Establishing Therapeutic Dialogue with Refugee Families

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<ul><li><p>ORI GIN AL PA PER</p><p>Establishing Therapeutic Dialogue with Refugee Families</p><p>Suzanne Guregard Jaakko Seikkula</p><p>Published online: 2 April 2013 Springer Science+Business Media New York 2013</p><p>Abstract The article describes an investigation into dialogues between native Swedishpsychotherapists and refugee families. Dialogue is needed to establish the therapeutic</p><p>alliance, which is ultimately important for healing, whether of individual sickness or</p><p>family crisis. However the development of dialogue is hindered by cross-cultural and</p><p>language barriers. We concentrate on one aspect of research originally presented in a</p><p>Doctoral Thesis by the first author, asking how culture and power differences, together</p><p>with their resettlement in a strange country, affected meetings with refugee families, and</p><p>how these problems were overcome; language and the presence of an interpreter are not</p><p>discussed. A multi-perspective methodology was used in the original research, combining</p><p>text analysis, review of video-recordings by the participating therapists, and interviews</p><p>with the families. All these forms of investigation are drawn on here, but particularly text</p><p>analysis. Significant hindrances to dialogue turn out to be differences in cultural values</p><p>between refugee and therapist, their different power positions, and the refugees weariness</p><p>and distrust of meetings. Strategies to minimise power differences are an essential aspect of</p><p>the Finnish open dialogue approach, which turns out to be particularly relevant to such</p><p>refugee meetings.</p><p>Keywords Refugee Dialogue Therapeutic alliance</p><p>Background</p><p>This article derives from doctoral research (Guregard 2009), where the second author was one</p><p>of her supervisors. At the time of this research, Suzanne Guregard (SG) had recently been</p><p>appointed head of the Child and Adolescent Psychiatric Clinic (here abbreviated to CAP)</p><p>S. Guregard (&amp;)South Alvsborg Hospital, Bramhultsvagen 53, 50182 Boras, Swedene-mail: suzanne.guregard@vgregion.se</p><p>J. SeikkulaDepartment of Psychotherapy, University of Jyvaskyla, P.O. Box 35, 40014 Jyvaskyla, Finlande-mail: jaakko.seikkula@jyu.fi</p><p>123</p><p>Contemp Fam Ther (2014) 36:4157DOI 10.1007/s10591-013-9263-5</p></li><li><p>in Boras, an area containing many refugees to Sweden. The thesis was concerned with the</p><p>development of therapeutic dialogue between Swedish therapists and refugee families</p><p>seeking treatment for themselves or their children. Most refugee families have suffered severe</p><p>trauma in their home countries. Many have also had difficulty with authority after reaching</p><p>Sweden, making them circumspect when making contact with Swedish officialdom, a cat-</p><p>egory in which social workers and psychotherapists become included. They have no natural</p><p>basis to trustthe staff are foreign, the circumstances are alien, and talking methods of</p><p>treatment may be unfamiliar. Moreover, for refugees, the inner basis for security may have</p><p>been torn away by trauma. Hence establishment of trust is the first priority. This trust must be</p><p>established across cultural barriers. This establishes the research questions for this article:</p><p>What form do these barriers take, and how are they overcome? The research was undertaken</p><p>by examining material from meetings between five Swedish therapists and six refugee</p><p>families, recorded by video-camera. To investigate what happens in the everyday situation,</p><p>the recorded meetings took place in the everyday working situation of two psychiatric clinics.</p><p>This article presents some of the thesis material. However most discussion concerning the</p><p>language barrier and the presence of an interpreter is omitted, while a minimum number of</p><p>families and meetings are used to address the research questions.</p><p>Our title refers to therapeutic dialogue. Unlike therapeutic alliance, discussed</p><p>below, dialogue is not a technical term but an ordinary word in the English language. The</p><p>Oxford English dictionary definition (Oxford 2006) is discussion directed towards</p><p>exploration of a subject or resolution of a problem. Wierzbicka (2006) argues that the</p><p>practice of dialogue opens up understanding in areas such as religion and politics, but also</p><p>between cultures and generations. Linnel (2009) writes that dialogical interaction is the</p><p>principle mechanism through which individuals and society makes sense of the world they</p><p>live in, and find a language through which to express this understanding. Hence dialogue</p><p>arises naturally in most situations where there is a problem to be resolved, and there is a</p><p>peer relationship between the participants. In therapeutic meetings, the unequal positions</p><p>of client and therapist mean that care may be needed for dialogue to develop. Our article</p><p>concerns the particular kind of care needed with a refugee family. Every participant in an</p><p>external dialogue engages in at least two different conversationsone outer and one inner</p><p>(Andersen 1997; Rober 2008). With trauma victims, this capacity for inner dialogue and</p><p>reflection is reduced (Blackwell 1997), so external dialogue can be hard to promote.