Addressing trauma in collaborative mental health ... - SAGE Journals

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CCP18110.1177/1359104512444117Rousseau et al.Clinical Child Psychology and Psychiatry

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Article

Addressing trauma in collaborative mental health care for refugee children

Clinical Child Psychology and Psychiatry 18(1) 121–136 © The Author(s) 2012 Reprints and permission: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1359104512444117 ccp.sagepub.com

Cecile Rousseau,Toby Measham and Lucie Nadeau McGill University, Montreal, Canada

Abstract Primary care institutions, including clinics, schools and community organizations, because of their closeness to the family living environment, are often in a privileged position to detect problems in traumatized refugee children and to provide help. In a collaborative care model, the child psychiatrist consultant can assist the primary care consultee and family in holding the trauma narrative and organizing a safe network around the child and family. The consultant can support the establishment of a therapeutic alliance, provide a cultural understanding of presenting problems and negotiate with the consultee and the family a treatment plan. In many settings, trauma focused psychotherapy may not be widely available, but committed community workers and primary care professionals may provide excellent psychosocial support and a forum for empathic listening that may provide relief to the family and the child. Keywords Children, refugee, trauma, collaborative care, mental health

Introduction Although the pertinence of collaborative care is well recognized in adult mental health services and addresses the paucity of specialized resources, collaborative care programs for children and adolescents are relatively rare. At the same time, the literature is increasingly making a case for the detection and treatment of mental health difficulties within primary care settings (Abrahams & Udwin, 2002; Puura et al., 2002; Richardson, McCauley, & Katon, 2009), where proximity-based care has been shown to improve access to services among adult immigrant and refugee patients because less stigma is associated with community-based services (Younes et al., 2005). The Canadian collaborative mental health initiative has emphasized the need to adapt collaborative care models servicing immigrant and refugee communities in order to take into account their cultural and historical specificities (Initiative Canadienne de Collaboration en Santé Mentale, 2006).

Corresponding author: Cecile Rousseau, CLSC Parc-Extension 204.10, 7085 Hutchison, Montreal, H3N 1Y9, Canada. Email: [email protected]

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Advocates of collaborative primary mental health care for children and adolescents underline its compatibility with systemic approaches which are likely to improve shared decision making and responsibility among providers (Chenven, 2010). Despite a lack of literature on culturally adapted collaborative clinical approaches, primary care health and social service professionals working with refugee children traumatized by organized violence often express a need for assistance in understanding cultural differences in the mental health consequences of organized violence and in understanding the strategies used by families and communities to cope with trauma. In addition to addressing cultural differences, situations involving children affected by extreme human-perpetrated harm often provoke strong emotional reactions in caregivers. Collaborative mental health care models can help to address these information- and practice-based needs. This paper describes a cultural consultation model in youth mental health collaborative care in multiethnic Montreal neighbourhoods. It will use three stories of refugee children who have experienced different forms of direct or transgenerational trauma in order to describe the process of cultural consultation in a primary care setting. The stories are used to illustrate the different steps of the process of cultural consultation in a primary care setting in order to highlight three issues that are at the forefront of cultural consultation requests for refugee families: alliance building, assessment and treatment. The challenges of cultural consultation in collaborative care settings addressing refugee children’s mental health are also discussed.

The collaborative care setting Over the past six years, a collaborative mental health care project has been implemented in three community-based health and social services clinics servicing multiethnic neighbourhoods in Montreal, Canada. Of the children and adolescents living within these clinics’ territories, 80% are first (35%) or second (45%) generation immigrants or refugees. Some of these children are experiencing difficulties often related to resettlement or to a previous experience of organized violence; few formally seek mental health support. The goal of the project is to provide mental health services to these children through their community-based clinics. Partners include first line clinical health professionals involved in the psychosocial care of children and adolescents, such as general practitioners, social workers and child care workers, as well as schools and community organizations. Each clinic has a Youth Mental Health Team which provides mental health care directly to children and families, and which also supports the work of other teams in the community clinic delivering general health and psychosocial care to the families. Bridges with community organizations and schools contribute to the establishment of support networks for the families. This systemic approach facilitates the appraisal of the child’s and family’s difficulties within a broader social and cultural perspective and the formulation and implementation of intersectorial (such as school– clinic–community organization) intervention plans.

Shiva and his mother Anna in the Canadian hospital maze This cultural consultation involved three meetings over a two-year period between the consultee, Mary, a clinic psychoeducator who visits schools and daycares in the clinic’s territory, and a child psychiatric consultant. Mary is the main clinic care provider for Shiva, a young boy who arrived in Canada at the age of four with his mother Anna. Shiva was born into a happy, wealthy, welleducated family in Sri Lanka. When Shiva was three, his father was kidnapped for political

