Psychopathology and Psychopathology and Psychotherapeutic Psychotherapeutic

interventions when working interventions when working with refugees and asylum with refugees and asylum

seekers.seekers.

By Divine CharuraBy Divine Charura

Specialist Psychotherapist Specialist Psychotherapist

Aims and ObjectivesAims and Objectives

• To explore psychopathological presentations To explore psychopathological presentations in refugees and asylum seekers.in refugees and asylum seekers.

• To present explore brain biology and To present explore brain biology and changes resulting from trauma.changes resulting from trauma.

• Focus on Post traumatic stress disorder Focus on Post traumatic stress disorder (PTSD)(PTSD)

• To present some evidence based To present some evidence based therapeutic interventions when working with therapeutic interventions when working with this client group.this client group.

• Explore possibilities and raise questions on Explore possibilities and raise questions on the future direction of this work.the future direction of this work.

What is an asylum seeker?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.”

What is an asylum seeker/ What is an asylum seeker/ refugee?refugee?• An asylum seeker is someone who is fleeing An asylum seeker is someone who is fleeing

persecution in their homeland, has arrived in another persecution in their homeland, has arrived in another country and made themselves known to the country and made themselves known to the authorities and exercised their legal right to apply for authorities and exercised their legal right to apply for asylum under the 1951 UN Refugee Convention asylum under the 1951 UN Refugee Convention ( Home office 1999). ( Home office 1999).

• To be granted asylum under the 1951 UN convention, To be granted asylum under the 1951 UN convention, an individual has to show a well founded fear of being an individual has to show a well founded fear of being persecuted in his or her country of origin for reasons persecuted in his or her country of origin for reasons of race, religion, nationality, membership, of a of race, religion, nationality, membership, of a particular group or political opinion. particular group or political opinion.

• A refugee is an individual granted asylum (UNHCR A refugee is an individual granted asylum (UNHCR 1992). 1992).

Asylum seekers and Asylum seekers and refugeesrefugees• Extremely heterogeneous group with diversity in Extremely heterogeneous group with diversity in

language, culture, political and religious affiliations, language, culture, political and religious affiliations, political histories, various social classes, and diverse political histories, various social classes, and diverse experiences of life experiences (Solace 2008). experiences of life experiences (Solace 2008).

• In 2003, Amnesty International estimated that there In 2003, Amnesty International estimated that there were thirty five recognised conflicts and one were thirty five recognised conflicts and one hundred and thirty two countries still practicing hundred and thirty two countries still practicing torture. torture.

• Since then this figure has continued to increase and Since then this figure has continued to increase and at the start of 2009, worldwide, there were over at the start of 2009, worldwide, there were over nineteen million asylum seekers/refugees and nineteen million asylum seekers/refugees and ‘others of concern’ (UNHCR 2009).‘others of concern’ (UNHCR 2009).

Needs of asylum seekers Needs of asylum seekers and refugeesand refugees

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

Problems of asylum seekers Problems of asylum seekers and refugeesand refugees• Many refugees who come to the U.K. have Many refugees who come to the U.K. have

experienced or witnessed experienced or witnessed • Torture, Torture, • Organised violence Organised violence • Sexual violenceSexual violence• War and trauma, War and trauma, • Multiple complex lossesMultiple complex losses• Dislocation from familiesDislocation from families• StressStress• Bereavement (Burnett and Peel, 2001).Bereavement (Burnett and Peel, 2001).

What is psychopathology?What is psychopathology?

• PsychopathologyPsychopathology is the study of is the study of mental illnessmental illness, mental distress and , mental distress and abnormal, maladaptive behaviour. abnormal, maladaptive behaviour.

• The term is most commonly used within The term is most commonly used within psychiatrypsychiatry where where pathologypathology refers to refers to disease processes. disease processes.

• Abnormal psychologyAbnormal psychology is a similar term is a similar term used more frequently in the non-medical used more frequently in the non-medical field of field of psychologypsychology. .

What is a diagnosis?What is a diagnosis?

• dia (Greek) meaning dia (Greek) meaning throughthrough

• gnosis (Greek) meaning gnosis (Greek) meaning knowledgeknowledge

• ““Diagnosis” is the establishing of the Diagnosis” is the establishing of the nature of a disease. nature of a disease.

