transcultural psychiatry

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Seekers' Groups in the Netherlands: ... within an asylum seekers' setting in the Netherlands. ...... Nederlands Tijdschrift voor Geneeskunde, 146, 1127–1131.

transcultural psychiatry March 2008 ARTICLE

Paraprofessional Counselling within Asylum Seekers’ Groups in the Netherlands: Transferring an Approach for a Non-western Context to a European Setting BARBARA KIEFT GGZ Dijk en Duin


JOOP T. V. M. DE JONG VU University

ASTRID M. KAMPERMAN Academic Medical Centre Abstract This article presents the application of a psychosocial care approach, which has been developed for and in a non-western context, within an asylum seekers’ setting in the Netherlands. The project aimed to increase access to basic psychosocial care to a target population that experiences difficulties in entering mental healthcare services, by a group of trained peer asylum seekers and refugees. The development of an informal paraprofessional support system makes better use of existing resources, provides secondary benefits for the participants and helps to overcome the Vol 45(1): 105–120 DOI: 10.1177/1363461507088000 Copyright © 2008 McGill University

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Transcultural Psychiatry 45(1) treatment gap between perceived needs and the formal mental healthcare system. The article describes the key components of such an approach, the Dutch context, the project implementation and finishes with a discussion on outcomes, strengths and weaknesses, risks and recommendations. In summary, we found this community approach to be applicable and relevant within an asylum seekers’ centre, as it incorporates an additional easy-access level of psychosocial care and social agency, which seemed to empower participants and help prevent psychosocial problems from becoming more severe. Key words asylum seekers • counselling • mental health • psychosocial • refugees

Introduction The reality of many refugees and asylum seekers is that they have undergone series of adversities as they move from war, to displacement, to resettlement (Eisenbruch, de Jong, & Van de Put, 2004), potentially resulting in cumulative distress and chronic trauma. Hence there is a need for careful planning of mental healthcare services for this population. The Transcultural Psychosocial Organization (TPO1) designed a project to provide accessible psychosocial care within Dutch asylum seekers’ centres by a group of fellow asylum seekers and refugees, trained as paraprofessional counsellors. In effect, TPO’s blueprint for psychosocial intervention within non-western settings (de Jong, 2002b) was applied to a Dutch setting, adding a component of service provision that can be integrated in a sustainable way into the mental healthcare system. The rationale of the project can be summarized in terms of four areas of attention, all of which were addressed following a public mental health perspective. First, there is a high prevalence of psychosocial and psychiatric problems among asylum seekers due to experienced adversities and the asylum-seeking process (Laban, Gernaat, Komproe, Schreuders, & de Jong, 2004). Second, mainstream mental healthcare service providers are not always attuned or sensitive to issues of mass traumatization and the cultural diversity of the target population (de Jong & Van den Berg, 1996; de Jong & Van Ommeren, 2002; Van Oort, Devillé, & De Bakker, 2003). Third, asylum seekers often do not connect to the formal mental healthcare system in the Netherlands (Feldmann, 2006; Van Oort et al., 2003). Fourth, ongoing and accumulated distress being common, it does not usually receive any clinical attention unless it evolves into severe psychological and psychiatric problems; ensuring that such ‘common’ distress does get adequate attention will therefore have a preventative function (Hemmings, 1997). 106 Downloaded from at Erasmus Univ Rotterdam on February 26, 2015

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A Framework for Paraprofessional Counselling in Non-western Settings Over the past decade several models for psychosocial support systems in (post-)conflict and/or (post-)disaster have been developed (de Jong, 2002b; Eisenbruch et al., 2004; Eisenman et al., 2006; Weine et al., 2002). Several interconnected key components constitute the core of these models, including an approach to training, the use of paraprofessional counsellors, cultural sensitivity and a public mental health approach.