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reasons and subsequently killed. Shiva and his mother were called to the hospital where, instead of finding Shiva’s father alive as they expected, they had to identify his tortured dead body. Anna, who was pregnant, was unable to protect Shiva from the horrific sight. Soon afterwards, Shiva and his mother were abducted and tortured, and Shiva witnessed his mother’s mistreatment. Later, relatives smuggled them out of the country and they arrived in Canada where they applied for refugee status. On arriving in Canada, Anna had to be hospitalized because the torture had provoked a miscarriage. For an entire week, she lay between life and death in intensive care. Shiva sat quietly on a chair by her bedside (very surprisingly, he was not placed in a foster care setting). It is not clear whether Anna was discharged without a referral for further mental health care services or whether she did not attend follow-up appointments. The family’s next contact with health and social services was established through Shiva’s daycare. The daycare workers were worried about Anna’s distrustful and avoidant behaviour. They reported that Shiva was extremely withdrawn, hid under tables and appeared to be terrified. They suspected physical abuse and severe neglect. Before reporting him to child protective services, they decided to consult Mary, who was their designated primary health care resource person. Mary’s work with Anna involved supporting her in organizing a survival network in her neighbourhood. She taught her about food banks and helped her find furniture and appropriate clothing. Mary also helped Anna continue with her application for refugee status. In the process of helping Anna fill out her immigration papers, Mary found out about Shiva’s traumatic background by reading the written narrative that Anna had had to provide for her refugee application – Anna never spoke about this. Mary also became increasingly aware of the ongoing physical pain that Shiva and his mother continued to experience, and was concerned about its relationship with their past traumatic experiences. Concerned about Anna and Shiva’s experiences, Mary encouraged the mother to consider mental health and medical support for the family, but Anna refused this. At this point, Mary requested a first consultation during which she discussed the situation in the absence of Anna. Mary explained how she had been working to change the daycare workers’ perceptions of Shiva’s mother from a paranoid and potentially dangerous person to a severely hurt woman who, in spite of her fragility and emotional unavailability, was deeply attached to her son. During the consultation, a thorough review of all the services involved revealed that in spite of Anna’s reluctance to see a mental health professional, she had been seeing several doctors for both herself and for Shiva due to medical complaints and had been taking a number of psychotropic drugs, without significant results. Mary was unsure whether or not she should directly address the family’s traumatic story with Anna, stressing the mother’s massive avoidance behaviours and the fragility of their alliance. Moreover, she remained worried about Shiva’s anxious behaviour, although she felt that since her involvement with the family he was showing some signs of improvement. Mary also felt overwhelmed by the story that had been indirectly revealed to her when she helped Anna fill in the immigration papers. She turned to the consultant to obtain confirmation that her work on the alliance between the mother and the daycare, trying to increase the level of empathy of the care providers, was effective. Mary felt a sense of emergency, which had led her to do a lot and to become exhausted. In spite of her intensive involvement, she felt helpless. The anger of the daycare workers was framed as a misunderstanding. The consultation provided comfort and helped her shape more realistic expectations. Mary was supported in her continued efforts to help Anna set up a safe and supportive environment for the family, which included helping the mother to continue with her asylum status application. Art therapy was also offered for Shiva, and his mother agreed to this, although she shared that she did not have the energy to take him to the clinic. She did agree to this being provided at the daycare by a clinic trainee, which offered

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significant support both for the daycare and for Shiva. The consultant also underlined the survival strengths of Shiva and Anna. This helped Mary to break out of the extremely stressful emergency mode of intervention which was burning her out, and helped her understand the feelings of helplessness engendered by her role as the only care provider who Anna would trust. The second meeting with the consultant took place one year later. This time Anna, Shiva and Mary attended. Mary requested this second consultation to monitor Shiva’s progress and to address family dynamics, as Anna had re-established some connections with relatives in Canada. Anna refused the services of an interpreter, even when offered a choice in the interpreter’s gender and ethnic origin, so the consultation took place in English, a second language for all parties involved. Anna shared that Shiva’s fearfulness, including fear of hospitals, had diminished somewhat. In preschool, though still withdrawn, he was clearly a talented and caring little boy. For the first time, Anna was willing to discuss the possibility that her own physical symptoms and Shiva’s numerous somatic complaints could be linked to their traumatic experience. She also began to talk about Karma as a means of understanding her past. Finally, with regard to family relations, she alluded to the burden associated with her status as a widow. ‘Is it possible to escape the fate of widows?’ she asked. At the explanatory level, the Western model of trauma causality coexisted with traditional cultural models (Karma and the role of the widow) to give meaning to the family’s suffering. After the second consultation, Mary discussed her feelings of isolation. Anna was refusing to let other people (an interpreter or family members) help or support her. Very invested in the therapeutic relationship, Mary felt protective of Anna and while did not feel she was angry, she felt overburdened and wanted help to re-establish social links for Anna. Anna finally gave Mary permission to contact their various doctors and to look for one family doctor who would be willing to coordinate all their medical needs. This consultation helped Mary to understand Anna’s ambivalence toward her relatives, opened the door to discussing both the protective (religious) and threatening (the role of widowhood) aspects of tradition and supported the co-ordination of services. The third consultation took place 10 months later. Mary asked their new coordinating family doctor, Anna’s physiotherapist, Shiva’s art therapist and Anna to attend the meeting. Anna showed up briefly and informed all the professionals that she could not stay. The ensuing discussion revealed splitting processes among the family’s various caregivers. Anna’s anxiety about her son’s and her own medical problems was being transmitted to all with a sense of urgency, along with strong feelings of anger at the inadequacy of treatment and the unfairness of the system. Anna was simultaneously asking for help and portraying the health care providers as aggressors, thus reliving her memories of the hospital scene in Sri Lanka. For her, the health care system had become a theatre of traumatic re-enactment. The consultation helped to resolve the splitting by addressing these issues and changing the perception of the mother among the caregivers. During this third meeting the family’s caregivers argued among themselves about who was not doing enough, contesting the saviour role they each wished to claim, but also share. They projected their feelings of moral obligation onto others and channelled their anger and frustration into the collaborative relationship. The consultant pointed out this splitting, noting that the effect of trauma had influenced the family’s interpersonal relationships. Since Anna’s arrival, the splitting had been shifting from the daycare to the extended family, and was finally being replayed among the caregivers themselves. The plan of action proposed a way to coordinate the physical and psychological care of Anna, who now agreed to enter psychotherapy, reframing the conflict as a symptom of the trauma. Mary remained the key player, with the child psychiatrist available to provide support. Shiva remained very involved in his art therapy sessions. He endlessly built fortresses that were always attacked by monsters and armed men. He also portrayed hospitals as scary places. Gradually, he introduced scenarios that ended in less catastrophic ways, as protection became possible to

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envision. In the last session, he spoke directly about his father for the first time. The therapist thought that the end of the sessions reminded him of his earlier loss, but also felt that he was offering her a gift, entrusting her with his most cherished memory before leaving.

