Psychosocial work with refugees

Dr. phil. Gertraud Schlesinger-Kipp
 

Work with refugees involves potentially overwhelming, painful affects. In the presented case, a psychoanalyst avoids becoming overwhelmed as she invests herself, assisted by language mediators.

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The political situation regarding the reception of refugees in Germany has changed in recent years. The assassination of district president Walter Lübcke on 2.6.19 in Kassel, by a right-wing extremist living there, reminds us of this. Lübcke was the one who set up the refugee camps in Kassel in 2015, where thousands of refugees arrived every day. He was the one who allowed us psychoanalysts and psychotherapists to set up psychosocial counselling for the refugees arriving in the camps, which was something unique in Germany (along with the special ‘Step by Step’ programme with Marianne Leuzinger-Bohleber near Frankfurt, also in Hesse). Lübcke was the one who thanked us for our work. He had to die for his humanitarian and, in his case, deeply Christian commitment to respecting human rights and treating refugees with dignity. 

The camps were hurriedly dissolved in mid- to late-2016. 
 


 
The illustration at the top of this article was drawn by an unknown refugee child on one of these bunk beds. During the hasty dissolution of this smaller facility, the bed was saved from the fire by the person in charge of the regional council. The drawing shows an overcrowded small boat with the refugees facing huge, frightening waves, on the left a police boat or rescue boat and on the right the ‘paradise’: Europe, Germany, with flowers and rain, not as it would probably be drawn in our country, with sun.

Since the foundation (by psychoanalytic/psychotherapeutic colleagues) of a centre for refugees, I have been offering consultation sessions at the centre once a week. The staff of the centre assign me patients, with whom I can have 5-10 conversations. The interpreters are also organised by the staff. So far, it has all worked very well, although since the lockdown I have been sitting in a home office, while refugees and language mediators sit with masks in the centre; this makes the work more difficult.  

In 2015, I developed a concept for these often one-off talks in the initial reception centres: 

1. Opening the conversation: Creating trust
The situation from which the refugees come, including the flight itself, rightly gives rise to suspicion and mistrust. The counsellor is not exempt from this mistrust. Moreover, the refugee is often unfamiliar with psychotherapy and counselling concepts. For this reason, it is important that we are introduced by a trusted person, the interpreter. In addition, we introduce the notion of a voluntary, independent conversation, including the duty of confidentiality, as soon as this is requested by the refugee. In any case, it is important to emphasise that we are not appointed by the authorities, but work freely and voluntarily and only intervene if this is desired by the refugee.

The practitioner must also, in contrast with the position of abstinence which is otherwise required of psychotherapists, express their political and personal solidarity, their stance against violence and war, because one of the main goals is to transform the private suffering of the victim of violence into public suffering. 

2. Trauma
After discussing the disaster in general, we can also ask about the individual traumatic history, depending on the assessment of each case and always accompanied by the question of whether the person wants to talk about it. For example, one can ask if they would like to recount what was worst about the experience. At the same time, one has to make sure that the refugee is not overwhelmed by his or her feelings. Language mediators are often helpful here. 

Respecting the unspeakable: Although in a protected space far away from the site of the traumatic experience itself, it can happen that victim and therapist or interpreter miss the chance to verbalise what has been experienced because the therapist can become a carrier of the feelings, as just mentioned. It is therefore important that we know we are experiencing at most a small part of the horror. 

We as therapists create a protective space for the refugee through our presence and support. He or she should not be overwhelmed by painful affects. It is important that we as therapists do not remain cool, but also show our sympathy, without letting ourselves be overwhelmed. 

3. Important: To relieve the feeling of shame and guilt 
Many victims of war, trauma and flight subjectively blame themselves for the effects of the trauma. Of course the political context, of which we unfortunately all too often have little or only very one-sided knowledge, is extremely important. The shame that accompanies the experience of the complete loss of identity, the loss of one's own values and ego ideal (how one would like to be), the shame of having abjectly submitted, the panic-stricken shame of being swamped by loss of identity and submission, is often unimaginable for us.

De-pathologisation: The symptoms and ailments are a normal reaction to the abnormal traumatic experience. Many believe their symptoms show that they have lost their mental health, must be going insane, that no one can help them anymore. Knowing that one is still normal and that the symptoms will disappear with time is a great relief. 

4. Towards the end of the conversation it is important that the refugee is not left in a helpless, overwhelmed situation, but that current worries and problems are talked about, practical help offered or contact made with relatives. It is also important to ask and encourage the refugee to find what they themselves can do, and to come up with their own ideas.

An example
An unaccompanied 17-year-old minor from an African country is booked in to see me. She seems very shy, with a roundish face and a hijab tight around her neck.

She tells me the following:

The patient lived in a village with her parents and three little brothers. There, she said, men from a clan that ‘owns’ the region seek out young women and simply take them with them. There was a knock and she opened the door with a little brother in her arms. A man grabbed her wrist hard and the brother fell down. Her father came and tried to help her. The men shot him and the little brother. Her mother immediately sent her to a doctor, a friend, who helped her to escape. During her escape, she lived in a camp/prison for a year and experienced a lot of violence there. She finds it difficult to talk about it. They treated her like an animal. That's all we can find out in this session. The interpreter and I are very depressed by this story. 