Training Approach The core features of an adjusted training programme can be summarized as follows (Jordans, Keen, Pradhan, & Tol, 2006). First, it should be skillsbased, by emphasizing basic counselling skills (from empathetic listening skills to assessment skills to problem-solving skills) (Egan, 1998; Ivey & Ivey, 1999), practical placements and extensive role-plays. Second, courses are medium- to long-term (typically between 4 and 6 months) to avoid minimizing a complex and intricate helping process to a one-week training programme. Third, clinical supervision is required as a tool to connect newly acquired skills to an actual service-provision setting, as well as to ensure ‘care for caregivers’ and guidance from peers and supervisor. Fourth, we emphasize cultural sensitivity, as highlighted later. Although these elements are common within the education of therapeutic practice in most western settings, they are mostly neglected when training counsellors in non-western settings, where training courses tend to be short (generally 1–2 weeks), theoretical and provided by expatriates with little knowledge of the cultural background (Jordans, Tol, Sharma, & Van Ommeren, 2003). The 4–6 months training trajectory described here therefore aims to be more thorough than the usual training practices in low-income settings and, as highly trained professionals are hardly sustainable in these low-income settings, more feasible than specialized western courses.

Eclectic and Paraprofessional Counselling A second key component is the use of trained paraprofessional counsellors, who are psychosocial care providers doing an array of activities ranging from case management and individual counselling to family support, psycho-education and public awareness. The counselling approach followed focuses on emotional support, problem solving (i.e., problem/function-focused coping styles), symptom management and the beneficial effects of a therapeutic relationship. The activities borrow 107 Downloaded from at Erasmus Univ Rotterdam on February 26, 2015

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largely from a western intervention approach (‘talking cure’ as structured and formalized helping behaviour), while making adaptations, encouraging local systems of coping and avoiding over-pathologizing normal responses. Working at the paraprofessional level is a way to link psychosocial and mental healthcare services with other existing formal and informal care structures. Moreover, client-centred paraprofessional counselling entails a shift of focus from psychiatry and psychopathology to more current, accumulated and secondary distress related to refugee status. This includes not automatically associating being a refugee or asylum seeker with post-traumatic stress disorder (PTSD) and treatment with introspective, analytical and exposure-oriented therapy, but rather counselling that is characterized as eclectic, streetwise and with background information on the client in which recounting of experiences is an option but not a necessity (de Jong, Komproe, & Van Ommeren, 2003a; Summerfield, 2001).

Cultural Sensitivity Cultural sensitivity is an obvious pre-requisite when working with western-oriented therapeutic assumptions in a non-western setting or with non-western clients. It entails integrating experiences and methodologies from public health, psychology, psychiatry and (medical) anthropology in order to find practical solutions to the complex problems of cross-cultural mental healthcare (de Jong, 2002a; Eisenbruch et al., 2004). Practically, it involves integrating culturally relativistic and universalistic aspects of mental healthcare, by recognizing that assessment and management of psychosocial and mental health problems in (post-)conflict and/or (post-)disaster situations cannot be simply equated with approaches common in high-income countries. At the same time, it is acknowledged that psychosocial distress and suffering are prevalent in the aforementioned populations and that exchange between cultures should not be avoided per se. We choose not to exaggerate the cultural divide in terms of common helping responses while adjusting the interventions to the local setting. Adjustments are made in the area of collaborations with existing healing methods, the nature of therapeutic relationships, the use of therapeutic concepts such as locus of control, introspection and abstraction, and in the focus on illness beliefs (cf. Tol, Jordans, Regmi, & Sharma, 2005).

Public Mental Health Approach Public mental health is the discipline, practice and systematic social actions that protect, promote and restore mental health of a population. 108 Downloaded from at Erasmus Univ Rotterdam on February 26, 2015

