Psychotherapy Articles

Psychotherapy Articles

Refugees and Asylum Seekers: Building a Relationship of Trust and Stability

It was in 2017 when I started to teach English to a group of refugees in the UK and became aware of the immense difficulties they faced in their lives. Many of them openly discussed the dangerous journeys they undertook to arrive in the UK. Several of these individuals had experienced or witnessed their boats sinking, leaving them with frightening and long-lasting memories that they struggled to process. Due to this, many of the individuals I worked with favored medical help rather than psychological support as they viewed drugs to be a more effective treatment method compared to therapy. This experience opened my eyes to the struggles that refugees and asylum seekers face and ignited my pursuit to engage refugees in psychotherapy to ensure that their mental health needs are being met. As often is the case for many, those who need psychotherapy the most are the most hesitant to begin.

The Refugee Experience and Mental Health

Leaving one’s home encompasses immense feelings of pain and anguish. The refugee experience is riddled with loss; loss of home, culture, food, environment and family. Not knowing if they will ever be reunited with what they have lost creates a complex mourning process. This experience combined with pre-migration risk factors (i.e., persecution, war, imprisonment in their home country), peri-migration risk factors (i.e., dangerous journeys to the host country) and post-migration risk factors (i.e., uncertain asylum applications, unemployment, social isolation) can leave refugees prone to mental health issues, such as post-traumatic stress disorder (PTSD), depression, anxiety, and psychosomatic disorders (World Health Organization, 2023). Considering this, it is important that the needs of refugees in psychotherapy are re-evaluated in light of these risk factors to provide them with the most effective mental health care.

The topic of refugees and asylum seekers has gained widespread attention in the media in recent years, most of which has been framed as a “crisis.” With the Russian invasion of Ukraine, the Taliban takeover of Afghanistan, the current conflict in Sudan, undocumented migrants at the US-Mexico border, and severe escalations between Israel and Palestine, the number of refugees worldwide reached a record high of 19 million people in 2022 alone (United Nations High Commissioner for Refugees, 2022). If all forcibly displaced peoples were to form a country it would be the 14th most populated country in the world, making this a pressing issue garnering greater attention (Al Jazeera, 2023).

Psychotherapy as the Treatment Method for Refugees

I believe that psychotherapeutic treatments are most effective and well-equipped to heal the deep-seated wounds and traumas (some of which are unconscious) that refugees experience. These experiences include recurrent intrusions of traumatic memories, a common symptom of PTSD and one that oftentimes leads to the suppression of memories that are unpleasant in nature. However, this can provoke the symptoms and increase emotional and psychological distress (Rubin & Moore, 2007). Therefore, psychotherapy can be an effective tool to bring these memories to the patient’s awareness. This means that they become consciously aware of their emotions which enables them to work through and deal with these difficult thoughts and feelings.

Implementing strategies in psychotherapy that incorporate psychoeducation, building a strong therapeutic alliance, and keeping the therapy room consistent should be considered when working with refugees. It is essential to take additional steps to acknowledge the patient’s cultural context (i.e., their belief systems) and assumptions about psychotherapy (i.e., what they expect psychotherapy to entail). These are important to consider when working with refugee populations as it contributes to building trust, whether that be trust with their therapist or trust of psychological treatments in general. When trust has been gained, meaningful work can begin to take place.

Gaining Trust When Working with Refugees

Trust plays a fundamental role when working psychotherapeutically with refugees. Many forcibly displaced individuals are often wary of whom they trust. This is especially true for those who are political refugees and who have escaped persecution, making them fearful for their own and their families’ lives. Therefore, therapists must place an emphasis on and spend significant time gaining the trust of their refugee patients and prioritize the therapeutic alliance. This is a crucial aspect of psychotherapy in general. A strong therapeutic alliance has been shown to reduce patient dropout, likely contributing to patients feeling at ease and allowing them to continue their therapy (Connolly Gibbons et al., 2003; Martin et al., 2000), whereas a poorer therapeutic alliance generally predicts early termination from therapy (Roos & Werbart, 2013).

To create an environment that fosters trust and safety, it is crucial the therapist refrain from discussing or contacting their patient’s local embassy of their country of origin. The embassy can be seen as a continuation of the government network and contacting them could impart anxiety in the patient from fear that the government will then be able to identify them (Tribe, 2005). Explaining to the patient who will and will not have access to the information discussed in therapy will forge a safe space where the individual will feel reassured to share openly with their therapist.

Another way the therapist can strengthen the therapeutic alliance with their refugee patient is to give them permission to openly voice any negative thoughts or emotions that they hold about the therapist and the therapeutic process. Additionally, being attuned to any slight indications of ruptures in the therapeutic alliance would serve to strengthen the relationship (Safran et al., 2001).