Lin and the transgenerational transmission of silence Lin is a six-year-old South East Asian boy, referred by his school to the clinic because of selective mutism. Lin is a pleasant and cooperative child who is liked by his peers and performs his academic tasks easily at school. He likes to play with other children without uttering a word, and will not speak in class. Joan, a clinic social worker, met with Lin’s parents at the clinic. She was impressed by his parents’ level of education and found them caring. She noticed that the family was quite isolated and that Lin never had playdates at home. She suggested this as an idea to help Lin with his mutism. Lin’s father was very eager to collaborate with her and accepted this recommendation. This, however, appeared to be a complex task for him and he repeatedly asked Joan for advice about how to organize the invitation. Joan was pleased about the family’s collaboration but had the impression that she was missing something. Joan requested a cultural consultation to help her understand the family. The past family history was vague. She knew the parents had survived the Pol Pot regime and had been in refugee camps as children. They were now working and were well established in the host country but they remained isolated. Before the consultation, the child psychiatric consultant inquired about the languages spoken at home. Joan stated that the father had an excellent mastery of French, but that she had no idea about the languages spoken at home. After inquiring, the father shared that the family spoke Chinese (Mandarin) at home but that his wife and he also spoke Khmer and Vietnamese fluently. With the parent’s permission, a Chinese interpreter was invited to the assessment. During the assessment, the father shared that he was six years old when Pol Pot took over Cambodia. His parents were highly educated. The whole family was put in concentration camps by the Khmer Rouge. At some point the camp guards asked the detainees about their origin, their education and their professional status. Numerous families stood up, believing that their social status would help them to obtain better life conditions, but his father told them not to say anything. This saved their lives and they learned to hide who they were and to be very careful about the way they spoke. Subsequently when the Vietnamese invaded Cambodia and overthrew the Pol Pot regime, it remained essential for them to hide their family status: their Chinese origin and their knowledge of French would have attracted retaliation. During his childhood in the camps, the father met his present wife, who was one of the children in his peer group. They were very close to each other and would trust only the members of this group. As adults, decades later, they maintained strong bonds, and a few within group marriages resulted. Lin was born in North America. Returning to Lin’s personal story, the father recalled an incident during which Lin spoke in French in a very normal way to a stranger on a bus in the US. Lin had realized that a little girl on the bus spoke French. He began to play and talk with her without any hesitation. Following this, however, he did not speak to other children. During the assessment Lin was playing and drawing while listening very carefully. His gaze would go from his father’s face to his mother’s. He did not speak but nodded firmly when asked by the child psychiatrist if he would like his parents to tell him more stories about their childhood. The assessment did not change the diagnosis of selective mutism but brought forward how it was linked to the intergenerational transmission of trauma. In this case, silence was not only an anxiety symptom signalling the anniversary reaction of the father’s exposure to trauma, but also the reenactment of a powerful coping strategy which had ensured the survival of Lin’s father’s family.

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The follow up plan included Joan supporting the progressive opening of the family to the outside world and the offer of play therapy for Lin. His parents were encouraged to discuss some aspects of their past life with him. They were recommended to register him in afterschool Chinese classes, thus providing a symbolic legitimacy to the Chinese language outside of the home. During therapy, Lin repeatedly enacted war between groups and themes of intragroup cohesion and trust. He constructed big walls to protect the family and, at first, consistently opposed any modification of his fortresses. With time the fortresses transformed into castles with gardens. At the same time Lin began to talk in class.

Marguerite: Moving out of traumatic paralysis Marguerite is a seven-year-old girl who was referred to the clinic by an adult psychiatrist who had seen her father in consultation for a post-traumatic stress disorder. Her father had reported that Marguerite was an anxious child, unable to use the school’s toilet – a symptom which was upsetting the school and the family. The subsequent two-year follow-up of this refugee family involved a close collaboration between the primary care clinic, two schools and a child psychiatric consultant. The clinic’s social worker had a good alliance with the family. She knew how difficult it was for the father to keep appointments, given his avoidance of traumatic reminders and his difficulties concentrating, and organized the consultation with this in mind. She knew how the assessments would be performed and could prepare and reassure the family. The first encounter was planned for the afternoon, but the family came to the clinic in the morning and had to be asked to come back later. They arrived very late in the afternoon and after a brief encounter a second assessment was scheduled. During the first meeting, Marguerite was very anxious and clung to her father and her sister. At the second meeting she had established some trust with the team and could tolerate separating briefly from her father. During the assessment, her father shared that Marguerite was born in a Nigerian village. She had always been in good physical health, and had developed normally. When she was five, armed men linked to a paramilitary group entered the house while she and her mother were home alone and pushed her into the toilet before killing her mother. Marguerite probably spent a number of hours alone before she was found by her father curled up and terrified in the bathroom. For a whole year following her mother’s death Marguerite was mute and would not use toilets alone. The family decided to seek refuge in Canada. After immigration, Marguerite slowly began to feel more confident, speaking mostly at home. Throughout her first school year in Canada, Marguerite could not use the toilet and was almost mute. The school did not understand what happening, but, because she was not having obvious difficulties, no active consultation was sought at that time. During the assessment it became clear that her older sister had post-traumatic symptoms, including somatic symptoms which were impairing functioning at school. She was referred to the clinic’s walk-in medical clinic on the day of the assessment because of terrible headaches. At the end of the assessment Marguerite was diagnosed with post-traumatic stress disorder and offered art therapy at the clinic. Her sister was offered follow-up care at the youth clinic servicing her high school (associated with another primary care institution). In order to address Marguerite’s fear of using the school’s toilet, the team offered to communicate with the school. Marguerite was worried that her peers would learn about her difficulties, and had to be reassured that only adults in the school would be aware of this. Both her father and the team communicated with the school principal, who was very moved by the family’s story. The principal discreetly informed Marguerite’s teacher, who was very caring, and proposed a solution

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regarding the toilet phobia. He suggested a change of schedule in order to build in a collective ‘toilet time’ before recess for all of the grade 1 and 2 students, so that Marguerite would not have to use the toilet alone. This proved to be a good solution for Marguerite and was also beneficial for her classmates. Marguerite’s follow-up in individual art therapy was challenging because of numerous missed appointments and late arrivals, despite repeated calls from her father saying that they were on their way a long time prior to their appointments. During the first year of therapy, Marguerite slowly engaged with the art material, expressing herself mostly through drawings. Progressively, she started to describe her drawings with words and to talk about her emotions, her helplessness and her grief. Her sister would occasionally come with her to the therapy, asking to participate in the sessions. The therapist chose to organize some common meetings, which seemed to help to establish a healing bond, while protecting the availability of an individual space for Marguerite. With the family’s consent, clinical phone discussions took place between the social, mental health and health professionals involved with the father and his two daughters in order to share a common understanding of the situation, including the family’s erratic compliance with appointments, and to discuss the complementarity of services. Negotiating an agreement around what could be reasonably expected from the family in terms of adherence to treatment and how to define the limits of the intervention was a challenge. Direct and regular communication ensured a coherent plan of treatment for the whole family, who improved continuously during this three year period.