</p><p>The concept of the therapeutic alliance is introduced here because of the evidence that a</p><p>strong alliance between client and therapist increases the prognosis for a good outcome</p><p>(Lambert and Barley 2001; Wampold 2001; Horvath and Bedi 2002; Elvins and Green 2008),</p><p>while the relationship between dialogue and outcome has attracted less attention. One</p><p>comparatively succinct definition of therapeutic alliance is given in Pinsoff and Catherall</p><p>(1986, p. 199): We define the therapeutic alliance as that aspect of the relationship between</p><p>the therapist system and the patient system that pertains to their capacity to mutually invest in,</p><p>and collaborate on, the therapy (our italics). Dialogue is needed to collaborate, and hence a</p><p>necessary condition for a therapeutic alliancethe personal bond is also important, and with</p><p>many refugees, this capacity to make attachments is reduced (Woodcock 2000). It is therefore</p><p>reasonable to claim that dialogue in therapeutic meetings is important for good outcome. The</p><p>strength of an alliance is usually measured by subsequent questioning of therapists and/or</p><p>clients following the meetings. With dialogue, it is possible to observe its development or</p><p>otherwise during the meeting itself, as this article shows.</p><p>The not-knowing position presented in Anderson and Goolishian (1992) addresses the</p><p>unequal power positions of client and therapist. However the term not-knowing implies</p><p>that the expert knowledge of the therapist is discounted, so has been replaced by</p><p>42 Contemp Fam Ther (2014) 36:4157</p><p>123</p></li><li><p>collaborative therapy (Anderson 2001). In collaborative therapy, there is a great</p><p>emphasis on language and the way new understanding emerges from the dialogue between</p><p>therapist and client. Sutherland (2007, p. 199) writes: As families, jointly with therapists,</p><p>come to make sense of their living systems differently, the problems dissolve or new</p><p>possibilities for living and relating emerge, rendering the initial problem irrelevant.</p><p>Making sense of ones living system implies reflection, so reflection in an utterance is also</p><p>considered in our text analysis.</p><p>Open dialogue (OD) is a collaborative therapeutic approach developed in Finland,</p><p>which has been used successfully with patients suffering from severe psychiatric illness</p><p>(Seikkula 2002; Seikkula et al. 2011). It is distinguished by its use of the network of family</p><p>and work-colleagues to support the patient and enrich the dialogue. New understanding</p><p>emerges from the polyphony of voices. The treatment meeting is the main forum for</p><p>therapeutic interaction, and occurs regularly during the whole treatment period. All</p><p>treatment decisions are made openly in these meetings. The task for the professional team</p><p>member is to identify as nearly as possible with the suffering of the patient and family.</p><p>Compare Lantz and Gyamerah (2002, p. 248), Empathic availability is a committed</p><p>presence to the client family, and an openness to their pain Careful following andresponding by therapists are essential characteristics of dialogue (Seikkula and Trimble</p><p>2005). However responding is not merely linguistic, but requires engagement and empathy.</p><p>It also requires therapeutic discernment to identify hidden voices in the talk, i.e. feelings</p><p>that are suggested but not made explicit. In OD, the lay members of the network are</p><p>encouraged to take the lead and set the agenda. This can be particularly important with</p><p>refugee couples; Reichelt and Sveaass (1994) found that, for good conversation, the</p><p>couples urgent need for practical help and advice had to come before any therapeutic</p><p>agenda. In order to investigate the dialogical quality of a meeting in detail, a text analysis</p><p>method is needed. Here dialogue sequence analysis (DSA) is used, outlined in Seikkula</p><p>(2002) and elaborated in Seikkula et al. (2011). This introduces a number of OD concepts,</p><p>so our article can be said to have an OD perspective.</p><p>When considering the cross-cultural problems to be overcome in meetings between</p><p>refugees and native therapists, many readers will think first of the language barrier. The</p><p>literature concerning the influence of the interpreter in meetings with immigrants or</p><p>refugees (e.g. Brune et al. 2011; Raval 2005) emphasises that the interpreter is much more</p><p>than a translator. Wadensjo (1992) describes the interpreter as a broker, reconciling the</p><p>standpoints of the participants. The interpreter can be someone from the home country</p><p>providing a role model of survival in the new country. Alternatively the interpreter can be</p><p>seen as a threat (Fatahi et al. 2010). The presence of an interpreter certainly influences the</p><p>development of the therapeutic alliance (Miller et al. 2005). However Guregard (2009) was</p><p>also concerned with specific language limitationsloss of spontaneity, problems of</p><p>translating humour and metaphor, failure to translate asides that contribute to informality.</p><p>These topics deserve a separate article.