PSYCHOLOGY OF THE REFUGEE, THE IMMIGRANT AND THEIR CHILDREN — DEVELOPMENT OF A CONCEPTUAL FRAMEWORK AND APPLICATION TO PSYCHOTHERAPEUTIC AND RELATED SUPPORT WORK Binnie Kristal-Andersson Department of Psychology University of Lund Sweden 2000 2 SUMMARY Psychology of the refugee, the immigrant and their children – development of a conceptualframeworkandapplicationtopsychotherapeuticandrelatedsupportwork BinnieKristal-Andersson,DepartmentofPsychology,UniversityofLund,Sweden Inrecentyears,awarenesshasgrownofthenecessityofunderstandingthe inner world of refugees (in particular traumatized refugees), immigrants, and their children. These groups have come in increasing numbers to Scandinavia, and otherwise confident and capable professionals in all arenas of mental health, social work and other fields have often felt inadequatewhenworkingwiththem. Aftermanyyearsofclinicalandsupervisorywork,Kristal-Andersson realizedthattherewasanacuteneedforatreatmentmodelthatconsiders the specific psychology of these groups. In her view, specialized process-relatedtraininginpsychotherapyanditsrelatedfields,andalsoin supportwork,isnecessarytoobtainpsychologicalunderstandingoftheir difficulties,andalsotobuilduptheknowledge,insightandconfidenceof professionalsandothersinworkingwiththem.Formulatingaframework and organizing a specialist form of education for various categories of professionalshavebeentheprincipalgoalsofherresearchworkandthis subsequent doctoral dissertation. The relevance of the framework (part I of the dissertation) is evaluated through experiences of a course of practicaltrainingbaseduponit(partII). Part I provides a summation of over twenty-five years of Kristal-Andersson’s and others’clinical and support work with refugees andimmigrants.First,itdescribesthecommonlyoccurringpsychological and other difficulties that the individual/family faces in the new country. Second, it presents a conceptual framework or treatment model evolved over many years of clinical work, supervision and consultation. The modelwasderivedthroughinteractionbetweenliteraturestudy,empirical researchandclinicalevaluation. Part II describes and evaluates a year-long process of training for caring professionals based on the framework, and summarizes and evaluates particular items of casework. The training was designed to expand the psychological understanding and confidence of the carers involved.Itsprimarypurposehereistovalidatetheuseoftheconceptual framework in treatment and support work. Method, documentation and evaluation include tape recordings of the theoretical education and supervision and evaluations of these; participants’ continuous oral and 3 written evaluations; summations and reports of casework sessions; and data from three written questionnaires administered at and after the final seminar. At a scientific level, the primary purpose of this dissertation is to provide further knowledge and understanding of the specific psychologicalandouterdifficultiesofrefugeeandimmigrantgroups,and promoteincreasedinterestinthisareaofpsychology.Afurtherpurposeis to describe a practical approach and mode of working in psychotherapy and support work with refugees and immigrants. In practical terms, it is hoped that the dissertation can assist in the development of educational, curative and preventive programs for assuring good mental health and improvedsocialconditionsforrefugees,immigrantsandtheirchildren.In turn, this might lead to improved adaptation and an improved social situation for them in their new country. Finally, it is hoped that the psychological knowledge obtained can help prevent and counteract discrimination,prejudiceandtension,andleadtomoreopenandsensitive attitudestowardsthesegroupsinthesocietiestowhichtheynowbelong. 