Working with families
The Problems Here
Being a refugee is like having learnt to play one game, and then finding that you are running onto the field, to play a game with quite different rules, and being unable to ask anybody about them, as you do not understand the language.
So for most refugees their most immediate concern is with the practicalities and frustrations of trying to settle down in this country. Whatever our reason for meeting refugee families, we will have to help them sort out their concerns about Housing-terrible, Money-not enough, Education-getting children into schools and older people into colleges-usually not too difficult, Health-finding refugees GPs in the first place, and helping find interpreters for them, Isolation--in a new land with a new language and high levels of worry, families may remain separated from the wider community.
For many refugees, particularly the ones we see at the Medical Foundation, asylum is a major concern. Those who have experienced violence, and threat in their home countries, become really upset when their asylum claim is turned down. Having faced the threat of getting harmed at home, they feel a great wave of different emotions, when they are told that they cannot stay. Fear at the prospect of return. Anger and upset at the country, that has so far been a safe haven for them, turning them away, and many others too. Many families, although upset and sad about what they have left behind are coping with their feelings, but with the threat of expulsion, all the feelings of
loss and of post- traumatic- stress, with flashbacks, fears of reminders, and sleep disturbance, become much worse, and much more troublesome.
Problems from the Past
Most refugee families have experienced a period of normality, before problems in their homeland began. This time of tranquillity is an important background to later feelings, that the world is an unreliable place, in which they have lost their way, and in which, at the bottom of the social
heap, they can suffer from very low self-esteem. It is perhaps important to bear in mind that many families coming from a distance, have to be rich to pay to get here. The poor cannot afford it.
So the things that refugee families bring with them, and cannot, as they often wish, simply be forgotten, are unpleasant
Other refugee problems are to do with family structure.
The father may be absent, or be incapacitated, so mother has to take charge. In a parent's absence a son or daughter may take on a parental role. Sometimes children have to continue to have problems, so that their mother and father can work together as parents, rather than having to look at their own marital relationship. This is known as "triangulation".
Families may consist of siblings only. Older siblings are rarely as good at caring as parents. Children in very unsettled families may be " emotionally unaccompanied"
In some refugee families there are problems with attachment. This may be too intense, when families are very anxious, leading to parents being overprotective of their children and reluctant to let them do things by themselves. The children may pick up their parents' worries and show
separation anxiety. Families may become, what family therapists describe as, enmeshed, with members oversensitive to one- another's feelings, so that if one person becomes distressed the rest of the family get drawn in.
In other families, where parents are depressed, or very concerned about their own problems, attachment may be too weak, and the children neglected and unsupported., with parents unable to give the children the time that they need.
Sometimes older children, who have had to manage their own lives, may become involved with peers and school, and attachment to the family weaken, so that they become over-independent.
So what can we do to help?
Family therapists have emphasised the importance of trust and attachment when working with refugees. Bad experiences in their home country, and sometimes in the UK, have led to families becoming much less trusting of other people than they were before. The therapist may be seen as a person, who can be trusted, and a strong attachment may develop. Jeremy Woodcock, principal family therapist at the Medical Foundation sees this as something to be worked with rather than avoided. Young children use their parents as a secure base from which to go out and explore.. I think of refugee families, as using therapists, as a similar sort of base, from which they can get
unanxious support, and then go out and be calmer and more flexible in their daily lives.
In building up the relationship, listening to what the family have to say, before trying to give advice, praise or reassure, is of central importance.
The therapist listens to the family, and helps the members of the family to listen to one another. The members of the family are helped to talk with each other about feelings, but also about practical matters. Sometimes the therapist will go gently, and help parents and children gradually to pay attention to one another. On other occasions the therapist will consider that the family are getting stuck and encourage them to be more courageous in the things that they are prepared to discuss.
It is helpful for families to have their own story about what has happened to them, so that they can begin to feel more comfortable about the past, about themselves as individuals, and with each other. As in all stories, each member of the family will have played a different part in the story.
One of the therapist's tasks is to work with families, to look at different ways of perceiving and interpreting, what has happened to them, so that they feel better about themselves.
Some of the ideas, behind the importance of a family narrative, are, that families are unique, that formulating things in a different way will help them to move on, and that, as with individuals, going over both traumatic and pleasant events, looking at the feelings and thoughts around them in
detail, helps them to become part of a person's memories rather than constantly intruding.
Refugees are survivors as well as victims. Many of them have been important and powerful in their own communities in the past. As refugees however often they feel helpless and impotent. One of the aims of the therapist is to empower them, by pointing out their strengths. Their week- to- week
successes need to be emphasised even if these are small and gradual. In practice it is amazing how well refugee families organise themselves and their children in the new environment. This needs to be pointed out to them. The therapist too can be trapped into seeing the failures, so it requires a
constant effort to see the positives as well.
Less anxiety, more flexible problem solving. More problems sorted, less anxiety.
One of the tasks of the therapist is to help families problem solve, whether the problems are practical, normal family problems, or problems peculiar to refugees. Just as it is important to help families talk through how they feel, it is important also to analyse with them exactly how they should deal with on going difficulties.
If there are structures in the family, such as a parental child or triangulation, that are unhelpful, these can be gently discussed. Parents can be helped to engage with children appropriately, giving them good warmth and stimulation, but moving away from getting too emotionally involved with
them at the expense of the marital relationship. Integration into the community can be encouraged and supported.
I will end with two quotations.
"It is not that they have forgotten what thy have been through, only that their personal balance has enabled them to accommodate the past and move ahead".
Nguyen Ba Thien
"In addition to the need for general improvement of the conditions under which refugees live, they must be given greater opportunities for personal development".