The next time, the interpreter was simply not there. I had the feeling she couldn’t handle the story.

A staff member gives me her mobile phone with a translation programme, but this doesn’t work out. I have the feeling that Nouri (name changed) cannot read – perhaps because of the emotional strain, but I get the idea that maybe she can't read at all. In the next session we have a new interpreter who is very sensitive but clear. We work with her for the remaining sessions. We learn, when the opportunity to ask arises, that Nouri has never attended school. She has never mentioned this to her teachers here. Her mother taught her to read and write a little.

I could hardly have endured these conversations without this new interpreter. She translates in a very motherly way, and it is obviously good for the patient to hear her own language. We ask a lot about her life before she fled, on the farm with her brothers and parents, to bring her a little bit closer to home. I keep telling her that the girl is still inside her, and that she will find her again. I ask the interpreter if they understand and they both nod vigorously. She tells me how nice it was, as the eldest, being with her mother in the fields and how they played with her little brothers. So she has a good inner object on which to base the processing of her traumatisation.

In the next session she seems happier. She has found her mother! An aunt and some other women from her country have helped her; tomorrow there will be a phone call with the mother. She is happy and excited. 

After the summer holidays, Nouri is very withdrawn and depressed. Yes, she spoke to her mother on the phone. She and the brothers are fine, they are alive. She talks only about longing for her mother. She needs her mother. She wants to catch up with her. The Youth Welfare Office wants to help her, but she has to find 500 euros. How is she supposed to do that?

She can't sit next to boys at school. She talks in more detail about her experiences in prison, in a camp during her flight. I will spare you that here.

In the next session she looks different, more cheerful. She tells us that she has already collected 400 euros for her mother: 200 from her aunt and 200 she collected at school.

She spoke in class and collected these 200 euros there! We acknowledge to her how brave she is now to speak in class about her siuation and also about her lack of schooling. I am looking for a therapy place for young people, for her.

Nouri has made an incredible inner journey. Until she came to us, she hadn't talked to anyone about her story. She had lost her trust in the world. The counsellor at the home only saw that she was secluding herself; she seemed depressed and was not keeping up at school. In six months with five sessions, she was able to regain confidence and thus self-confidence, to show herself in class and attract attention, as well as tackling the shift to seeing a therapist. 

Concluding reflections
 


 

I took this photo right in front of my flat on the Fulda in Kassel, at the beginning of the Documenta 2017 art exhibition. The artwork is by the Danish artist Jens Galshiot, who travels around the world with it. It was an extremely touching experience to go out on my balcony in the morning and suddenly see this boat passing by the peaceful Fulda. After the closure of the Balkan route, people are again trying to flee across the Mediterranean. Thousands drown in the process. They disappear three times: first when they disappear from their families, from their homes, then when they drown, and for the third time when no one knows who died: no one buries the drowned, no one records their names.

Many of us are afraid of losing our identity, our home, of being lost in the world. The refugees who have lost everything make us feel this fear inside. Working with them, professionally or voluntarily or both, requires a willingness to be exposed to this shock. Joshua Durban, an Israeli psychoanalyst who works with Syrian and Lebanese refugees in Israel, puts it this way:

Our sense of home, of having a home or being at home, comes as naturally to us as the air we breathe. It is as natural to us as our physical-mental existence. To live somewhere, not to be alone, to be seen and understood is part of our humanity. And yet this is an important developmental achievement that we should not take for granted’ (Durban, 2019, p. 26).

And later,

Among these unimaginable fears is the threat of feeling like a circumscribed psycho-biological entity... having neither an inside nor an outside, leaking, becoming empty, melting, freezing, burning, falling, dissolving, having no sense of space and time’ (ibid, p. 32).

Against these unimaginable fears, which Durban calls ‘nowhereness’, there are various defences:

to find an object, that is, a human being, who can become a real object that promotes development and provides the refugee with a protective umbrella; that is, gives him or her a kind of home. Or, against this unimaginable fear, one puts on a rigid, impenetrable layer of protection which, with the help of weapons, ideologies, contributes to the externalisation of fears, to burning, dissolving, freezing, banishing the other... (ibid, p.32)

Could it be that a whole society also has these two options? That the refugees who stand before us as living examples of our own unimaginable fears must therefore be so warded off, encapsulated, sent back, banished?
 

This project at the Alexander Mitscherlich Institute and the Psychosocial Centre for Refugees in Kassel attempts to be a temporary home for them. The tent is also an object in Documenta 17, with the names of the refugee camps in the Middle East.
 
References
Durban, J. (2019). Heimat, Heimatlosigkeit und Nirgendwosein in der frühen Kindheit, Psyche – Z Psychoanal 73, 2019, 17–41.

Translation: Anthony Hills
 

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