Psychopathology and Psychotherapeutic interventions when working with refugees and asylum seekers.

1. Psychopathology and Psychotherapeutic interventions when working with refugees and asylum seekers. By Divine Charura Specialist Psychotherapist

2. Aims and Objectives • To explore psychopathological presentations in refugees and asylum seekers. • To present explore brain biology and changes resulting from trauma. • Focus on Post traumatic stress disorder (PTSD) • To present some evidence based therapeutic interventions when working with this client group. • Explore possibilities and raise questions on the future direction of this work.

3. What is an asylum seeker? ….departure your country for an unknown destination is traumatic. I did not know i was coming to Britain. It could have been anywhere as long as it was safe for me and my children. But as an asylum seeker in Britain, I soon discovered that it was far from being a warm and welcoming place and i was presented with more traumas.”

4. What is an asylum seeker/ refugee? • An asylum seeker is someone who is fleeing persecution in their homeland, has arrived in another country and made themselves known to the authorities and exercised their legal right to apply for asylum under the 1951 UN Refugee Convention ( Home office 1999). • To be granted asylum under the 1951 UN convention, an individual has to show a well founded fear of being persecuted in his or her country of origin for reasons of race, religion, nationality, membership, of a particular group or political opinion. • A refugee is an individual granted asylum (UNHCR 1992).

5. Asylum seekers and refugees • Extremely heterogeneous group with diversity in language, culture, political and religious affiliations, political histories, various social classes, and diverse experiences of life experiences (Solace 2008). • In 2003, Amnesty International estimated that there were thirty five recognised conflicts and one hundred and thirty two countries still practicing torture. • Since then this figure has continued to increase and at the start of 2009, worldwide, there were over nineteen million asylum seekers/refugees and ‘others of concern’ (UNHCR 2009).

6. Needs of asylum seekers and refugees • The process of exile which refugees and asylum seekers experience inevitably challenges the very foundations of their lives in their communities, disempowering them personally and politically (Tribe and Raval 2003).

7. Problems of asylum seekers and refugees • Many refugees who come to the U.K. have experienced or witnessed • Torture, • Organised violence • Sexual violence • War and trauma, • Multiple complex losses • Dislocation from families • Stress • Bereavement (Burnett and Peel, 2001).

8. What is psychopathology? • Psychopathology is the study of mental illness, mental distress and abnormal, maladaptive behaviour. • The term is most commonly used within psychiatry where pathology refers to disease processes. • Abnormal psychology is a similar term used more frequently in the non-medical field of psychology.

9. What is a diagnosis? • dia (Greek) meaning through • gnosis (Greek) meaning knowledge • “Diagnosis” is the establishing of the nature of a disease. • Problems with subjectivity (Psychiatrist) and Objectivity (research and evidence)

10. Mental health presentations of asylum seekers and refugees • Trauma • Post traumatic stress disorder • Psychosis • Depression • Anxiety • Conditions resulting from impact of torture • Other medical conditions

11. Multiaxial DSM-IV • AXIS i clinical disorders • Axis ii personality disorders & Mental retardation • Axis iii General medical conditions • Axis iv Psychosocial and environmental problems • Axis V Global assessment of functioning (GAF)

12. Diagnostic Classification • Communication • Clinical research and statistical uses • Categorical not dimensional • International classification of diseases ICD-10 • DSM-IV • Other cultural

13. Cross section of the brain

14. Trauma • Psychological trauma is a type of damage to the psyche that occurs as a result of a traumatic event. When that trauma leads to posttraumatic stress disorder, damage may involve physical changes inside the brain and to brain chemistry, which damage the person's ability to adequately cope with stress.

15. PTSD • Arises as a delayed response to a stressful situation. • Predisposing factors, i.e. personality traits • Typical features- flashbacks, nightmares, sense of numbness, detachment from other people. • unresponsiveness to surroundings, anhedonia, avoidence of activities reminiscent to the trauma.

16. PTSD • Emotional reactions to stress are often accompanied by: • muscle aches and pains • diarrhoea • irregular heartbeats • headaches • Depression • feelings of panic and fear • drinking too much alcohol • using drugs (including painkillers).