4 Totherefugee Totheimmigrant Totheirchildren 5 PREFACE Therehasalwaysbeenanacuteneedforunderstandingofandinsightinto the inner difficulties of refugees, immigrants and their children. These difficultiesarecaused,affectedorcomplicatedbyfleeingfromorleaving a native land, and the changes and conflicts experienced in living in and adaptingtoanewcountry. Thepurposeofthisdissertationistopresentandattempttovalidatea conceptualframeworkofunderstandingforpsychotherapeuticandrelated support work. In terms of subject area, the work might be regarded as lying at the interface between clinical psychology and empirical pedagogics. Itisthehopeoftheauthorthattheresultsofthisresearchcanbeused tocontinuetotreat,superviseandeducateothers.Ihopetohaveaddedto knowledge of the psychology of the refugee, the immigrant, and their children,andlookforwardtofurtherresearchinthearena. It would be impossible to acknowledge everyone who has supported me–indifferentways–inthisendeavor.Iwillnamejustafew. First, I want to mention Professor Alf Nilsson, Department of PsychologyatLundUniversity,thesupervisoroftheresearchprojectand dissertation; the refugees and immigrants, and their children, for sharing their inner and outer worlds; my parents, who were both of refugee background, and residents of the Flatbush neighborhood of Brooklyn, New York, where I grew up; my colleagues, teachers and supervisors, in particular Gunnela Westlander, Carl Martin Allwood, Carl Otto Jonsson, Björn af Forselles, Inga Sylvander, Merit Hertzman-Ericsson (now deceased),UllaBertlingandStinaThyberg,andespeciallyAliceBreuer, Per Stenfelt and Imre Scezsödy, for their belief and encouragement; and, thepeople–bothinsideandoutsideSweden–whohaveencouragedmeto believe in what I am doing. My special thanks go to Kjell Jönsson, Kjell Öberg, the now-deceased Hans Göran Franck and Arne Trankell, Robert Vargás,andJohnGiordiano. The process-training program based on the framework, organized in Finland by Åbo Akademi University’s Center for Extension Studies, would neverhavecomeaboutwithoutthesteadfastdeterminationofmycolleague, Kristina Saraneva. We benefited from the constant involvement of Kerstin Sundman.MargitaVainoauthorizedandsupportedtheproject.Bythetimeof writing,twoothertrainingprogramshavebeencompleted.Iwanttothankall 6 the professionals participating, and also the individuals with whom they worked.Withouttheirefforts,thispartoftheprojectwouldneverhavebeen completed. I thank Kerstin Hallén, Jason Andersson, Jerrold Baldwin and Jon Kimberfortheirassistancewiththemanuscript. I also wish to express my gratitude to the island of Lefkada, Greece, wheremuchofthisdissertationwaswritten–fortheinnerpeaceIfound there, and to Sweden – for giving me the security and the opportunity furthertodevelopmywork. Finally,Iwanttothankmysons,JasonandDanjel,forgivingmethe meaning,willanddeterminationtoattempttomaketheirworldandmine moreunderstandableandhumane. MythankstoallIhavementionedandthoseIhavenot. BinnieKristal-Andersson 7 TABLEOFCONTENTS SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Theneedforresearch . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Outlineofthedissertation . . . . . . . . . . . . . . . . . . . . . . . 10 Caseworkmaterial . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 2. RESEARCHPLATFORM . . . . . . . . . . . . . . . . . . . . . . . 13 Experienceandfamiliaritywiththeproblemarea . . . . . . . . . . . 13 Aclinicalapproach . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Evaluationaccordingtoatransactionmodel. . . . . . . . . . . . . . 15 PARTI–ACONCEPTUALFRAMEWORK. . . . . . . . . . . . . . . 17 3. INTRODUCTIONTOTHECONCEPTUALFRAMEWORK . . . . 18 Identificationofsignificantkeydimensions . . . . . . . . . . . . . . 20 Developmentoftheconceptualframework . . . . . . . . . . . . . . 20 Suggestedapplicationsoftheconceptualframework . . . . . . . . . 23 Intendedaimsandfunctionsoftheframework. . . . . . . . . . . . . 25 Relevantstudiesandliterature . . . . . . . . . . . . . . . . . . . . . 25 Definitionsofterminology–therefugeeandtheimmigrant. . . . . . 44 4. THEREFUGEE/IMMIGRANTSITUATION . . . . . . . . . . . . . 84 Outerprocessesofchange . . . . . . . . . . . . . . . . . . . . . . . 