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It provides the framework to incorporate the three aforementioned components in a systematic and integrated response to large-scale human suffering (de Jong, 2002b). One of the reasons why a public mental health approach is warranted is the above-mentioned lack of mental healthcare professionals in low-income countries (de Jong, Komproe, & Van Ommeren, 2003b; World Health Organization, 2005). This approach entails a combination of interventions that have the functions of problem containment, support, as well as prevention, protection and empowerment. To address this, de Jong (2002a) describes three levels of interventions: (a) universal interventions, aimed at the community-at-large and people not in need of any curative interventions (e.g., psycho-education and social reconnection); (b) selected intervention for people with expressed psychosocial problems aimed at reducing distress and promoting adaptive adjustments; and (c) indicated interventions, which entail a set of more advanced, individual and long-term interventions for clients/families with severe problems and/or psychopathology aimed at reducing severe psychological distress (cf. United States Committee on Prevention of Mental Disorders, 1994). The approach used in developing countries has implications for the current mental healthcare system for asylum seekers in the Netherlands. Rather than following what is essentially a specialized mental healthcare approach, a public mental health approach would introduce an added paraprofessional level of care. Access to and relevance of care can be increased by matching the level of care with the severity of the problems (often generalized and accumulated distress rather than severe psychopathology) and by matching the cultural backgrounds of clients and service providers. Such a community-oriented approach further entails moving from a mainly psycho-medical tertiary care level to include secondary and primary levels of care.

Asylum Seekers and Refugees in the Netherlands The difference between asylum seekers and refugees is a juridical difference. The terms asylum seeker and refugee reflect the residence permit status of the person. As opposed to asylum seekers, refugees have passed the assessments of the asylum procedure successfully and are in the possession of an official residence permit. As of August 2005, there were 33,260 asylum seekers living in the Netherlands. The largest groups of asylum seekers are Iraqi (3264), Afghan (3258) and Azerbeidzjani (2428) (Centraal Orgaan Opvang Asielzoekers [COA], 2005a). Most asylum seekers are male (57%) and younger than 35 years of age. This stems from the fact that young men are more likely to take the risk of fleeing their country. As in other European countries, from 109 Downloaded from at Erasmus Univ Rotterdam on February 26, 2015

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2000 onward there has been a steep decline in asylum applications as a result of tightening the immigration and asylum policy (Immigration and Naturalization Service Information and Analysis Centre [INDIAC], 2005). During 2003, 30% fewer applications were submitted than in 2002 (Immigratie-en naturalisatiedienst [IND], 2005). The number of refugees is more difficult to estimate. Some refugees have Dutch nationality and are therefore difficult to identify within population registries. The largest groups of refugees currently include former Yugoslavs (76,000), people from the former USSR (39,000), Afghans (34,000), Iraqis (42,000), Iranians (28,000), and Somalis (28,000) (Centraal Bureau voor de Statistiek, [CBS], 2004). Although the Dutch government aims to complete the asylum procedure within 12 months, a 2003 inventory showed that two thirds of the asylum seekers were more than two years in procedure. The COA (central care structure for asylum seekers) is responsible for the care taking of asylum seekers. During the procedure approximately 75% of the asylum seekers are housed in large-scale centres; some live in alternative housing such as apartments, caravans or share a house with private persons. Living with several persons in one room is common practice. Basic living necessities, such as beds and food are provided. During the procedure, the asylum seekers are not allowed to follow (language) courses or education, or to engage in any activity that is aimed at integration in Dutch society. Seasonal labour is allowed for a period of 12 weeks. Voluntary labour is allowed without limitation (COA, 2005b). As a result of the length and uncertainty of the outcome of the asylum procedure, the social circumstances and the poor living conditions, many asylum seekers in the Netherlands complain of psychosocial and psychiatric problems (Hondius & Willigen, 1992; Laban et al., 2004; Roodenrijs, Scherpenzeel, & de Jong, 1998). Furthermore, this is a group with a high risk for developing mental health problems related to previous traumatic experiences (Eisenbruch et al., 2004; Hondius & Willigen, 1992). Previous research among Iraqi asylum seekers showed that 54% of the asylum seekers suffered from one or more psychiatric disorder, i.e. PTSD (37%), depressive disorders (35%), anxiety disorders (22%) and somatoform disorders (9%). It was shown that the length of the asylum procedure was a stronger indicator for the presence of these disorders than previous traumatic experiences (Laban et al., 2004). In the asylum seekers centres, medical teams comprised of social medical doctors, social nurses and administrative personnel are active. A special department of the national healthcare services (GGD Nederland), the MOA (medical care structure for asylum seekers) is responsible for these medical teams. The assignment of the MOA medical team is to provide preventative medical care, i.e. assessment of the health situation of asylum 110 Downloaded from at Erasmus Univ Rotterdam on February 26, 2015