Consulting for refugee children in a collaborative care setting Primary care services are likely to detect vulnerable refugee children who may not reach specialized mental health services because of the precarity of the family’s life circumstances or the family’s avoidance strategies. The close connection between primary care clinics and children’s living environments, as well as the perception that they are less stigmatizing than specialized mental health services, facilitate service use. Directly involved in psychosocial support, community organizations and first-line services create strong alliances around refugee family survival needs. They become aware of children’s symptoms or impairments and wish to refer them to specialized mental health services. This is, however, often very difficult because of limited resources, because of the reluctance of institutions to work through interpreters (Rousseau, Measham, & Moro, 2011) and especially because parents often resist being referred for consultation to an outside agency, in particular, to psychiatry. Hodes (2008) and Duncan (1985) describe how schools may effectively provide mental health services for refugee children who otherwise would probably be unable to access assessment or therapy. Our clinical experience in collaborative care indicates that primary care professionals in community clinics, like community schools, may also successfully fulfil this mandate if they are supported by an ongoing child psychiatry cultural consultation team.

Alliance building and trauma transmission Alliance building in cultural consultation is a multilayered task. It includes an alliance between the consultant and the person requesting the consultation (consultee), as well as an alliance among the various professional care providers involved and an alliance between them, the child and the family. These relations are often mediated by the consultee, who transmits to the consultant a coherent narrative constructed from fragments of stories and observations. The consultation

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request is organized around an image of the child and family that reveals a lot not only about the consultee–family relationship, but also about the relation between the consultee, surrounding institutions and their associated caregivers. When a family narrative is partially structured by war and organized violence, images of family members and of host country professionals tend to be polarized along a projective continuum. A traumatic story typically conjures up visions of a helpless victim, yet in the background there lays a troubling sense of unease, often expressed as a suspicion that the alleged traumatic experience is not authentic, or that the supposed victim is manipulative, or that the victim is neglectful or dangerous. The image of the benevolent self is protective for the primary care provider, and is sometimes also extended to other care providers and host-society institutions. Quite often, however, the illusion of individual and collective benevolence explodes when strains on the therapeutic relationship emerge. In many ways the dynamics of an encounter with a refugee family mirrors larger societal processes framing the moral economy of our relation to the ‘other’ (Watters & Ingleby, 2004), confirming the benevolence of democratic, wealthy, immigrant-receiving countries and identifying refugees themselves as mainly responsible for the exclusion or rejection they may experience. The consultant–consultee alliance can be beneficial in indirectly addressing such representations by proposing a complex appraisal of all the players involved and helping them to get beyond the splitting by acknowledging the complexities of individual and collective identities, including humanity’s universal capacity for being both helpers and aggressors, and for individuals to have both benevolent and angry, vengeful and hateful feelings. In order to resist splitting, the consultant needs to model the capacity to understand, reflect on and hold the negative projections and the experience of extreme harm that is being transmitted, and to acknowledge the gift that the patient is offering the caregivers by conveying his experiences to them (Rousseau & Foxen, 2010). In parallel, the consultant assumes with the caregivers and host country institutions the fact that the host society may both perpetuate harm and alleviate it. This entails acknowledging the collective political responsibility of host country professionals for the historical events that have led to violence (for example, colonization) and for the exclusion or marginalization that minorities face in host countries as a result of structural and institutional discrimination (Henry, 1994). As an ambivalent figure – a good-enough helper who at times may also be an aggressor – the consultant supports the consultee as he or she comes to terms with the loss of their idealized role as saviour and helps him or her realize that sooner or later, they too will be perceived as aggressors. Recognizing that this perception is not only a mere projection but also corresponds to the darker side of our collective and personal humanity is painful. In most cases, the consultee’s burden stems not so much from the many difficulties that must be overcome – difficulties in comprehension and in providing resources to people who are vulnerable and isolated and whose right to resources is often limited – but rather from the fact that the encounter forces caregivers to confront the aggressor in themselves. This is where the consultation holding takes place. The capacity to reconcile the two sides of themselves enables consultees to subsequently hold families through the recognition of their own anger and ambivalence.

Assessment: Who is asking for what? The difference between the identified patient or problem and the heart of the problem is a question that arises in all in child psychiatry consultations. In cultural consultation with refugee families, the primary caregiver will frequently make a request centred on traumatic issues, even though this may not be the family’s priority. Often, parents will accept mental health assessments and treatment