17. Traumatic encoding

18. Shrinkage of the hyppocampus • Shrinkage due to heightened level of cortisol which is toxic causing behavioural disinihibition and hyperresponsiveness to environmental stimuli.

19. Pathophysiology of PTSD • Parietal Lobes- Integrate information between areas • The Amygdala- evaluates incoming information for emotional significance, activated when people are exposed to trauma triggers • Hippocampus –creates a cognitive map that allows the categorization of experience. • The Corpus Callosum integrates emotional and cognitive aspects of experience

20. Phamacological interventions • Selective serotonin reuptake inhibitors (SSRI) i.e. Fluoxetine • Anticonvulsants, i.e.. Carbamazepine, Gabapentine • Benzodiazepines i.e. Clanazepam • Β-Blockers i.e. Propranolol • Antipsychotics- i.e. Resperidone, Clozapine. • N.B. these may also have serious side effects and medical supervision is important.

21. The therapeutic modalities • Client centred therapy • Psychoanalytic/ psychodynamic • Gestalt therapy • Family and systemic therapy • Transcultural • Other psychotherapies • Complimentary therapies

22. Client centred therapy • Developed by the humanist psychologist Carl Rogers in the 1940s and 1950s. • Core conditions • Non directivity • Tendency towards self actualisation • It is stated that the organism has one basic tendency which is to strive to actualise, maintain, and enhance its experiencing (Rogers 1951)

23. Family and systemic therapy • Started in Milan in 70’s (Milan school) • Gianfranco Cecchin and Luigi Boscolo. • Psychiatric model to psychoanalytic therapeutic model. • Treatment of families (nuclear) examples are solution focused, collaborative, strategic therapy (AFT 2010).

24. Family systemic concepts • What is a family • Systems • Genograms • Circular questioning • Hypothesis • Curiosity • Neutrality • Irreverence

25. Transcultural work • Transcultural therapy is paramount in our practice • Issues of identity vs impact of torture and being a foreigner i.e. refugee/asylum seeker • interactions between the natural and the supernatural often affirming beliefs and experiences of Voodoo, magic, witchcraft and sorcery. • Ways of understanding serious physical or mental illness or serious misfortune

26. Complimentary/other therapies • EMDR • Massage • Reiki • Alexander technique

27. Working with interpreters • Training • Debrief, After session • In session sitting position • Communication • The therapeutic alliance • Understanding of the importance of somatic language rather than literal translations is paramount in understanding what the client will be really saying. • Authors on working with interpreters (Haenal 1997, Holder 2004; Marshall et al 1998; Tribe and Raval 2003).

28. Complex Issues • Power • Gender • Class • Culture • Other issue • Discuss how each of these could impact on the therapeutic relationship?

29. Research • Limited research that focuses directly on the perspectives of refugees and asylum seekers perspectives of therapy/ counselling (Lambert 2007; Blackwell 2005). • Three randomised controlled trials (RCT’s) (Bellamy and Adams 2000; Murray et al., 2003 and Ridsale et al 2001) stated that counselling is effective in alleviating clinical symptoms such as depression and anxiety (which refugees and asylum seekers often present with • Cooper (2008) showed that person centred therapies are empirically supported by multiple lines of scientific evidence; including ‘gold standard’ RCT’s. Large RCT- equivalent studies in the U.K. Stiles et al (2006 and 2007)

30. Research • The Psychobiology and pharmacology of PTSD, (Van der Kolk 2001) • Effectiveness of CBT, Person centres and psychodynamic therapies as practiced in the U.K. NHS Settings (Styles et al 2006) • Psychological treatment outcomes in routine NHS services on Stiles et al 2007, (Clark et al 2007) • Clients (Asylum seekers and refugees) Perceptions of therapy (Charura 2009)

31. Future of this work • More access and availability to services • Political recognition of impact of delayed processing of asylum seekers immigration status • More evidence based studies needed throughout therapy modalities • More funding needed • Psychotherapy/counselling and psychiatry models which offer

32. Conclusion • Descriptions, Challenges and complexities of psychopathology. • Complexities in working with refugees and asylum seekers • Different modalities of working • Working with interpreters • Issues of power, gender, class & culture • Research evidence suggests dodo effect • Room for development and future research