• Problems with subjectivity Problems with subjectivity (Psychiatrist) and Objectivity (research (Psychiatrist) and Objectivity (research and evidence)and evidence)

Mental health Mental health presentations of asylum presentations of asylum seekers and refugeesseekers and refugees• TraumaTrauma

• Post traumatic stress disorder Post traumatic stress disorder

• PsychosisPsychosis

• DepressionDepression

• AnxietyAnxiety

• Conditions resulting from impact of Conditions resulting from impact of torturetorture

• Other medical conditionsOther medical conditions

Multiaxial DSM-IVMultiaxial DSM-IV

• AXIS i clinical disordersAXIS i clinical disorders• Axis ii personality disorders & Mental Axis ii personality disorders & Mental

retardationretardation• Axis iii General medical conditionsAxis iii General medical conditions• Axis iv Psychosocial and Axis iv Psychosocial and

environmental problemsenvironmental problems• Axis V Global assessment of Axis V Global assessment of

functioning (GAF)functioning (GAF)

Diagnostic ClassificationDiagnostic Classification

• CommunicationCommunication

• Clinical research and statistical usesClinical research and statistical uses

• Categorical not dimensionalCategorical not dimensional

• International classification of International classification of diseases ICD-10diseases ICD-10

• DSM-IVDSM-IV

• Other culturalOther cultural

Cross section of the brainCross section of the brain

Trauma Trauma

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

PTSDPTSD

• Arises as a delayed response to a stressful Arises as a delayed response to a stressful situation.situation.

• Predisposing factors, i.e. personality traitsPredisposing factors, i.e. personality traits

• Typical features- flashbacks, nightmares, Typical features- flashbacks, nightmares, sense of numbness, detachment from sense of numbness, detachment from other people. other people.

• unresponsiveness to surroundings, unresponsiveness to surroundings, anhedonia, avoidence of activities anhedonia, avoidence of activities reminiscent to the trauma.reminiscent to the trauma.

PTSDPTSD

• Emotional reactions to stress are often Emotional reactions to stress are often accompanied by:accompanied by:

• muscle aches and pains muscle aches and pains • diarrhoea diarrhoea • irregular heartbeats irregular heartbeats • headaches headaches • DepressionDepression• feelings of panic and fear feelings of panic and fear • drinking too much alcohol drinking too much alcohol • using drugs (including painkillers).using drugs (including painkillers).

Traumatic encodingTraumatic encoding

Shrinkage of the Shrinkage of the hyppocampushyppocampus

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

Pathophysiology of PTSDPathophysiology of PTSD

• Parietal Lobes- Integrate information Parietal Lobes- Integrate information between areasbetween areas

• The Amygdala- evaluates incoming The Amygdala- evaluates incoming information for emotional significance, information for emotional significance, activated when people are exposed to activated when people are exposed to trauma triggerstrauma triggers

• Hippocampus –creates a cognitive map that Hippocampus –creates a cognitive map that allows the categorization of experience.allows the categorization of experience.

• The Corpus Callosum integrates emotional The Corpus Callosum integrates emotional and cognitive aspects of experience and cognitive aspects of experience

Phamacological Phamacological interventionsinterventions• Selective serotonin reuptake inhibitors Selective serotonin reuptake inhibitors

(SSRI) i.e. Fluoxetine (SSRI) i.e. Fluoxetine • Anticonvulsants, i.e.. Carbamazepine, Anticonvulsants, i.e.. Carbamazepine,

GabapentineGabapentine• Benzodiazepines i.e. ClanazepamBenzodiazepines i.e. Clanazepam• ΒΒ-Blockers i.e. Propranolol-Blockers i.e. Propranolol• Antipsychotics- i.e. Resperidone, Clozapine.Antipsychotics- i.e. Resperidone, Clozapine.• N.B. these may also have serious side N.B. these may also have serious side

effects and medical supervision is effects and medical supervision is important.important.

The therapeutic modalitiesThe therapeutic modalities

• Client centred therapyClient centred therapy

• Psychoanalytic/ psychodynamicPsychoanalytic/ psychodynamic

• Gestalt therapyGestalt therapy

• Family and systemic therapyFamily and systemic therapy

• Transcultural Transcultural

• Other psychotherapiesOther psychotherapies

• Complimentary therapiesComplimentary therapies

Client centred therapyClient centred therapy

• Developed by the humanist psychologist Developed by the humanist psychologist Carl Rogers in the 1940s and 1950s.Carl Rogers in the 1940s and 1950s.

• Core conditionsCore conditions• Non directivityNon directivity• Tendency towards self actualisation Tendency towards self actualisation • It is stated that the organism has one It is stated that the organism has one

basic tendency which is to strive to basic tendency which is to strive to actualise, maintain, and enhance its actualise, maintain, and enhance its experiencing (Rogers 1951)experiencing (Rogers 1951)

Family and systemic Family and systemic therapytherapy• Started in Milan in 70’s (Milan school)Started in Milan in 70’s (Milan school)

• Gianfranco Cecchin and Luigi Boscolo.Gianfranco Cecchin and Luigi Boscolo.

• Psychiatric model to psychoanalytic Psychiatric model to psychoanalytic therapeutic model.therapeutic model.

• Treatment of families (nuclear) Treatment of families (nuclear) examples are solution focused, examples are solution focused, collaborative, strategic therapy (AFT collaborative, strategic therapy (AFT 2010).2010).