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plans, but the therapist may feel uncomfortable on discovering that the family’s immediate goal is not psychotherapy but a letter to support their immigration application or some material help that is directly useful for survival. Professionals tend to focus their assessments around the therapy they can provide, and the cultural consultant may have to support the consultee in widening their gaze. When family survival is at stake, it usually takes priority over the alleviation of children’s psychic suffering, however intense. Similarly, in a refugee child mental health assessment, establishing a differential diagnosis, although important, is often less essential than a systemic appraisal of the family’s pathway to survival and an interruption of further traumatic losses and the negative chain of consequences that can ensue from these (Miller & Rasmussen, 2010). The traumatic story may be at the forefront of the family narrative and directly related to the care provider at the first encounter. This is a common problem in the consultation process: the consultee may be overwhelmed by the traumatic story and completely identify the family with it, so that other aspects of the family’s life remain relatively underexplored, or else traumatized family members may have difficulty modulating their experiences and may disclose their experiences in a graphic manner. In such cases the assessment difficulty is two-fold: on the one hand, the consultant will need to obtain sufficient information in order to understand the family’s difficulties, while on the other the consultant will need to protect other family members, especially children, from exposure to a repetitive narrative that often includes graphic details (Measham & Rousseau, 2010). In other situations, avoidance reigns and the traumatic events and all aspects of the past, whether good or bad, are ignored or barely mentioned. In both cases, the consultant needs to strive to find a way to build an assessment that can in some way explore the family’s experiences in their home and host country, investigate their children’s and other family members’ symptoms, review their strengths, resources and previous help seeking trajectories, and begin to help negotiate the complex reconstruction of the family and its social network in a way that is respectful of their strengths and vulnerabilities. Although there is a general clinical consensus recommending disclosure and warning clinicians about the risks of collusion through avoidance and denial, controversial findings regarding interventions based on debriefing, as well as emerging questions about the trauma focused paradigm, suggest that disclosure needs to be rethought carefully in each clinical encounter (Miller & Rasmussen, 2010; Sijbrandij, Olff, Reitsma, Carlier, & Gersons, 2006). The intrapsychic and interpersonal dynamics involved in the timing and rhythm of disclosure are influenced by the cultural norms and taboos associated with specific trauma (as is classically the case for women – but is also true for men – who have been raped), but also by the host society’s representations of the minority to which a patient belongs, which tend to reinforce stereotypical expectations about a patient’s experiences. Pushing disclosure in a Western way with respect to events that are culturally taboo can be harmful. Consultants have an important role to play in teaching consultees how to work with cultural brokers to try to understand what is at stake when there is a suspicion of trauma but nothing has been said about it. In the case of children, indirect, nonverbal allusions to trauma through art, play, and metaphor may reveal important information, while not being experienced by family members as overly intrusive (Measham & Rousseau, 2010). The issue of truth is another central concern often raised in consultations with refugee families. On the one hand, the trauma narrative may be strongly framed as a discursive strategy whose primary aim is to obtain asylum and, through this, to reach safety or open the door to family reunification. On the other hand, even after refugees have been accepted in the host country, their narratives may remain multilayered and contradictory (Rousseau & Foxen, 2005). This reflects both the fragmentation effect of trauma on memory and the shaping of the story by complex cultural codes. Family members’ narratives may vary according to their developmental level, their

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memory of events and the family dynamics (Nadeau, 2007). Because of the public perception of refugees as liars, these shifting stories frequently have a strongly negative effect on the ability of caregivers to trust refugee families: caregivers want to know the ‘truth’ not only because they think that it is essential to their intervention, but also because they need to reassure themselves that they are protecting and investing their energy in ‘legitimate’ refugees. Helping consultees understand the effects of trauma on memory and the complex construction of narratives helps them to learn to live with uncertainty, to understand that stories are not perfectly coherent and consistent, to work with fragments and to deal with partial coherence – these are all important dimensions of the consultation.

Suffering, symptoms and diagnosis Assessing psychopathology involving people who have been exposed to organized violence is not a straightforward task in transcultural settings. The generalized use of DSM and of the posttraumatic stress disorder (PTSD) diagnosis, with or without co-morbidity, has given clinicians a common language, but its focus on the presence of a core universal cluster of symptoms has, at the same time, underplayed the cultural and developmental variations of the consequences of trauma. Anxiety disorders widely overlap in severely traumatized children, and the dominance of a particular pattern may be attributed to cultural influences on the expression of distress (Hinton, Rasmussen, Nou, Pollack, & Mary-Jo, 2009), to a child’s stage of development at the time of trauma or to an individual’s constitution (Pynoos et al., 2009; Scheeringa, Zeanah, & Cohen, 2011). Selective mutism can be a presenting symptom in situations of organized violence, linking speaking up with death (Babikian, Emerson, & Wynn, 2007; Hollifield, Geppert, Johnson, & Fryer, 2003). Beyond the fact that selective mutism is a sign of anxiety, it may also replay, as in the case of Lin, complex avoidance strategies linked to survival. The victim identity associated with the PTSD label may be useful in promoting more empathic responses from the environment. The PTSD diagnosis is also well accepted in legal circles, where it is often seen to lend credibility to a traumatic story and its absence is, incorrectly, often considered proof that the person alleging trauma is lying (Stein, Seedat, Iversen, & Wessely, 2007). Thus, a diagnosis that does not recognize the post-traumatic aspects of symptoms can inadvertently be unsupportive to people whose refugee status is in question. On the other hand, the attribution of a victim identity though a PTSD diagnosis may unduly medicalize the problem and disempower the family and social network. It may also be stigmatizing, because it may be interpreted as signalling that the dysfunction is rooted in the individual rather than in the society, even if the symptoms originate from an adverse environment. Finally, in communities for which mental illness is a stigma, being given a mental health diagnosis by a psychiatrist may be seen as a curse or as a sign of weakness, and thus become a source of shame.

Strengths and reconstruction strategies Because of the overwhelming feelings of helplessness that extremely traumatized patients often elicit in caregivers, the importance of identifying strengths and agency is commonly forgotten (Stein et al., 2007; Tummala-Narra, 2007). The mere ability to elicit a sense of urgency and to mobilize professionals to secure support may be considered a strength. Of greater concern are the children who raise little attention because they do not cry for help, as was the case for Marguerite at school.