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seekers, referral to medical care facilities, addressing health threatening factors, and health education. Asylum seekers with health complaints need to visit a MOA nurse. If necessary, this nurse may refer the patient to a general practitioner (GP) or other curative or preventative (mental) healthcare facilities. All asylum seekers are collectively insured for necessary medical care (Baris, 2005). On average, an asylum seeker consults a MOA nurse six times a year. In a typical asylum-seeker centre, a MOA nurse is available 11⁄2–2 days per week for medical consultancy. Because several nurses are responsible for the consulting hours in a refugee centre, the continuity of care is limited. In 10% of consultations mental or psychosocial complaints are presented. Particularly for these complaints, referral to a GP or other (mental) healthcare professional is uncommon (Gernaat, Malwand, Laban, Kamproe, & de Jong, 2002; Van Oort et al., 2003). Many nurses (71%) indicate encountering difficulties in assessing the need for such a referral, in part due to language or cultural barriers (de Jong & Van den Berg, 1996; Van Oort et al., 2003). Nurses report difficulties in coping with inconsistencies in their assignment. On the one hand, they are not supposed to diagnose the client, on the other hand, they are responsible for assessing the need for referral (Van Oort et al., 2003). Also, asylum seekers report difficulties in understanding the distinction between preventative and curative care, and the central role of the GP in the Dutch medical system (Somers, 2002).

Counselling Project Implementation with Asylum Seekers in the Netherlands As described earlier, a community-based counselling approach was adjusted to fit the needs of asylum seekers living in Dutch asylum seekers’ centres. Adjustments to the programme were made regarding the content of the training, directed – after the post-traumatic effects of war and flight – mainly at the chronic stress of the asylum-seeking procedure and centre situation. Operational adjustments regarding the mode of intervention included matching implementation with the inhabitants, regulations and structure of the centre context.

Objectives This project aimed to reduce the aforementioned prevalence of psychosocial and psychiatric problems (Laban et al., 2004) by strengthening the support and care system at asylum-seeker group level, and consequently prevent the unfolding of more severe mental problems. Stated objectives were: (a) improving the psychosocial health of asylum seekers; (b) improving the access of asylum seekers to the professional mental healthcare 111 Downloaded from at Erasmus Univ Rotterdam on February 26, 2015

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institutions; (c) strengthening the community support system for asylum seekers; and (d) increasing skills, and thereby future work opportunities, for the participating psychosocial counsellors.

Description of the Project In collaboration with the COA in the northern region of the Netherlands, 15 asylum seekers and refugees were selected based on a former social/medical profession or interest and interpersonal skills. The trainee group represented 10 nationalities (Afghanistan, Azerbeidjan, Iraq, Kosovo, Ukraine, Rwanda, Congo, Cameroon, Somalia, Sierra Leone). The majority of the counsellor trainees were themselves living in one of seven asylum seekers’ centres involved in the project, a small group had already completed the asylum procedure and were living in the vicinity of one of those centres. The training model alternated classroom-based learning with supervised practical placements. The initial training, conducted by a psychologist (MJ) with long-term experience in non-western settings, lasted for seven weeks. During one week a supervised practical placement was carried out within their respective or assigned asylum seekers’ centres. The training course focused on understanding counselling concepts and processes, understanding psychosocial problems, and the application of counselling skills and specific intervention strategies. Through role-plays, lectures, experiential learning and group work the training included psychosocial issues specific to asylum seekers as well as generic concepts such as working with coping strategies, problem-management techniques (e.g., relaxation), psychoeducation, and the identification and strengthening of existing resources. After the initial training, counsellors returned to provide direct paraprofessional psychosocial assistance to fellow asylum seekers. Clinical supervision was provided by a psychologist (BK) on ongoing basis, at both an individual and group level. The trained counsellors operated independent of any other institution or care facility but agreements were made with centre authorities in order to obtain approval to work within public areas and centre-owned private rooms (otherwise not accessible to inhabitants) to provide counselling services. Contact with the MOA was established to ensure referral options and create interaction between counsellors and (mental) health professionals when needed.