84 Accompanyinginnerchanges . . . . . . . . . . . . . . . . . . . . . 84 5. ASPECTONE–THESTATESOFBEING . . . . . . . . . . . . . . 88 Stateofbeing:thestranger . . . . . . . . . . . . . . . . . . . . . . . 90 Stateofbeing:loneliness . . . . . . . . . . . . . . . . . . . . . . . . 93 Stateofbeing:missing . . . . . . . . . . . . . . . . . . . . . . . . . 96 Stateofbeing:longing . . . . . . . . . . . . . . . . . . . . . . . . . 99 Stateofbeing:guilt . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Stateofbeing:shame . . . . . . . . . . . . . . . . . . . . . . . . . 106 Stateofbeing:separationandloss . . . . . . . . . . . . . . . . . . 110 Stateofbeing:sorrow . . . . . . . . . . . . . . . . . . . . . . . . . 113 Stateofbeing:languagedegradation . . . . . . . . . . . . . . . . . 118 Stateofbeing:valuedegradation . . . . . . . . . . . . . . . . . . . 123 Stateofbeing:inferiority . . . . . . . . . . . . . . . . . . . . . . . 126 Stateofbeing:non-identity . . . . . . . . . . . . . . . . . . . . . . 131 Stateofbeing:rootlessness . . . . . . . . . . . . . . . . . . . . . . 138 Stateofbeing:bitterness . . . . . . . . . . . . . . . . . . . . . . . 142 Stateofbeing:suspicion. . . . . . . . . . . . . . . . . . . . . . . . 147 Stateofbeing:prejudice. . . . . . . . . . . . . . . . . . . . . . . . 151 Stateofbeing:thescapegoat–asyndrome. . . . . . . . . . . . . . 158 8 6. ASPECTTWO–THEADAPTATIONCYCLE . . . . . . . . . . . 165 Stage1–arrival . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 Stage2–confrontation . . . . . . . . . . . . . . . . . . . . . . . . 167 Stage3–flashback . . . . . . . . . . . . . . . . . . . . . . . . . . 167 7. ASPECTTHREE–CHILDHOODEXPERIENCES. . . . . . . . . 173 Thepsychodynamicprofile . . . . . . . . . . . . . . . . . . . . . . 173 8. ASPECTFOUR–RELEVANTBACKGROUNDCONDITIONS . 179 Theconditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 9. ASPECTFIVE–THEREASON. . . . . . . . . . . . . . . . . . . 193 Therefugee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193 Theimmigrant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195 10. ASPECTSIX–TRANSITION-RELATEDCONDITIONS . . . . . 211 Therefugee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211 Theimmigrant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222 11. SUMMARYOFPARTI. . . . . . . . . . . . . . . . . . . . . . . . 231 PARTII–THEFRAMEWORKINATRAININGSETTING . . . . . 237 12. ATRAININGPROGRAM . . . . . . . . . . . . . . . . . . . . . . 238 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238 Planningtheprogram . . . . . . . . . . . . . . . . . . . . . . . . . 239 Structureofthetrainingprogram . . . . . . . . . . . . . . . . . . . 241 Realizationofthetrainingprogram. . . . . . . . . . . . . . . . . . 248 Methodsofdocumentationandevaluation . . . . . . . . . . . . . . 249 Thesupervision . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249 13. CASEWORKINTHETRAININGPROGRAM. . . . . . . . . . . 254 Implementationofcaseworksupervision . . . . . . . . . . . . . . . 255 Methodsofdocumentationandevaluationofthecasework . . . . . 257 Summationsofandexcerptsfromthecasework . . . . . . . . . . . 257 Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305 14. RESEARCHEVALUATIONSOFTHETRAININGPROGRAM. . 308 Discussionofresultsoftheevaluations. . . . . . . . . . . . . . . . 330 15. CONCLUDINGREMARKS . . . . . . . . . . . . . . . . . . . . . 335 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 348 APPENDICES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370 9 1. INTRODUCTION This chapter offers an introduction to the dissertation. It describes the development of a conceptual framework designed to aid caring professionals in their work with refugees (especially traumatized and tortured refugees) and immigrants. The framework is based on over 25 years of the author’s experience in the field. The cases on which the frameworkisbasedaredescribedinawidevarietyofrespects. Leaving one country for another, by will or by force, has