mental health services, many will benefi t from seeking and obtaining help. Receiving the referral should give rise


to refl ection about the referred person’s and/or families’ cultural and language background and social situation. It is important to consider, and if in doubt fi nd out, what the referrer has explained about the referral and what the family understands by it and hopes for. It may be appropriate for the referrer to bring the family, to make the link with clinicians for an exploration of concerns. Many asylum seekers and refugees do


not have spoken English and so the initial inquiries will enable clarifi cation about the need for an interpreter. Beyond the general competencies required for working with interpreters (Tribe & Lane, 2009), working with interpreters with this population requires special sensitivities. T ere may be gender issues (for example, women who have a history of sexual assault), so that female interpreters may be required. Furthermore, there is the appropriateness from a cultural and political point of view of a specifi c interpreter. Some may share the language of the referred family but come for an ethnic, social or religious group that has perpetrated the abuse and persecution the family has experienced. T ere may also be fears that the interpreter will be indiscreet and break confi dentiality. Some families might want to rely on an adolescent family member acting as interpreter. While this is problematic, it might be appropriate for the initial engagement and aſt er contact to reconsider the viability of the arrangement, and enter more detailed discussions about what characteristics the interpreter should have for the family to feel comfortable. Despite the above concerns, interpreters


may play a very useful role that extends beyond interpreting. T ey may be from the same cultural background as the family and help as “culture brokers”, so that they explain to the clinicians some aspects of the cultural and migration background (Raval, 2005). As with all referrals, fl exibility is needed


about whom to invite and see for the initial contact. T ere needs to be awareness of the disrupted lives, possibly family losses, oſt en of fathers who are detained or killed, and the presence of parental psychiatric disorder associated with high impairment. T e referred child may be seen initially with an older sibling who is more familiar with the language and health care system.


16


Starting the conversation and


clarifying what is the problem At the beginning, clarifying the reason for


the meeting is important. T e family may wish to gain something diff erent to what the referrer wants, and initially diff erent to what the clinician thinks is “needed” or appropriate. Asylum seeking families may want help with practical aspects of their lives, such as school access for children, improved and more stable housing and support for asylum claims. T ese requests need to be taken seriously as these issues may, at this phase, dominate the conversation. For some families, these aspects of their lives may improve if asylum application is successful. Taking these mat ers seriously may promote trust and facilitate discussion about psychological issues. Some families may not understand what the various agencies’ roles are, so this might need clarifying. For other families, whose individual members are referred with somatic presentations, at endance at a “mental” health service may be confusing (Kastrup, 2006). However, some families may want to tell their migration story and relate this to mental health problems from the outset (van der Veer & van Waning, 2004). T is raises dilemmas for clinicians


working in the rather bureaucratised and managed NHS, such as CAMHS, in which an assessment may be required to elicit enough information to complete the assessment form, obtain data for psychiatric diagnosis, risk assessment and routine outcome measures. It may take a number of sessions before these areas can be covered. Families or individuals who want help with the practical aspects of their lives, or even psychiatric symptoms, but do not want to address or explore past traumatic events, may heighten the dilemma for clinicians. T ey may regard this as unnecessary, thinking that their post-traumatic experiences are “normal“ for their community, or feel survivor guilt, that as they have reached relative safety, it is an indulgence to focus on past events rather than focusing on improving their situation. For some families looking back is too stressful, as is it evokes traumatic memories and perhaps fl ashbacks, and may need to be explored later in therapy.


Building trust Asylum seekers are required to undertake


multiple interviews with immigration offi cials, and may have experienced coercive


interrogation in their own countries. Care is needed to ensure as much as possible, interviewing for psychological and therapeutic purposes is diff erent. At ending to the families’ aff ect, listening to their story when they want to tell it, taking practical concerns seriously, and accepting the need to address current psychological diffi culties, perhaps at a symptom level, may help this (van der Veer & van Waning, 2004). Clarifying the distinction between assessment in health set ings and immigration set ings is important with regards to confi dentiality, as asylum seekers may fear information disclosed may result in deportation. It may also be necessary to make distinctions between health set ings and local authority social-care set ings, as the lat er don’t appear to hold information confi dentially, having been penetrated by UK Home Offi ce offi cials (see ht ps://www. theguardian.com/uk-news/2019/feb/16/ home-offi ce-hires-out-staff -hunt-migrants- hostile-environment) Related to the engagement is the stance


of the interviewer. Interviewing can be stressful, but the interviewer will help the family by an appropriate warm and empathic aff ect. Challenging the family early in therapy, to disrupt communication pat erns and interactions, which could occur as an aspect of “joining” described in structural family therapy (Minuchin & Fishman, 1981) will increase stress and arousal and is not recommended. Furthermore, a stance of “neutrality” regarding experiences of adversities and abuse is likely to undermine the development of trust and experience of the clinic as a safe place (van der Veer & van Waning, 2004).


Conclusions Knowledge of asylum seeking and


refugee families’ past experiences, and oſt en current challenging living situations, and adopting appropriate communication, including empathic style, are important. T e work is oſt en diffi cult, but it can be rewarding, and may help families obtain the help from which they might benefi t.


Acknowledgements


T anks to Nasima Hussain for helpful comments on an earlier draſt of this article.


References Adamson, J., Warfa, N. & Bhui, K. (2011) A case study of organisational cultural competence in mental healthcare. BMC Health Services Research, 11, 218. doi:10.1186/1472-6963-11-218


Context 169, June 2020


Thinking about engagement and joining with asylum seeking and refugee families


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