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The consultant may help the consultee to recognize the strength represented by the call for help and in a family capacity and their capacity to mobilize him or her to act on their behalf. Consultation can help to reinterpret family roles in a way that acknowledges the strengths in post-traumatic reconstruction strategies. For example, children’s ‘parentified’ obligations toward the nuclear or extended family are often negatively perceived as a burden, but these roles may also be structuring and thus reassuring. Although parentified children are suffering, their sense of having a purpose and a mission is often simultaneously protective. A family’s presentation as helpless is not a one-sided process. It is partially constructed by caregivers’ expectations, which are conveyed either through media representations of the helpless victim (Kleinman & Kleinman, 1997) or through the assessment’s questions. By focusing on symptoms and traumatic experiences, the assessment implicitly assigns less value to the family’s survival capacity, even though this capacity enabled them to escape and flee to safety. There are as many coping strategies as there are families. Most commonly, on the road to rebuilding a life, there is a trade-off between maintaining some continuity with the past and adopting new strategies. The two ends of the spectrum – expecting to re-establish a previous life and rejecting all that was important in the past – are equally problematic. Through the identification of strengths, the consultant may assist the consultee in assessing the degree of continuity, or lack thereof, between the family’s past life and present experience. A yearning for total continuity indicates a problematic grieving process and a need to explore whether a family is ready to begin working on accepting that some things have been lost forever (Rousseau, Rufagari, Bagilishya, & Measham, 2004). On the other hand, too little continuity points to an avoidant split between before and after, which calls for a progressive rebuilding of bridges in nonthreatening areas. Spirituality plays a central role for many families (Boehnlein, 2007), in the form of personal prayer or the support derived from attending religious rituals and celebrations, and these social networks may give children a sense of belonging. They may, however, also act as a traumatic reminder if religion was associated with trauma. Artistic activities, sports, work and study, if they establish continuity with meaningful aspects of the life of a child before the experience of migration and traumatic disruption, are important strengths. The same activities may also be new to a child and when given the appropriate support to learn these new roles they can represent positive dimensions of their painful transformation.

Treatment: The strengthening of the reconstruction process Reconstruction involves personal, family and sociocultural collective dynamics with the aim of restoring a sense of normality for a child by allowing life to go on (social integration) and overcoming the paralysis that terror and grief can cause (symptom reduction). Although theoretically entangled and simultaneously targeted by treatment, these two aspects – social integration and symptom reduction – are not given the same weight in the standard treatment process. The chief aim of psychotherapy and medication is to reduce symptoms, and their effectiveness is measured in these terms: gain in terms of reduction of impairment and improvement in functioning are often not considered, although their relation to symptoms is not linear (Pynoos et al., 2009). The main implication of these observations for consultation is that it is just as important to restore the continuity of life by facilitating a child and family’s social integration into the host country as it is to reduce symptoms. The capacity of a refugee or organized-violence survivor to reach a relative level of objective safety is the necessary foundation for relaunching any life project. Typically, until asylum claimants are accepted as refugees, they are in an uncomfortable limbo, in which the threat of being

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sent back is a permanent reminder of an ongoing traumatic situation. This is associated with intense suffering and high levels of symptoms for both adults and children (Steel et al., 2009). A number of clinicians feel uneasy when asked to help asylum claimants with their immigration papers. The support provided by a clinician to an asylum claimant family through a letter supporting his immigration application is an explicit testimony that the clinician acknowledges the authenticity of the family’s refugee experience (Rousseau & Foxen, 2005). This support, even if it proves ineffective, can partially counteract the destructive impact of a rejection of the asylum claim, which can be profoundly retraumatizing. Solving everyday problems plays a key role in achieving a certain normality that allows the establishment of routine. Most refugee families will, sooner rather than later, request some type of help from community organizations, primary social and health care services, or even from schools in resolving settlement problems. Sometimes, reestablishing contact with families from the same homeland through community organizations may facilitate the development of a social shield. However, it may be a mistake to assume that a loosely defined compatriot community can offer a protective shield, as many societies torn by organized violence are fragmented and remain conflictual in exile. The consultant may support the consultee in negotiating the least threatening level of proximity to or distance from the client’s homeland group. If it proves difficult to reconnect a person to a specific social network, as in the case of Shiva’s mother, this indicates a need to try to identify the interaction between intrapsychic issues, which may be the subject of therapeutic intervention, and complex social dynamics, which may have to do with class, religion, caste or other factors. Trauma-related anxiety disorders (mainly studied with respect to PTSD), depression stemming from multiple losses in an exile setting, and the interaction of the two can be treated through various forms of psychotherapy, psychopharmacology (although there is no evidence of efficacy for children and adolescents) or alternative therapies, including traditional treatments. In cultural consultation in primary care settings the recommendation of one type of treatment over another must be based on considerations such as the resources available to the consultee and the cultural and clinical appropriateness of these resources. Acknowledging beforehand that access to specialized therapeutic resources in the host country is limited safeguards the consultee and the patient against unrealistic expectations. Short-term therapy – either cognitive behavioural therapy (CBT) or narrative exposure therapy (NET) – has been promoted for refugee children and adolescents not because it provides a complete resolution of trauma-related suffering, but because it is helpful in alleviating symptoms and can realistically be implemented in standard-care settings (Ehntholt & Yule, 2006; Kataoka et al., 2003; Ngo et al., 2008). Drawing up an inventory of available resources prior to consultation is essential for a realistic treatment plan. In many settings, specialized psychotherapy may not be widely available, but committed community workers and primary care professionals may provide excellent therapeutic support and a forum for empathic listening that may provide relief to a patient. According to Peres et al. (2007), therapy helps reduce the fragmentation of memory caused by trauma by providing the patient with a coherent account. The success of highly divergent methods aimed at eliciting a narrative – some emphasizing structure, others the value of openness to what emerges – echoes clinical reality. In clinical practice, some patients seem to need to borrow an external structure in order to reconstruct coherence. They may prefer a culturally distant frame of reference like CBT or NET, for example, or opt for a more traditional framework that emphasizes the coherence of their experience within the range of representations of their culture of origin (Peltzer, 1997). Other patients will resist such structures because they see them as representing a repetition of the constraints to which they were subjected. They need to talk at length and to be

