Supporting refugees with a 'shattered assumptive world'

Spencer, K., 2024. Supporting refugees with a 'shattered assumptive world'. Reformulation, Winter, p.8-12.

Refugess 'are people forced to flee their own country and seek safety in another country’ (UNHCR, 2024)

This article explores how we can work with Cognitive Analytic Therapy (CAT) to support refugees, assimilating pluralistic bereavement counselling models and theory, and considering how these approaches can be used and adapted to support those who have been displaced. This is particularly relevant within our current and challenging sociopolitical, and environmental, global reality.

Assumptive World Theory, originating out of Colin Murray Parkes’ work with amputees (Wilson, 2014), informs our understanding around refugees’ loss and their view of the world, through a process of re-learning and assimilation in a CAT-informed way. Working with this diaspora requires an understanding of trauma, post-traumatic stress disorder (PTSD) and dissociation - symptoms ideally treated before the grief work e.g. using eye movement desensitisation and reprocessing (EMDR). It is argued that “a successful working through of a traumatic experience depends on the survivor’s capacity to mourn” (Garland, 1998, p.145).

Ideally, therapy will offer clients a non-judgemental and compassionate space, contained within a relationship of mutual curiosity. It is within this space of acceptance and safety, cultural awareness and sensitivity, that grief-work and mourning can take place. ‘Grief,’ originating from the Latin word ‘gravare’ meaning ‘heavy,’ describes the oppressive sadness often permeating refugee work. Refugees often arrive in the UK with no possessions – yet emotionally weighed down. They are often desensitised by their traumatic passage and grieve over what they have lost: family and friends, occupational roles, traditions, values, foods, language and culture.

Self-care and supervision as a therapist are vital when engaged with this challenging work, which can often feel heavy and weighty for the therapist. On-going self-reflection and supervision is critical, to explore how our own position of privilege within the social hierarchy plays out in the space between us. Therapists require ongoing support and self-care to scaffold our “capacity to tolerate related emotional discomfort” and “capacity to enable a mutual and sensitive psycho-political literacy, to the benefit of clients” (Brown, Ch.11, p.171, The Oxford Handbook of Cognitive Analytic Therapy, 2024).

The Cultural Context:

“No one knows you,

The language slows you

The thick accent smothers your presence.

You sound foreign to yourself;”

(O’Donohue, 2008, p.109) 

Beginning the therapeutic journey involves assessing language and communication barriers, ideally involving an interpreter or a therapist who speaks the client’s native tongue. As therapists, we need to familiarise ourselves with cultural influences and relational communication norms, such as eye contact, as well as gendered influences such as acceptance around a male therapist working with a female client. 

We also need to appreciate the cultural context around loss and mourning, which create templates and schemas informing clients’ behaviour and beliefs. For example, in Bali bereavement rituals are traditionally short, whereas in Iran there is an extended mourning period. Individual mourning versus community grieving also varies culturally, and as a result, managing grief alone can be experienced as overwhelmingly isolating. There are also cultural gendered responses to grief, whether intuitive or instrumental responses, with ‘intuitive’ reactions typically seen as feminine responses and ‘instrumental’ responses being perceived as more masculine, with an avoidance around vulnerability (Martin, 2000).

Cultural influences can impact optimistic versus pessimistic differences in judgements. Western mythology often emphasises “justice, control, optimism, and a positive outlook” (Janoff-Bulman, 1992, p.154) encouraging individualisation, particularly in the USA - the ‘land of opportunity’. Trauma victims, in contradicting this heralded positive norm, can unconsciously be culturally disregarded, disrespected and treated with ambivalence by family members and within the wider public context.

When working with a (preferably) translated and simplified diagrammatic CAT Psychotherapy File, these cultural influences must be considered when collaboratively considering relational responses. Gendered cultural stereotyping around victimhood is also relevant, for example, vulnerability versus perceived strength. We must work collaboratively to challenge negative comparison processes and negative internal dialogues – such as, ‘I am coping well’ as opposed to ‘I am weak’- working towards limiting cognitions that are linked to reciprocal roles (RRs) around judgment, control and criticism. Through the therapeutic alliance, we can support the client to understand that they have choices in regaining control – they may not have been able to choose their fate, but with support, they can make choices and learn coping strategies for increased ‘resilience’. This process is about adaptation and moving towards a ‘new normal.’