Outcomes Over a six-month period, 14 active counsellors registered 241 counselling sessions. Seventy-four clients from 29 countries (49 men and 25 women) 112 Downloaded from at Erasmus Univ Rotterdam on February 26, 2015

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received counselling.2 The average number of sessions was 3.25 per client. Because not all sessions were registered this is an underestimate of the actual number of client contacts. The vast majority of the sessions (82%) were carried out by counsellors who had a similar cultural background to the client. This reflected the client and/or counsellor’s preference for the same language, shared contextual information (e.g., about the conflict in their country of origin) and existing social networks of the counselling within the community. Crosscultural counselling sessions (18%) were mostly reported by counsellors from the ex-Soviet countries. It is unclear whether these cross-cultural counselling sessions were simply due to the unavailability of counsellors with the same cultural background as the client or whether this represents a conscious choice by the clients (e.g., depending on the client’s personality, age, educational level; a choice of a ‘neutral’ counsellor from a different country; a choice for a same-sex counsellor superseding the same-culture need). Two-thirds of the clients were male, which might be explained by a similar representation of male counsellors. Counsellors from Asia and the Middle East, who were all male, did not report sessions with female clients. Cross-sex sessions were most common with counsellors from African countries. As expected, the majority of the complaints presented were not direct indications for professional help, but were nevertheless risk factors for the development of future psychiatric problems. Complaints expressed most frequently during counselling sessions were: loneliness, sleeping problems, feelings of depression and guilt, problems due to the insecurity of asylum procedure outcome, stress and tension, somatic complaints, alcohol abuse, marital and family problems. Interventions were directed at diminishing these moderate psychosocial complaints through basic counselling mechanisms, such as emotional support, symptom management, problem solving and a therapeutic relationship. Contrary to expectations, referrals to the MOA medical team and/or consequently to professional mental healthcare or other services were rarely established. Only seven referrals were registered. This may be explained first, by the fact that the majority of complaints presented by clients were relatively mild, and therefore may have not required professional care. Second, it is possible that the counsellors were not sufficiently able to judge the severity of the presented problems. Third, the counsellors experienced difficulties in relating to the health professionals.

Limitations There is a disparity between the help-seeking population and the formal (mental) healthcare system for asylum seekers (de Jong & Van Ommeren, 113 Downloaded from at Erasmus Univ Rotterdam on February 26, 2015

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2002). This discrepancy also played a role in this project, and can be explained in several ways: (a) medical consultancy is, on average, available only 11⁄2–2 days a week; (b) there is no provision of specific mental healthcare attached to the general medical consultancy; (c) counsellors themselves are likely to have had negative experiences with MOA services, and therefore not likely to make quick referrals, especially for mental healthrelated complaints which have typically been overlooked; and (d) from the MOA side there might have been too little recognition of the counsellors as colleagues, albeit paraprofessional. These problems are compounded by the fact that (external) mental health services are not always willing to serve asylum seekers due to lack of knowledge, prejudice, difficulties in working with interpreters, etc. Despite introducing the project to the MOA and the aim of directly linking counsellors and the respective MOA services, we do not seem to have been able to overcome that discrepancy. Several obstacles were encountered during the pilot implementation. Asylum-seeker care policies and reorganizations (i.e., centres closing and asylum seekers being moved from one region to another) were some of the largest obstacles. This affected both counsellors and clients, often resulting in a forced ending of the counselling contact. Counsellors who were moved to other centres lost their already acquired position and consequently had to build up new social networks and gain trust from both the inhabitants and centre authorities. In addition to these imposed transfers, changes in the personal circumstances of some counsellors led to them withdrawing from the project. During the six-month implementation phase, seven counsellors (50%) had to stop their activities. Some potential risk factors of a peer psychosocial support system should be noted. First, ‘re-traumatization’ of the counsellor is possible, as issues brought up during counselling sessions might resemble and revive personal experiences. Second, due to real or perceived similarities between the counsellor and client, the counsellor faces the risk of developing a subjective view on the client’s problems, sympathizing too much rather than keeping a personal distance and reflecting on the client’s emotion. Handling these (counter)transference issues was addressed extensively in supervision meetings.