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the architects of their life stories. The therapist, provided he or she does not enter into a struggle for control, can help them to avoid the vicious circle of traumatic repetition and reintroduce key fragments of their past to help them with their posttraumatic reconstruction (Rousseau & Measham, 2007). Unilateral imposition of either Western cutting-edge expertise or culturally sensitive modalities may be experienced as coercive if the family or child’s choice of opting in or out of his own culture at a particular time is not taken into account. Traditional and creative arts based therapies – such as art therapy – are sometimes preferred by refugee families, in part because these therapies often emphasize nonverbal therapeutic methods, thus helping persons who are reluctant to engage in verbal therapy – which may reflect either cultural attitudes or the fact that verbal approaches may be seen as being disrespectful of certain avoidance strategies. Some clinicians may thus regard non-verbal therapies as a partial collusion with the essence of the psychopathology – avoidance. But avoidance should not be seen as uniformly harmful, nor as solely a sign of psychopathology. While the West may favor a more direct working-through of trauma, focusing therapeutic work ‘on’ trauma, other cultural traditions prefer to work ‘around’ trauma, institutionalizing avoidance as a collective strategy. At one end of the spectrum stands the culture of Jewish Holocaust survivors, in which the collective pressure to remember has resulted in a ‘duty of memory’. The duty of memory is not always associated with individual healing, however, although this collective strategy affords protection through the corollary slogan ‘never again’. There are examples of how this duty can also be an individual burden; a source of suffering and even of death (Semprun, 1994). At the opposite end of the spectrum, some cultures will avoid direct individual or collective references to specific trauma and instead emphasize their people’s survival and continuity, their ability to overcome all adversity (Rousseau, de la Aldea, Viger Rojas, & Foxen, 2005).

Conclusion Cultural consultation with refugee children whose families have experienced premigratory trauma requires a combination of cultural knowledge and trauma therapy methods that encompass not only individually focused psychotherapy and alternative and traditional approaches, but also systemic interventions addressing the consequences of organized violence on the family’s social relationships. Primary care institutions, including clinics, schools and community organizations, because they are very close to the family living environment, may be particularly appropriate to help establish a support network around a refugee child and his or her family. They may however experience more difficulties in providing specialized therapy. The child psychiatric consultant can assist the primary care consultee and family in holding the trauma narrative and organizing a safe network around the child and family. Beyond the technical transfer of know-how, the consultant supports the consultee so that the trauma transmission process, which is an essential aspect of recovery, may become more fruitful than harmful. Beyond clinical documentation, collaborative mental health care for immigrant and refugee children needs to be studied in terms of children’s outcomes in order to determine if this can be a helpful and accessible means to provide mental health services to multiethnic neighbourhoods. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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Conflict of interest None declared.

References Abrahams, S., & Udwin, O. (2002). An evaluation of a primary care-based child clinical psychology service. Child and Adolescent Mental Health, 7(3), 107-113. Babikian, S., Emerson, L., & Wynn, G. H. (2007). Significance of cultural beliefs in presentation of psychiatric illness: A case report of selective mutism in a man from Nepal. Military Medicine, 172(11), 1213. Boehnlein, J. K. (2007). Religion and spirituality after trauma. In L. J. Kirmayer, R. Lemelson & M. Barad (Eds.), Understanding Trauma: Integrating biological, clinical, and cultural perspectives (pp. 259-274). New York, NY: Cambridge University Press. Chenven, M. (2010). Community Systems of Care for Children’s Mental Health. Child Adolescent Psychiatric Clinic of North America, 19, 163-174. Duncan, J., & Kang, S. (1985). Using Buddhist ritual activities as foundation for a mental health program for Cambodian children in foster care. Unpublished manuscript. Mountlake Terrace, WA: Lutheran Social Services. Ehntholt, K. A., & Yule, W. (2006). Practitioner review: assessment and treatment of refugee children and adolescents who have experienced war-related trauma. Journal of Child Psychology and Psychiatry, 47(12), 1197-1210. Henry, F. (1994). The Caribbean diaspora in Toronto: Leaning to live with racism. Toronto: University of Toronto Press. Hinton, D. E., Rasmussen, A., Nou, L., Pollack, M. H., & Mary-Jo, G. (2009). Anger, PTSD, and the nuclear family: A study of Cambodian refugees. Social Science & Medicine (1982), 69(9), 1387-1394. Hodes, M., Jagdev, D., Chandra, N., & Cunniff, A. (2008). Risk and resilience for psychological distress amongst unaccompanied asylum seeking adolescents. Journal of Child Psychology and Psychiatry, 49(7), 723-732. Hollifield, M., Geppert, C., Johnson, Y., & Fryer, C. (2003). A Vietnamese man with selective mutism: The relevance of multiple interacting cultures in clinical psychiatry. Transcultural Psychiatry, 40(3), 329. Initiative Canadienne de Collaboration en Santé Mentale. (2006). Établissant des initiatives axées sur la collaboration entre les services de soins de santé mentale et les services de soins de santé primaires pour les populations ethnoculturelles. Un document d’accompagnement pour la trousse d’outils de l’ICCSM sur la planification et la mise en oeuvre pour les prestataires de soins de santé et les planificateurs [Establishing collaborative initiatives between mental health and primary care services for ethnocultural population. A companion to the CCMHI planning and implementation toolkit for health care providers and planners]. Mississauga, Ontario: Initiative canadienne de collaboration en santé mentale. Kataoka, S. H., Stein, B. D., Jaycox, L. H., Wong, M., Escudero, P., Tu, W. …Fink, A. (2003). A schoolbased mental health program for traumatized Latino immigrant children. American Academy of Child & Adolescent Psychiatry, 42(3), 311-318. Kleinman, A., & Kleinman, J. (1997). Introduction. In A. Kleinman, V. Das & a. M. Lock (Eds.), Social Suffering (pp. ix-xxvii). Berkeley, Los Angeles, London: University of California Press. Measham, T., & Rousseau, C. (2010). Family disclosure of war trauma to children. Traumatology, 16(2), 14-25. Miller, K. E., & Rasmussen, A. (2010). War exposure, daily stressors, and mental health in conflict and post-conflict settings: Bridging the divide between trauma-focused and psychosocial frameworks. Social Science & Medicine, 70(1), 7-16. Nadeau, L. (2007). L’altérité dans la rencontre de pédopsychiatrie transculturelle. In M. Cognet & C. Montgomery (Eds.), Éthique de l’altérité. La question de la culture dans le champ de la santé et des services sociaux [Ethics of alternity-The question of culture in health and social services] (pp. 177190). Montréal: Les Presses de l’Université Laval.