This resilience is also influenced by the refugee’s attachment style, personality (optimism/negativity, problem solver or dormant personality), life history and economic resourcing (particularly relevant within displaced communities). Other approaches relevant to refugee work include exploring ‘disenfranchised grief’, and ‘survivors’ guilt’; the client often feeling unworthy of help. Within therapy, we can help to challenge guilt and self-blame – feelings that often form an early response to victimization.

For survival, human beings depend on an ability to attach and form relationships to belong and find meaning. Isolation and detachment often create strong grief reactions, as seen from Bowlby and Ainsworth’s work with children around attachment styles (Ainsworth, Blehar et al., 1978). Risk factors for complicated grief include a lack of family cohesion and low income (Burke and Neirhamer, 2013) - factors that are particularly relevant for refugees.

Therapists should also be aware of our use of language and non-verbal behaviour, and the negative impact of the media’s damaging and de-humanising language around refugees – often portrayed as ‘aliens’, ‘swarms’, and an ‘invasion’. ‘Othering’ words challenge refugees’ positive identity assumptions, such as, ‘the world is good, and I have value.’ Instead, negative messaging reinforces the world as a place of threat, and further confronts beliefs around identity, assumptions or theories of reality, and schemas around the client’s value in the world. The formula ‘Power + Prejudice = Racism’ (Wilson, 2014) is often conveyed publicly through the media, reducing self-worth, and increasing feelings around lack of control and powerlessness, which as professionals we can work to challenge and name through compassion and respect.

Neuroscience:

Neuroscience informs our work, and neuro-education is powerful in understanding how anxiety and pain is held and felt in the body. The nucleus accumbens, located in the brain area responsible for yearning, is activated in complicated grief (O’Connor, 2022). Assisting the refugee to move between grief and grieving, as Mary O’Connor suggests, is transformative, largely focusing on learning and adapting. Grief and pain are both seen to originate in the same part of the brain, with grief felt as a physical pain (Wilson, 2020) and, as Sue Gerhardt identified: “all the major systems of the body are linked by this neurobiological information” (Gerhard, 2015; p.77).

There are long-term health benefits in working to reduce stress hormones (created within the hypothalamus) affecting the immune system by releasing cortisol into the bloodstream. Using bodywork to explore how the body holds on to trauma is powerful, such as by using body scans, yoga, dance, chanting, and singing (which helps to create continuous bonds), whilst channelling positive paradigm shifts and feelings of wellbeing.

The Assessment Phase:

The assessment phase, and agreeing a contract with the client, helps to establish whether the client is currently ready, willing, and able to work. Active listening is vital, being present to both spoken word and body language, intonation and the unspoken. There is a heightened need to assess for risk and available support, whilst also assessing other factors such as socioeconomic status. An in-depth assessment also scaffolds the client’s ‘meaning-making process’ and potential resilience.

Within the assessment, we consider factors affecting the refugee’s individual grief, such as their culture, history, attitudes, and attachment style (secure, avoidant, anxious/ambivalent/disorganised), as well as the support available around them. Working with refugees, depending on funding and resources, takes time.

Within traditional bereavement counselling, clients may be offered up to 12 sessions. Refugee work takes longer, usually requiring a minimum of 16 sessions, but more often 22 sessions; the CAT model timeframes are appropriate in this setting. Within time-limited work, navigating the client towards a ‘good ending’ can be very powerful. Resources permitting, some clients may need more time or an open-ended therapy approach. The work is lengthy and complex, with the client often experiencing chronic grief reactions. It can be helpful to assess the client’s capacity to self-regulate - we might use a ‘Calm Place’ visualisation exercise, alongside checking for signs of dissociation.

Bereavement counselling is often not recommended until 6 months after the loss (Wilson, 2020), when complicated grief can be identified.  Refugees often do not present for counselling, partially due to the delays in in getting their ‘right to remain’ status (Ukrainians, however, were given immediate refuge, based on approved sponsorship within the UK). Trauma work, if needed, should ideally be addressed as soon as possible upon arrival into the UK - or better still, prior to arrival. Experiences of complex trauma threatens the client’s survival, bringing them in touch with mortality, annihilation and fragility and a shattered sense of security. Often within this process, the cognitive belief system is altered around power, control, defectiveness, and safety, linking intimately with their own RR patterns of relating to self, other and the world.

