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The work I have done over the course of the past seven years as Director of Psychological Services at the Hasbro Pediatric Refugee Clinic in Providence, Rhode Island, United States (U.S.) is undoubtedly the most difficult and rewarding role of my professional life. Over time, the experiences of the families I have served (and thus of myself as a clinician) have changed in ways that I think are important to document. The purpose of this Clinician’s Corner column is to provide an overview of our work with refugees, including intervention implementation with interpreters, adaptations of evidence-based treatments, and sensitive care in politically charged climates. I provide case examples, altered slightly to preserve anonymity, each of which are representative of at least a dozen other families across multiple cultures.

Some Context and Pediatric Refugee Populations

During a routine brief psychological screen with an adolescent who was meeting with her pediatrician, an adolescent confessed to me constant preoccupation and sadness related to worries about her mother who remained behind in their country of origin and who was in poor health; the adolescent reported frequent feelings of panic after their infrequent calls or after meetings that made efforts to bring her to the U.S. seem hopeless. In her darkest hopeless moments, she thought about killing herself and no one in her life realized that this straight-A model student/daughter/sister was struggling to survive hour by hour. (See Centers for Disease Control and Prevention, 2013 for more about suicide in one U.S. refugee population.)

When I began work with refugee children, I was surprised by how often children resettled in the U.S. have a parent or siblings who remain behind in active danger. This is especially common for refugees who have experienced extreme trauma that required them to flee in a manner that either resulted in separation of some family and/or meant that documentation of marriage was lost. In some cases, one parent is resettled in advance of the children so that when the parent is finally able to bring their child(ren) to the U.S. they have not been the caregiving parent for their child for many years. The resettled child and parent are both learning to live together, at the same time that the child is mourning separation and loss related to the parent who remains behind. In these cases, intervention is focused on a mix of parenting training (with psychoeducation about child/adolescent development and adjustment), family intervention efforts aimed at solidifying the relationship between reunified parent and child(ren), and enhancing capacity to cope with the feelings that come with separation from a parent who is in potential danger (Birman et al, 2005; http://nctsn.org/trauma-types/refugee-trauma/learn-about-refugee-trauma). In some cases I have seen, family members left behind have died (due to medical concerns, bombings, violence) while awaiting processing of their applications for resettlement. Even when family members are resettled together, many children have talked to me about their feelings of guilt and sadness when they eat a meal or receive new clothes as they think about the starvation and fear of those who remain behind.

Working with Interpreters

The ability to work with interpreters is an essential skill for clinicians working with refugee populations. Based on early evidence (Miller, Martell, Pazdirek, Caruth, & Lopez, 2005; Searight & Searight, 2009), I have approached work with interpreters in a manner that acknowledges the interpreter as a cultural broker and a human participant in the therapeutic process. Importantly, however, I take care to make clear that the focus is on my interactions with the family and not with the interpreter. When interacting with a child or parent, my eye contact and body orientation are focused on the patient and not on the interpreter. I use language that communicates directly to a child (i.e., “Ramadan without your sister is going to be incredibly sad.”) rather than to interpreters about a child (i.e.,“Please tell XXX that I said ‘Ramadan without her sister…’”). However, I also incorporate the interpreter as a part of the process by asking the family and interpreter together about language and culture directly (i.e., “In many countries there is a word for or concept of ‘resilience’ or of ‘rising above’ something - do you have something like this in your language?”). In this way, we can engage with the content as a team and the child, family, interpreter can be the experts. When the interpreter responds in English, I ask them to repeat their response to the family and to ask the family if they agree with the interpreter’s perspective – to encourage families to elaborate on their own idiographic perspectives. This is contrasted with “black box” approaches that treat an interpreter as a direct/automated translator of words as well as with triangle approaches in which the provider and patient are each talking to the interpreter rather than with one another.