Cultural Competence in Working with Refugees

It is crucial that therapists who work with refugees demonstrate knowledge of their patients’ culture, as a lack of culture-dependent knowledge can create barriers to developing a meaningful connection in therapy (Khairat et al., 2023). When the therapist is seen as culturally competent by the patient it instills the feeling of being understood. This was articulated by a refugee in a study by Khairat and colleagues (2023) when a participant stated, He knows the whole refugee deal… he knew where I was coming from, he knew what was happening. So it was really helpful, he understood everything” (p.33). To increase a therapist’s cultural competency, it is fundamental that they take the opportunity to understand their patient’s history, their reasons for leaving their home country, and to also gain geo-political knowledge of their patient’s home country (Liedl et al., 2017).

Psychoeducation When Working with Refugees

Psychotherapists working with refugees should also consider educating their patients on the process and expectations of psychotherapy. Oftentimes patients from different cultural backgrounds have various assumptions of what psychotherapy entails. Therefore, the therapist should spend time at the beginning of the therapeutic alliance to discuss any misconceptions the patient has about psychotherapy and explain to them realistic outcome goals, helping to prepare the patient, especially those who are doubtful of psychological treatments (Jacobs et al., 1972; Walitzer et al., 1999). This is especially important for refugee patients as they may be unfamiliar with Western psychotherapy and may be unaware that this is a collaborative process where the patient and therapist work together (Dahl, 1989). Forgoing psychoeducation may lead to unmet needs on the patient’s side which have been shown to decrease attendance in therapy (Swift et al., 2012). When the patient has preconceived expectations of psychotherapy that are not met, dropout may occur, emphasizing the importance of providing psychoeducation.

Due to cultural differences, refugee patients often expect the relationship between the therapist and patient to resemble that of a teacher and student, which can lead the patient to place the therapist on a pedestal (Dahl, 1989). Therefore, those working with refugees should take time to explain that psychotherapy is a collaborative process whereby the patient is a master of their own feelings and the therapist is there to navigate the patient to a better understanding of these feelings.

Creating Stability When Working with Refugees

Upon arriving in their host country, the lives of refugees are often very turbulent and unstable. This can also act as a mirror to their internal world, as arriving in a new country can be a confusing and unsettling experience. Refugees are often riddled with mixed feelings: relief that they have arrived at their destination, guilt for leaving loved ones behind, and uncertainty about what the future will hold. Therefore, it is important that the therapist creates a consistent space for their patient to return to each week. Contemporary psychoanalytic theories have demonstrated the importance of consistency in the therapeutic environment and with objects in the healing stages for refugees (Akhtar, 1999; Volkan, 2018). This can look like keeping the furniture and objects in the room consistent, helping the patient embody feelings of cohesion and security within themselves.

Moving Forward

With all this in mind, mental health professionals working with refugees should tailor their work to suit each individual’s needs. This can create a safe and trusting environment where patients are given space to be authentic, allowing them to mourn their losses and better navigate their feelings and emotions. This works to empower refugees, validate their feelings of self-worth, and enable them to regain their confidence.

Many have reduced refugees and asylum seekers to the images we see in the media: boats of migrants crossing the Mediterranean and undocumented refugees entering the US through Mexico. However, we should not allow such depictions to cloud our judgment. These are human beings in search of safety and a chance at a normal life as “no one leaves home unless home is the mouth of a shark” (Shire, 2015, p.1). Psychotherapy is in a unique position to allow refugees to tell their stories and make sense of their past. Implementing strategies, such as integrating psychoeducation, elevating the therapist’s cultural competence and establishing a stable therapeutic environment can help foster trust and stability, making the therapeutic journey one of hope and confidence.

In conclusion, the enhancement of psychotherapy for refugees necessitates a multifaceted approach. By addressing these key pillars, we not only facilitate more effective healing processes but also contribute to the overarching goal of promoting resilience and well-being among individuals navigating the complex challenges of displacement, trauma, and mourning.

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Eva is a PhD student at University College London (UCL) in the Psychoanalysis Unit. Her research focuses on understanding the experiences of refugees in psychotherapy in the UK. Her project utilises qualitative interviews to gain an in-depth understanding of how refugees view psychotherapy which will be analysed using thematic analysis. She graduated from Cardiff University in 2020 where she studied Psychology (BSc) she then gained her MSc from UCL in Theoretical Psychoanalytic Studies.

Cite This Article

Gharibi, E. (2024, May). Refugees and asylum seekers: Building a relationship of trust and stability. Psychotherapy Bulletin, 59(3).

References

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