gone on throughout the ages. People have fled from persecution, poverty and famine, or have emigrated with a dream of a new and better life for themselves,theirfamily,oranygrouptowhichtheymightbelong. Howdoessuchchangeaffecttheinnerandouterworldoftherefugee, theimmigrantandtheirchildren? Cantheexperiencesoftherefugeeandimmigrantbesystematizedina mannerthatwillprovideguidelinesfortherapeutictreatmentandsupport? Isitpossibletoevaluateandvalidateanysetofguidelinesarrivedat? The primary aim of this dissertation is to attempt to approach an answertothesequestions.Todoso,itdescribesaconceptualframework that has been developed and systematized by the author to facilitate understandingoftheinnerandouterworldsofrefugees,traumatizedand tortured refugees, immigrants, and their children. The framework has evolvedinstages,andisbasedontheaccumulatedclinicalexperienceof theauthor. A secondary aim is to address the question: “What common and specificproblemsarefacedbyrefugeesandimmigrantsrespectively?” Thepurposeoftheconceptualframeworkistoallowpsychotherapists and other support workers more efficiently to be able to apply their experienceandtheoreticalknowledgeinhelpingthesegroups. Thevalidityoftheapproachistestedthroughtheprocessevaluationof aone-yeartrainingprogram,basedontheframework,forpsychotherapists, mental-healthcarersandsupportworkers. THENEEDFORRESEARCH The psychological difficulties of the refugee/immigrant have not always been considered or understood, nor are the problems of children born in thenewcountry.Mostrefugees,immigrantsandtheirchildrendonotseek psychological support before finding themselves in deep or acute crisis. 10 Those who receive psychotherapy, mental-health care and other support seldomstayontocompleteit.Thepsychotherapist,mental-healthcareror support worker then feels inadequate, and the refugee/immigrant dissatisfied.Overtheyears,theauthorhasmetmanypeopleworkingwith and trying to support these groups, and also many refugees and immigrantswhorecognizetheirneed. Currently, it is of the utmost importance to achieve greater understanding of the outer (economic, cultural, environmental, and social) and inner (specific psychological) difficulties of refugees and immigrants. Broadly speaking, outer difficulties are regarded as being withmatterssuchasadaptationtoanewwayoflife,possiblyevensimply the climate, inner difficulties with particular psychic states of being, e.g. theexperienceofbeingastrangerorloneliness.Manycountriesthatwere oncelargelyhomogeneousarenowmorediverse.Accordingly,thereisan acute need for clinically based, structured knowledge of the specific psychological and outer difficulties and problems of the refugee and immigrant. Ways of working with these groups in psychotherapy and supportwork,andinpreventiveandeducationalprograms,mightthenbe developedaccordingly. OUTLINEOFTHEDISSERTATION PartI(chapters3-11)describesandillustratestheconceptualframework. PartII(chapters12-15)evaluatesanddiscussestheconceptualframework inthelightofatrainingprogrambaseduponit. PartIdescribesthedevelopmentandsystematizationoftheconceptual framework, and its background and utilization in individual and family clinicaltreatmentoftherefugee,theimmigrantandtheirchildren.Thereis a particular emphasis on traumatized and tortured refugees. Each component of the framework is described in a separate chapter and exemplified with excerpts from 69 cases (of men, women and children of different ages, backgrounds and cultures). All cases are drawn from the author’sclinicalandsupervisorywork.DocumentationforpartIcomprises written notes and tape-recorded sessions, and oral and written reports (of theauthor,andofpsychotherapists/supportworkersshehassupervised). Part II is offered as support of the conceptual framework’s validity and utility by considering the processes undergone by other clinicians. It consists of a description and evaluation of a year-long specialized programoftraining,basedontheframework,formental-healthandother