Effective work with interpreters ideally involves providing some training in mental health interpreting, which often does not happen in a formal way in less common languages. I have needed to develop and build trust with interpreters as we work together, this trust is incredibly important as good assessment and intervention often involves open communication that may feel uncomfortable to interpreters who do not know why you are asking questions or do not yet know that you can be trusted. In some cases, interpreters have been protective of patients and avoidant of any questions that they thought were sensitive (even questions about sadness). I was especially humbled and honored when, after about a year of work with refugees through their medical home in our clinic (usually seeing children referred by their pediatrician or resettlement agencies), the interpreters (who are often leaders and cultural brokers in their communities) began referring members of their community directly to me.

More often than not, the interpreters are an incredible resource for therapy. Skilled interpreters can match the tempo, tone and can even gently, respectfully shift the effect of someone’s words simply by repeating it in English. My favorite moments are when I am able to watch, listen, experience as a family is talking and I can say aloud the gist, the emotional and meaningful components, of what they are sharing even before the interpreter speaks; in such a moment, the family has a chance to be truly heard in a different kind of way. Some of the most powerful sessions happened when communication was not about words. Indeed, sometimes this work has reminded me that words are sometimes a distraction and the discrepancies we look for between nonverbal and verbal experiences can be especially apparent when we first hear the nonverbal experience before getting the interpreted words.

At times, though, work with interpreters can present challenges when families in small refugee communities have fears about what interpreters know about their family, when there are delays/changes/interruptions in interpreter availability, when a phone interpreter is the only option, and when the patient’s experiences trigger difficult emotions for interpreters. I have had times when interpreters have made assumptions about a range of beliefs based on a family’s origin (particularly when the interpreters and family are from a common group) and part of therapy has been exploring how that particular family may not completely ascribe to a particular cultural framework. On a few occasions, I have had interpreters suddenly switch from interpreting (usually trauma of war/genocide) a family member’s experience and begin to share their own experiences. In such situations, I have found ways to gently refocus the interpreter by first briefly acknowledging the interpreter’s experience and then, after a moment of quiet to slow the pacing of the session and to provide a space between the interpreter’s disclosure and the patient’s experience, I then return the focus to the patient with a combination of a question and nonverbals aimed at the patient. After the session, I check in with the interpreter separately to validate their pain and, if appropriate, to offer a referral to an adult clinician.  
Adapting Evidence Based Interventions for Refugee Children

Unfortunately, more research is needed to systematically evaluate interventions for refugee children (Tyrer, & Fazel, 2014). One challenge to such evaluations is the reality of assessing interventions focusing on a full range of ages (I have seen children as young as 18 months and adolescents into emerging adulthood) and presenting concerns, providing me with the opportunity to consider everything from assessment/intervention for depression, anxiety, posttraumatic stress, and adjustment disorders all the way to assessments of autism, eating disorders, psychosis, and conduct disorders. In talking with families who often come from countries where mental health services were minimal and/or highly stigmatized, I focus on the concrete concerns like sleep or behavior that they bring to me rather than on the psychiatric labels of the latest Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases.

In a majority of cases, components of established evidence based interventions such as Trauma Focused Cognitive Behavioral Therapy (TF-CBT; i.e., Cohen, Mannarino, & Deblinger, 2006), Narrative Exposure Therapy (NET; Schauer, Schauer, Neuner, & Elbert, 2011), Parent Child Interaction Therapy (PCIT; Hembree-Kigin & McNeil, 2013), and parenting training programs such as Triple P (Sanders, 1999; see www.triplep.net/) may be easily adapted for work with refugee families. Most often, I find myself adapting TF-CBT and Triple P (in younger children) interventions; in adolescent populations, I often incorporate elements of Motivational Interviewing (Miller & Rollnick, 2012).

