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 explore psychopathological presentations in refugees and asylum seekers. To present explore brain biology and changes resulting from trauma. To present explore brain biology and changes resulting from trauma. Focus on Post traumatic stress disorder (PTSD) Focus on Post traumatic stress disorder (PTSD) To present some evidence based therapeutic interventions when working with this client group. 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. 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). 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. 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). 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). 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. 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). 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). 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 Many refugees who come to the U.K. have experienced or witnessed Torture, Torture, Organised violence Organised violence Sexual violence Sexual violence War and trauma, War and trauma, Multiple complex losses Multiple complex losses Dislocation from families Dislocation from families Stress Stress Bereavement (Burnett and Peel, 2001). Bereavement (Burnett and Peel, 2001).

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

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

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

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

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

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

16. PTSD Emotional reactions to stress are often accompanied by: Emotional reactions to stress are often accompanied by: muscle aches and pains muscle aches and pains diarrhoea diarrhoea irregular heartbeats irregular heartbeats headaches headaches Depression Depression 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).

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

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

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

22. Client centred therapy Developed by the humanist psychologist Carl Rogers in the 1940s and 1950s. Developed by the humanist psychologist Carl Rogers in the 1940s and 1950s. Core conditions Core conditions Non directivity Non directivity Tendency towards self actualisation 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) 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) Started in Milan in 70’s (Milan school) Gianfranco Cecchin and Luigi Boscolo. Gianfranco Cecchin and Luigi Boscolo. Psychiatric model to psychoanalytic therapeutic model. Psychiatric model to psychoanalytic therapeutic model. Treatment of families (nuclear) examples are solution focused, collaborative, strategic therapy (AFT 2010). Treatment of families (nuclear) examples are solution focused, collaborative, strategic therapy (AFT 2010).

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

25. Transcultural work Transcultural therapy is paramount in our practice Transcultural therapy is paramount in our practice Issues of identity vs impact of torture and being a foreigner i.e. refugee/asylum seeker 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. 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 Ways of understanding serious physical or mental illness or serious misfortune

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

27. Working with interpreters Training Training Debrief, After session Debrief, After session In session sitting position In session sitting position Communication Communication The therapeutic alliance 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. 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). Authors on working with interpreters (Haenal 1997, Holder 2004; Marshall et al 1998; Tribe and Raval 2003).

28. Complex Issues Power Power Gender Gender Class Class Culture Culture Other issue Other issue Discuss how each of these could impact on the therapeutic relationship? 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). 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 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) 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) 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) 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) 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) Clients (Asylum seekers and refugees) Perceptions of therapy (Charura 2009)

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

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