is the adaptation of the CAT framework to group, school, service and community based contexts, either as a direct intervention or through a process of secondary consultation.
There is a very real potential for the CAT framework to be of value in supporting existing frameworks and services in better understanding, assessing, engaging and supporting refugees in a manner that enables professionals and services to step out of unhelpful patterns and enhance reciprocal relationship patterns that support the recovery process.