The Work: -

Rebuilding Assumptions, Hope and Resilience:

“May you be blessed with a wise and compassionate guide

who can accompany you through the fear and grief

Until your heart has wept its way to your true self”

 (O’Donohue, op cit., p.169) 

The Working Alliance:

The relationship between the client and the therapist is at the heart of the therapeutic work, helping the client feel accepted, respected, and seen. Bearing witness to and validating the client’s story, with compassion and respect, is arguably the foundation of the journey together. Working within the client’s Zone of Proximal Development (ZPD) creates a space where the client can hopefully feel less overwhelmed, or underwhelmed, opening their window of tolerance and thinking space.

Creative Work: 

As therapists, we might actively promote creative work, which can be particularly transformative in challenging language barriers and freeing up the unconscious through play. Fortunately, CAT encourages us to work within this creative space. Creating the CAT map together and working non-verbally and creatively with body and mind, offers powerful therapeutic opportunities. Creativity can break down barriers, reducing the reliance on the spoken word, and allowing access to unconscious feelings. For example, we can use and adapt ‘The Six-Part Story Method’ within this work, which creatively allows “some of the teller’s inner world to be projected in a meaningful way” (Bent-Brown, Ch.41, p.700, The Oxford Handbook of Cognitive Analytic Therapy, 2024). As therapists, we must also be alert to our own bodily-held emotions, as trauma will overwhelm listeners as well as speakers (Van der Kolk, 2015).

Culturally influenced family systems and expectations, roles, and rules can be creatively explored using stones, shells, and buttons of different sizes and colours. Genograms are powerful in gaining a joint understanding of the client’s role and family history, and in formulating the client’s relational behaviours, linking this back with a possible lack of an early containing environment. Genograms also help us to understand together how cascading generational shame can negatively impact the client’s ability to give themselves permission to assimilate, and to find enjoyment and hope in their new life.

Generational shame is also often culturally influenced, as with religion. Singing, chanting, movement, poetry, and storytelling can all be powerful tools. Dream work is also an important part of therapy – for example, a client may bring dreams about falling into the therapy session, and this may open a conversation around anxiety, fear, and lack of control/ feelings of powerlessness. Grief work can be sedentary and static, so it can be powerful to bring in breathwork, yoga movements, body scanning, and mindfulness. Awareness of the effects of oxytocin, adrenalin, dopamine, and serotonin and counteracting these effects using twisting and stretching, can feel remedial.

The use of rituals imbued with symbolic meaning, such as lighting a candle, can be particularly powerful when working inter-culturally, where rituals can often form an integral part of the client’s community. Another powerful exercise can be to support the client to write a ‘no-send letter’ in their own language, or a letter self-self, to be opened at a date in the future.

There are many therapeutic activities that could be discussed here, but those I find to be most beneficial include activities where we bring ‘a rescuer’ into the dialogue and consider what they might say and do to support the client. This can help to encourage a more compassionate and tender internal voice. Another visual activity that can be therapeutic for the client is an exercise where they sketch their ‘Life’s Path’ – the crossroads, bumps, and curves. I have also included bridges, linking the here and now with experienced prior losses. You can also use imagery, such as a ‘waterfall of grief,’ and chart feelings using a ‘grief barometer.’  

Fig. 1.

Tonkin’s (1996) Circles Model is relevant during the early stages of therapy, as it demonstrates visually how, although the grief remains, the client ‘grows’ around it. In expanding their world, the client can learn to live with the loss, but also find new ways to flourish. Personality also influences the work, exploring the client’s outlook - such as glass half-full versus half-empty - and challenging fears around vulnerability, whilst being mindful of cultural, gendered beliefs. In this work, we can support the client to give themselves permission to be vulnerable and cared for, and to self-care, with the aim of challenging survivor’s’ guilt - reframing together both what they have achieved, as well as what is lost.

Fig. 2.