Conclusion This article describes a pilot project of paraprofessional communitybased psychosocial care for asylum seekers in the Netherlands, based on a psychosocial care model developed for use in non-western settings. The project was able to establish a paraprofessional psychosocial support system between informal social support and existing formal mental healthcare provision. This made psychosocial care more directly available 114 Downloaded from at Erasmus Univ Rotterdam on February 26, 2015

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to a population that is at risk for under-utilization of mental healthcare services, despite the high prevalence of psychosocial and mental health problems. There were some indications that the project had a positive effect on the well-being of the asylum seekers that received the counselling services. Although we did not conduct effectiveness research on the intervention, we did evaluate the project by interviewing clients and counsellors about their experiences. The majority of clients expressed some form of positive change as a result of the counselling service. However, a significant number of clients reported no change. Owing to the quality and number of the responses we were not able to validate or generalize these findings. In future projects, the actual effectiveness of this type of counselling service should be determined. Despite the positive efforts of the programme, increased provision of formal mental healthcare through referrals was not sufficiently realized, as the number of referrals to professional healthcare was lower than expected. The remaining distance between formal mental healthcare and community-based psychosocial care seemed to be an important barrier and indicates that the cooperation between counsellors and the professional mental healthcare services needs specific attention in future implementations. Overall, these findings suggest that paraprofessional community-based psychosocial care by peer asylum seekers is a useful additional form and level of care for asylum seekers. Psychosocial interventions in non-western and immigrant settings often emphasize the beneficial effects of same-culture interaction. In general, cultural similarity is expected to facilitate the communication and interaction and optimize the effects of the interventions. However, adverse effects of cultural matching have also been described (Karlsson, 2005). The majority of the counselling sessions in our pilot were carried out between counsellors and clients with similar cultural backgrounds, suggesting a preference of both clients and counsellors for ethnic matching. However, for some of the counsellors, same cultural contacts were less frequent. Besides pragmatic reasons, it is plausible that distrust might exist between people of the same cultural background, due to, for example, civil conflicts or divergent political affiliation in the country of origin. In addition, crosscultural exchange might have facilitated discussion of topics that are taboo in the home country. In these cases, relationships between a counsellor and client of different nationalities may have been preferred (Karlsson, 2005). Another aspect that affected trust for some cultural groups was gender (e.g., Afghans). In order to make the counselling services available to the entire asylum-seeker population, both same- and cross-cultural interactions should be made possible. This implies that a diverse team of counsellors should be trained. 115 Downloaded from at Erasmus Univ Rotterdam on February 26, 2015

