Psychopathology and
Psychotherapeutic interventions
when working with refugees and
asylum seekers.
By Divine Charura
Specialist Psychotherapist
Aims and Objectives
• To explore psychopathological presentations in
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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.
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/ refugee?
• An asylum seeker is someone who is fleeing persecution
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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).
Asylum seekers and refugees
• Extremely heterogeneous group with diversity in
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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).
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).
Problems of asylum seekers
and refugees
• Many refugees who come to the U.K. have
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experienced or witnessed
Torture,
Organised violence
Sexual violence
War and trauma,
Multiple complex losses
Dislocation from families
Stress
Bereavement (Burnett and Peel, 2001).
What is psychopathology?
• Psychopathology is the study of mental
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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.
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)
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
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)
Diagnostic Classification
• Communication
• Clinical research and statistical uses
• Categorical not dimensional
• International classification of diseases
ICD-10
• DSM-IV
• Other cultural
Cross section of the brain
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.
PTSD
• Arises as a delayed response to a stressful
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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.
PTSD
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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).
Traumatic encoding
Shrinkage of the hyppocampus
• Shrinkage due to heightened level of
cortisol which is toxic causing behavioural
disinihibition and hyperresponsiveness to
environmental stimuli.
Pathophysiology of PTSD
• Parietal Lobes- Integrate information between
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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
Phamacological interventions
• Selective serotonin reuptake inhibitors (SSRI)
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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.
The therapeutic modalities
• Client centred therapy
• Psychoanalytic/ psychodynamic
• Gestalt therapy
• Family and systemic therapy
• Transcultural
• Other psychotherapies
• Complimentary therapies
Client centred therapy
• Developed by the humanist psychologist Carl
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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)
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).
Family systemic concepts
• What is a family
• Systems
• Genograms
• Circular questioning
• Hypothesis
• Curiosity
• Neutrality
• Irreverence
Transcultural work
• Transcultural therapy is paramount in our
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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
Complimentary/other therapies
• EMDR
• Massage
• Reiki
• Alexander technique
Working with interpreters
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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).
Complex Issues
• Power
• Gender
• Class
• Culture
• Other issue
• Discuss how each of these could impact
on the therapeutic relationship?
Research
• Limited research that focuses directly on the
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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 RCTequivalent studies in the U.K. Stiles et al (2006 and
2007)
Research
• The Psychobiology and pharmacology of PTSD,
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(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)
Future of this work
• More access and availability to services
• Political recognition of impact of delayed
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processing of asylum seekers immigration status
More evidence based studies needed throughout
therapy modalities
More funding needed
Psychotherapy/counselling and psychiatry
models which offer
Conclusion
• Descriptions, Challenges and complexities of
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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