</p><p>A survey of trauma experienced by refugees is given in Papadopoulos (2007). Even if</p><p>torture is not involved, separation from homeland, home, social structure, and employment</p><p>are traumatic enough. There is also the psychic stress endured by many asylum seekers</p><p>entering the host country (Heeren et al. 2012). At the time of the doctoral research, waiting</p><p>times for a residence permit in Sweden could extend to several years, placing severe stress</p><p>on families (they have now become shorter). Two of the six families participating in the</p><p>research experienced great difficulty with Swedish Immigration. They refused to accept</p><p>one mothers statement that the police had abducted her own mother, even though this was</p><p>witnessed by the grandchildren. With another family, they refused to accept that the</p><p>Contemp Fam Ther (2014) 36:4157 43</p><p>123</p></li><li><p>parents were living together and with their children, and interrogated them in separate</p><p>rooms about family meals. Such experience can make asylum seekers deeply mistrustful, a</p><p>distrust latent in every therapeutic meeting.</p><p>Methodology</p><p>Overview</p><p>The research covers two or three early meetings between native-born Swedish therapists</p><p>and six refugee families. They were recorded by video camera and subsequently tran-</p><p>scribed for text analysis. Extracts from each therapy meeting were selected for replay to a</p><p>team consisting mainly of the participating therapists plus the first author, here termed the</p><p>reflecting team.1 These discussions are here termed video-reflections. Each extract</p><p>was first commented in writing by the individual team members, and then discussed</p><p>between them. These team discussions were also videotaped, and a selection transcribed.</p><p>To obtain the families own perspective, the first author interviewed them after their</p><p>second therapeutic meeting. These interviews were audio-recorded and transcribed for</p><p>analysis. Thus the research material consists of four datasets:</p><p> transcriptions of each therapy meeting written comments by the therapists. transcriptions of selected video-reflections transcriptions of each family interview</p><p>The amount of material is considerable, so only a selection is used here to illustrate the</p><p>problems and solutions that emerged.</p><p>The research was carried out in the naturalistic setting of two clinics. Neither therapists</p><p>nor interpreters were given special training for the research. Apart from the presence of a</p><p>video camera to record the therapy meetings, they were carried out under routine condi-</p><p>tions for each clinic. This method was adopted in order to draw lessons for clinical</p><p>practice. There can be a great gap between theory and everyday practise, so from a patient/</p><p>client perspective the identification of both good practice and shortcomings is very</p><p>important.</p><p>Participants</p><p>One therapist from the Gothenburg Crisis and Trauma Centre working with families, both</p><p>adults and children, and four therapists from CAP volunteered to participate. Since CAP</p><p>therapists normally work in pairs, this gave three sets of therapists. Each agreed to meet</p><p>two families under research conditions previously discussed. It was proposed to record two</p><p>or three early meetings with each of the six families. Early meetings were chosen because</p><p>it is then that the therapeutic alliance should be established. In fact 15 meetings were</p><p>recorded. Two of the five therapists were psychologists, the others social workers. Only</p><p>one psychologist and one social worker were accredited as therapists at the time, which is</p><p>not untypical for Swedish psychiatric clinics. For each set of therapists, the first two</p><p>refugee families who agreed to participate in the research were accepted. There were no</p><p>other selection criteria. These families had fled from Afghanistan, Azerbaijan, Bosnia, Iraq</p><p>1 Not to be confused with the term as used by Tom Andersen (Andersen 1997)</p><p>44 Contemp Fam Ther (2014) 36:4157</p><p>123</p></li><li><p>and Iran, all countries with an Islamic culture, as with most recent refugees to Sweden,</p><p>although not all were practising Moslems. Family members were very different in edu-</p><p>cation, homeland environment and traumatic experience. Nevertheless many had experi-</p><p>enced an unwelcoming reception in Sweden, accompanied by an enduring fear of</p><p>expulsion, so there are important commonalities. Ongoing stress before and after the flight</p><p>can lead to physiological and psychological problems (Roth 2006), and also affect family</p><p>relationships (Woodcock 2000). Only one family consisted of children living together</p><p>with both parents. The term means only that biological parents attended meetings,</p><p>sometimes with their children. Of the 15 meetings, the 10 early meetings at CAP were</p><p>primarily exploratory. Hartzell et al. (2010) discuss such meetings and writes (pp. 274,</p><p>275) When the families come they are in a difficult situation and are vulnerable It is notintended to be a therapeutic meeting, but it could be therapeutic and helpful if conducted in</p><p>a sensitive and open way</p><p>Multiple Perspectives</p><p>Text analysis of the transcribed therapy meetings gives the most detailed information on</p><p>what was actually spoke...</p></li></ul>

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