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Recommendations Evaluation showed that the involved stakeholders (i.e., centre authorities, counsellors and clients) expressed a need for easy-access psychosocial care, as it aims to overcome the discrepancy between the perceived need for care and the accessibility of formal mental healthcare services. Efforts will have to be made to better link paraprofessionals and professional caretakers. This can be done either by intensifying organizational cooperation between the services or by a stronger emphasis in the counsellor training on referring protocol to existing services. Several counsellors should be available for each asylum-seeker centre, aiming at an equal division and presence of male and female counsellors within every centre. This for the obvious reasons that in many cultures open communication between the sexes is not the norm and problems related to sexual violence are relatively common in these particular groups. Although the training course focused heavily on issues of confidentiality, follow-up and client monitoring, future implementation should ensure that structural impact evaluation is to be incorporated, to assess actual client changes and experiences. We believe that replication of the approach described here, thereby providing easy-access psychosocial care, is warranted within Dutch asylum-seeker centres. However, especially due to continued instability in the situation of the asylum seekers, we recommend that selection of potential counsellors focus on refugees. The use of refugees as counsellors would ensure more continuity between counsellor and the formal healthcare system in place (a collaboration which should have structural lines of communication), and more stability for the counsellor, centre and project. There would be less risk of counsellors being severely distressed themselves due to an ongoing asylum-seeking process. It may encourage integration of the refugee within the host society through career development. An additional effect of the project was an improved sense of well-being for the counsellors themselves. This was attributed by the counsellors to involvement in the project, training and being able to help fellow asylum seekers. The acquired skills and experience were acknowledged by the counsellors as helpful tools for future community functioning and work opportunities. Increased sense of meaning, future perspective, sense belonging, reflective skills and meaningful activity might all explain such secondary effects. Although the improved sense of well-being is beneficial, unrealistically high expectations with regard to the counsellors’ (professional) futures should be dealt with carefully. In conclusion, an added level of easy-access paraprofessional psychosocial care might increase service provision for the perceived need for mental healthcare (especially for mild-to-moderate problems), make 116 Downloaded from at Erasmus Univ Rotterdam on February 26, 2015

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better use of existing resources, provide secondary benefits for the participants and help overcome the perceived gap between help seeking and the formal mental healthcare system. Using strengths within the community to build and use community care networks may be more compatible and thus adequate, especially in light of the apparent under-use of mental healthcare facilities. However, changes in policy and regulation regarding asylum (seekers) negatively affected project continuity. Therefore, the effects of future implementation will depend on the political and organizational context in which the structure is embedded.

Acknowledgements This project was implemented with financial help from the European Refugee Fund. We thank the psychosocial counsellors involved for their commitment. Furthermore, we would like to thank Wietse Tol for his useful contributions to this article.

Notes 1.


TPO recently merged with Healthnet International, forming Healthnet TPO, to better achieve the inclusion of psychosocial and mental health efforts in (post-)conflict and (post-)disaster settings within a public health perspective. Iraq, Iran, Syria, Afghanistan, Congo, Sierra Leone, Guinea, Rwanda, Sudan, Angola, Somalia, Uganda, Cote d’Ivoir, Burundi, Liberia, Kenya, Nigeria, Ethiopia, Kazakhstan, Ukraine, Tjetjenia, Georgia, Azerbeidzjan, Uzbekistan, Russia, Kyrgyz, Former-Yugoslavia, Kosovo, Romania.