Rousseau et al.

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Ngo, V., Langley, A., Kataoka, S. H., Nadeem, E., Escudero, P., & Stein, B. D. (2008). Providing evidence-based practice to ethnically diverse youths: Examples from the cognitive behavioral intervention for trauma in schools (CBITS) program. Journal of the American Academy of Child and Adolescent Psychiatry, 47(8), 858-862. Peltzer, K. (1997). Counselling and rehabilitation of victims of human rights violations in Africa. Psychopathologie africaine, XXVIII(1), 55-87. Peres, J. F. P., Newberg, A. B., Mercante, J. P., Simao, M., Albuquerque, V. E., Peres, M. J. P., & Nasello, A. G. (2007). Cerebral blood flow changes during retrieval of traumatic memories before and after psychotherapy: a SPECT study. Psychological Medicine, 37, 1481-1491. Puura, K., Hilton, D., Papadopoulou, K., Tsiantis, J., Ispanovic-Radojkovic, V., Rudic, N. …Day, C. (2002). The European early promotion project: A new primary health care service to promote children’s mental health. Infant Mental Health Journal, 23(6), 606-624. Pynoos, R. S., Steinberg, A. M., Layne, C. M., Briggs, E. C., Ostrowski, S. A., & Fairbank, J. A. (2009). DSM V PTSD diagnostic criteria for children and adolescents: A developmental perspective and recommendations. Journal of Traumatic Stress, 22(5), 391-398. Richardson, L., McCauley, E., & Katon, W. (2009). Collaborative care for adolescent depression: A pilot study. General Hospital Psychiatry, 31, 36-45. Rousseau, C., de la Aldea, E., Viger Rojas, M., & Foxen, P. (2005). After the NGO’s departure: Changing memory strategies of young Mayan refugees who returned to Guatemala as a community. Anthropology and Medicine, 12(1), 3-21. Rousseau, C., & Foxen, P. (2005). Constructing and deconstructing the myth of the lying refugee: Paradoxes of power and justice in an administrative immigration tribunal. In E. Van Dongen & S. Fainzang (Eds.), Lying & illness: Power and performance (pp. 56-91). Amsterdam, Netherlands: Aksant. Rousseau, C., & Foxen, P. (2010). Look me in the eye: Empathy and the transmission of trauma in the refugee determination process. Transcultural Psychiatry, 47(1), 70-92. Rousseau, C., & Measham, T. (2007). Posstraumatic suffering as a source of transformation: A clinical perspective. In L. J. Kirmayer, R. Lemelson & M. Barad (Eds.), Understanding trauma: Integrating biological, clinical and cultural perspectives (pp. 275-293). Boston: Cambridge University Press. Rousseau, C., Measham, T., & Moro, M. R. (2011). Working with interpreters in child mental health. Child and Adolescent Mental Health, 16(1), 55-59. Rousseau, C., Rufagari, M., Bagilishya, D., & Measham, T. (2004). Remaking family life: Strategies for reestablishing continuity among Congolese refugees during the family reunification process. Social Science & Medicine, 59(5), 1095-1108. Scheeringa, M. S., Zeanah, C. H., & Cohen, J. A. (2011). PTSD in children and adolescents: toward an empirically based algorithm. Depression and Anxiety, 28(9), 770-782. Semprun, J. (1994). L’écriture ou la vie. Paris: Gallimard. Sijbrandij, M., Olff, M., Reitsma, J. B., Carlier, I. V. E., & Gersons, B. P. R. (2006). Emotional or educational debriefing after psychological trauma. British Journal of Psychiatry, 189, 150-155. Steel, Z., Chey, T., Silove, D., Marnane, C., Bryant, R. A., & van Ommeren, M. (2009). Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: A systematic review and meta-analysis. Journal of the American Medical Association, 302(5), 537-549. Stein, D. J., Seedat, S., Iversen, A., & Wessely, S. (2007). Post-traumatic stress disorder: medicine and politics. The Lancet, 369(9556), 139-144. Tummala-Narra, P. (2007). Conceptualizing trauma and resilience across diverse contexts: A multicultural perspective. Journal of Aggression, Maltreatment & Trauma, 14(1/2), 33-53. Watters, C., & Ingleby, D. (2004). Locations of care: Meeting the mental health and social care needs of refugees in Europe. International Journal of Law and Psychiatry, 27(6), 549-570. Younes, N., Gasquet, I., Gaudebout, P., Chaillet, M.-P., Kovess, V., Falissard, B., & Hardy Bayle, M-C.. (2005). General practitioners’ opinions on their practice in mental health and their collaboration with mental health professionals. BMC Family Practice, 6(1), 18-24.

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Author biographies Cécile Rousseau is a Professor of Psychiatry at McGill University working with refugee and immigrant children. She has developed and evaluated school-based prevention programs for immigrant and refugee children using different creative expression modalities. Presently, her research is focusing, on the effect of the international context around 9/11 on minorities and mainstream community, on the impact of migratory politics on mental health of refugees and on the evaluation of collaborative care models in multiethnic neighborhoods. Toby Measham is an Assistant Professor in the Department of Psychiatry at McGill University in Montreal, Canada, and a member of its Divisions of Social and Transcultural Psychiatry and Child Psychiatry. She works as a Child Psychiatrist at CSSS de la Montagne, the Montreal Children’s Hospital -McGill University Health Centre and at the Jewish General Hospital in Montreal, Quebec. Lucie Nadeau is an Assistant Professor in the Department of Psychiatry at McGill University, and member of its Divisions of Child Psychiatry and of Social and Cultural Psychiatry. She works as a child psychiatrist in Montreal at the CSSS de la Montagne, Montreal Children’s Hospital (McGill University Health Center) and at the Jewish General Hospital, and is a child psychiatry consultant for the Inuulitsivik Health Centre (Nunavik).