Family systemic conceptsFamily systemic concepts

• What is a familyWhat is a family• SystemsSystems• GenogramsGenograms• Circular questioningCircular questioning• HypothesisHypothesis• Curiosity Curiosity • NeutralityNeutrality• IrreverenceIrreverence

Transcultural workTranscultural work

• Transcultural therapy is paramount in our Transcultural therapy is paramount in our practicepractice

• Issues of identity vs impact of torture and Issues of identity vs impact of torture and being a foreigner i.e. refugee/asylum seekerbeing a foreigner i.e. refugee/asylum seeker

• interactions between the natural and the interactions between the natural and the supernatural often affirming beliefs and supernatural often affirming beliefs and experiences of Voodoo, magic, witchcraft experiences of Voodoo, magic, witchcraft and sorcery. and sorcery.

• Ways of understanding serious physical or Ways of understanding serious physical or mental illness or serious misfortunemental illness or serious misfortune

Complimentary/other Complimentary/other therapiestherapies

• EMDREMDR

• MassageMassage

• ReikiReiki

• Alexander techniqueAlexander technique

Working with interpretersWorking with interpreters

• TrainingTraining• Debrief, After sessionDebrief, After session• In session sitting positionIn session sitting position• CommunicationCommunication• The therapeutic allianceThe therapeutic alliance

• Understanding of the importance of somatic language Understanding of the importance of somatic language rather than literal translations is paramount in rather than literal translations is paramount in understanding what the client will be really saying.understanding what the client will be really saying.

• Authors on working with interpreters (Haenal 1997, Authors on working with interpreters (Haenal 1997, Holder 2004; Marshall Holder 2004; Marshall et al et al 1998; Tribe and Raval 1998; Tribe and Raval 2003). 2003).

Complex IssuesComplex Issues

• PowerPower• GenderGender• ClassClass• CultureCulture• Other issueOther issue

• Discuss how each of these could Discuss how each of these could impact on the therapeutic relationship?impact on the therapeutic relationship?

ResearchResearch

• Limited research that focuses directly on the Limited research that focuses directly on the perspectives of refugees and asylum seekers perspectives of refugees and asylum seekers perspectives of therapy/ counselling (Lambert 2007; perspectives of therapy/ counselling (Lambert 2007; Blackwell 2005). Blackwell 2005).

• Three randomised controlled trials (RCT’s) (Bellamy Three randomised controlled trials (RCT’s) (Bellamy and Adams 2000; Murray and Adams 2000; Murray et al.,et al., 2003 and Ridsale 2003 and Ridsale et alet al 2001) stated that counselling is effective in alleviating 2001) stated that counselling is effective in alleviating clinical symptoms such as depression and anxiety clinical symptoms such as depression and anxiety (which refugees and asylum seekers often present (which refugees and asylum seekers often present with with

• Cooper (2008) showed that person centred therapies Cooper (2008) showed that person centred therapies are empirically supported by multiple lines of scientific are empirically supported by multiple lines of scientific evidence; including ‘gold standard’ RCT’s. Large RCT- evidence; including ‘gold standard’ RCT’s. Large RCT- equivalent studies in the U.K. Stiles equivalent studies in the U.K. Stiles et alet al (2006 and (2006 and 2007)2007)

ResearchResearch

• The Psychobiology and pharmacology of The Psychobiology and pharmacology of PTSD, (Van der Kolk 2001)PTSD, (Van der Kolk 2001)

• Effectiveness of CBT, Person centres and Effectiveness of CBT, Person centres and psychodynamic therapies as practiced in psychodynamic therapies as practiced in the U.K. NHS Settings (Styles et al 2006)the U.K. NHS Settings (Styles et al 2006)

• Psychological treatment outcomes in Psychological treatment outcomes in routine NHS services on Stiles routine NHS services on Stiles et alet al 2007, 2007, (Clark et al 2007)(Clark et al 2007)

• Clients (Asylum seekers and refugees) Clients (Asylum seekers and refugees) Perceptions of therapy (Charura 2009)Perceptions of therapy (Charura 2009)

Future of this workFuture of this work

• More access and availability to servicesMore access and availability to services

• Political recognition of impact of delayed Political recognition of impact of delayed processing of asylum seekers immigration processing of asylum seekers immigration statusstatus

• More evidence based studies needed More evidence based studies needed throughout therapy modalitiesthroughout therapy modalities

• More funding neededMore funding needed

• Psychotherapy/counselling and psychiatry Psychotherapy/counselling and psychiatry models which offer models which offer

ConclusionConclusion

• Descriptions, Challenges and complexities Descriptions, Challenges and complexities of psychopathology.of psychopathology.

• Complexities in working with refugees and Complexities in working with refugees and asylum seekersasylum seekers

• Different modalities of workingDifferent modalities of working• Working with interpretersWorking with interpreters• Issues of power, gender, class & cultureIssues of power, gender, class & culture• Research evidence suggests dodo effectResearch evidence suggests dodo effect• Room for development and future researchRoom for development and future research