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Kieft et al.: Counselling for Asylum Seekers Jordans, M. J. D., Tol, W., Sharma, B., & Van Ommeren, M. (2003). Training psychosocial counselling in Nepal: Content review of a specialised training program. Intervention: The International Journal of Mental Health, Psychosocial Work and Counselling in Areas of Armed Conflict, 1(2), 18–35. Jordans, M. J. D., Keen, S. A., Pradhan, H., & Tol, W. A. (2006). Provision of psychosocial counselling in Nepal: Perspectives of counsellors and (in-)direct beneficiaries. Manuscript submitted for publication. Karlsson, R. (2005). Ethnic matching between therapist and patient in psychotherapy: An overview of findings, together with methodological and conceptual issues. Cultural Diversity and Ethnic Minority Psychology, 11, 113–129. Laban, C. J., Gernaat, H. B. P. E, Komproe, I. H., Schreuders, B. A., & de Jong, J. T. V. M. (2004). Impact of a long asylum procedure on the prevalence of psychiatric disorders in Iraqi asylum seekers in The Netherlands. The Journal of Nervous and Mental Disease, 192, 843–851. Roodenrijs, T. C., Scherpenzeel, R. P., & de Jong, J. T. V. M. (1998). Traumatische ervaringen en psychopathologie onder Somalische vluchtelingen in Nederland. Tijdschrift voor Psychiatrie, 40, 132–142. Somers, M. H. C. (2002). Voorzieningen voor vluchtelingen en asielzoekers [Services for refugees and asylum seekers]. In J. E. de Neef, J. Tenwolde, & K. A. A. Mouthaan (Eds.), Handboek interculturele zorg (Vol. I 2.6–1). Maarssen, The Netherlands: Elsevier. Summerfield, D. (2001). Asylum-seekers, refugees and mental health services in the UK. Psychiatric Bulletin, 25, 161–163. Tol, W. A., Jordans, M. J. D., Regmi, S., & Sharma, B. (2005). Cultural challenges to psychosocial counselling in Nepal. Transcultural Psychiatry, 42(2), 317–333. United States Committee on Prevention of Mental Disorders. (1994). Reducing risks for mental disorders: Frontiers for preventive intervention research. Washington, DC: National Academy Press. Van Oort, M., Devillé, W., & De Bakker, D. (2003). Monitoring huisartsenzorg aan asielzoekers [Monitoring general practitioners care to asylum seekers]. Utrecht, The Netherlands: Nivel. Weine, S., Danieli, Y., Silove, D., Van Ommeren, M., Fairbank, J., & Saul, J. for the Task Force on International Trauma Training. (2002). Guidelines for international training in mental health and psychosocial interventions for traumaexposed populations in clinical and community settings. Psychiatry, 65, 156–164. World Health Organization. (2005). Mental health atlas. Geneva, Switzerland: WHO. Barbara Kieft, MA, holds a position in a Dutch mental healthcare organization, where she is responsible for the development, implementation and evaluation of preventive programmes. After obtaining her MA in Psychology, she started working in (occupational) counselling, psychodiagnostic research and training of social and occupational skills. Gradually her interest moved towards psychosocial interventions for special groups, of which refugees and asylum seekers became the main focus. She was the project coordinator of the described pilot project and is 119 Downloaded from at Erasmus Univ Rotterdam on February 26, 2015

Transcultural Psychiatry 45(1) currently active embedding a similar project within the mental healthcare structure in the Netherlands. Address: GGZ Dijk en Duin, Department of Prevention, Westzijde 120, 1506 EJ Zaandam, The Netherlands. [E-mail: [email protected]] Mark J. D. Jordans holds an MA in Developmental Psychology. He is currently working as a technical advisor for Healthnet TPO in Amsterdam, The Netherlands, with a special focus on implementing a five-country project to provide and research school-, and community-based psychosocial care for children in areas of armed conflict. He has lived in Nepal for 7 years, where his work concentrated on the development of long-term training courses in psychosocial interventions. His interests, and current research activities, relate to the development, adaptation and implementation of comprehensive psychosocial care systems from a transcultural perspective. Address: Healthnet TPO, Tolstraat 127, 1074 VJ Amsterdam, The Netherlands. [E-mail: [email protected]] Joop T. V. M. de Jong, MD, PhD, is Professor of Mental Health and Culture at the VU University Amsterdam, The Netherlands and adjunct Professor of Psychiatry at Boston University School of Medicine. He founded TPO and over the last 11⁄2 years he was Director Public Health and Research at Healthnet TPO. Currently he is Medical Director of the Municipal Health Services of Amsterdam. Address: GGD Amsterdam, PO Box 2200, 1000 CE Amsterdam, The Netherlands. [E-mail: [email protected]] Astrid M. Kamperman, MA, PhD, is a Psychologist. She has worked for 8 years as a researcher on migrants’ and refugees’ mental health for Healthnet TPO, The Netherlands. Furthermore she was responsible for the development and coordination of projects aimed at improving the mental health of migrants, refugees and asylum seekers. In 2005 she joined the Academic Medical Centre for the coordination of research on the mental health of refugees and asylum seekers. Address: Equator, Academic Medical Centre, Dept. of Psychiatry, University of Amsterdam, Meibergdreef 5, 1105 AZ Amsterdam, The Netherlands. [E-mail: [email protected]]

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