I adapt these interventions by starting with the pieces that already come naturally to families and by providing one way of contextualizing existing and new skills. For example, a number of refugees recently resettled come from countries where the use of physical discipline is prevalent. Shortly after arriving, one family presented to the clinic completely overwhelmed as their previously wonderfully behaved son was holding the entire family hostage, reminding parents that they “couldn’t do anything” because he could call the police if they used physical discipline. When I met with the family, it turned out that in their home country they’d actually never used physical discipline but it was the threat that they could use it that had been perceived by the family to be the reason that the children were so wonderfully behaved. Yet, it became clear that they had used a wealth of common parenting strategies (e.g., positive reinforcement, selective attention, praise, natural consequences) and had never realized that these were likely the salient predictors of positive outcomes in their children. After a very brief intervention, the family was able to return to using the strategies they’d had all along (with a few new ones).

Flexible adaptations are the definition of work with refugee families who often present with a complex combination of presenting concerns, often bring multiple children to appointments (often with mothers breast feeding intermittently throughout appointments to calm restless little ones), and experience appointments as influenced by interpreters. If you like a challenge and even occasional chaos – this is the work for you! Although many nonverbal cues are cross-cultural, there are many (such as avoidance eye contact) that may reflect culture rather than psychological symptoms or interpersonal concerns, making it important for clinicians to become familiar with these potential miscommunications/misinterpretations and to go ahead and find gentle ways to check on assumptions they may be making that are not culturally consistent. Some familiarity with a range of religious practices is also important in refugee work. More than a few adolescents have been referred to me after or during Ramadan with questions related to whether the teen might actually have an eating disorder, requiring a careful adjustment of assessment and intervention that acknowledges the religious and cultural context of the adolescent.
Changing Political Climates

I am repeatedly amazed by the resilience of refugee children and adolescents. For example, when I asked one teen whether it felt lonely or isolating to attend school in an English Language Learner classroom where the classmates and teacher all spoke Spanish, he enthusiastically replied, “I’m learning Spanish too!” Given this inspiring resilience, in the face of unfathomable levels of trauma, it is incredibly heartbreaking to see hopeful children overcome their past and then, in a “country of opportunity and freedom,” to face bullying, insults, and sometimes outright assault.

Recent years have seen an incredible humanitarian crisis and politicized and intense attitudes about refugee resettlement from the citizens of host countries (Esses, Hamilton, & Gaucher, 2017). It has been truly frightening to witness a shift in the past six months in the frequency and severity of abuses that the refugee children I work with face. It has long been heartbreaking, when a majority of the children (even young children) have told me that they were frequently told “go back to Africa” or were called a range of horrible slurs and insults. On select occasions, adolescents (often living in under-resourced schools) would tell me that these incidents escalated to pushing or even hitting. In the past few months, however, this has escalated alarmingly.

Families come to me with 6 and 7 year olds who are bruised and beaten by classmates and with teenagers who have been assaulted on the bus. A handful of adolescents (from a range of countries) report incidents during walks to/from school in which others in the school have thrown liquids at them, even in their eyes. In some cases, parents feel afraid to send their children to school. As one mother said, “In this country, you tell me I cannot beat my child yet I must send my child to school to be beaten by others?” This experience is hardest on families who have faced genocide, who have been targeted before for being different. I met with a family who had hoped to bring the children’s father to the U.S. just as a ban was put into place, preventing this desperately needed reunification. The children had been crying inconsolably, particularly at night when they most missed the reassurance of their dad’s presence. Mom explained her incredible hopelessness and sadness and the interpreter, overwhelmed by this and so many similar stories in their community, turned to me and said, “Please, you must stand for us. We have no voice in this time. We need people like you to help.”

About the Author

Nicole Nugent, PhD, is Director of Psychological Services at the Hasbro Pediatric Refugee Clinic at Hasbro Children’s Hospital in Rhode Island, USA and is an Associate Professor in the Departments of Pediatrics and Psychiatry and Human Behavior at the Warren Alpert Brown Medical School. Dr. Nugent has an active program of research related to understanding the influences of social context and individual biological factors on psychological well-being during times of stress and transition. https://vivo.brown.edu/display/nnugent 


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