A Shelter for the Mind: A Short Psychological First Aid and Mental Treatment Guide for Refugees and Asylum Seekers

A Shelter for the Mind

A Short Psychological First Aid and Mental Treatment Guide for Refugees and Asylum Seekers

 By Yael Mayer and Ido Lurie

This Guide is also available in Hebrew.

Background

Migration is a growing global phenomenon that affects many areas and populations worldwide. Significant multiple and ongoing stressors accompany the process of immigration and the state of being a refugee¹ . Thus, asylum seekers, refugees, victims of human trafficking, and displaced persons, in general, are prone to develop emotional distress and mental difficulties, including depression, anxiety, post-traumatic stress disorder (PTSD), psychosis, self-harming behavior, and alcohol and psychoactive substance use, as a means of self-medication (Hollander et al., 2016; Lindert et al., 2009; Mayer et al., 2021; Steel et al., 2009).

The trauma experienced by refugees, asylum seekers, and displaced persons is often stratified and complex. It begins with events that preceded the need for forced migration, which is followed by further witnessing of and exposure to trauma, violence, and death. The migrants may also endure various other adverse experiences throughout their journey to the destination country and after their arrival (Mayer, Ilan, Slone, & Lurie, 2020). The host country's migration policies and the risk of deportation may add further stress and anxiety to their mental trauma(s). If the displaced people are deported once, this may start an ongoing cycle of deportations from different countries. A visa refusal in one of the OCED countries can lead to a chain of refusals in others (Mayer et al., 2020). Upon arrival in the host country, finding a place to live, employment, and limited support systems may be challenging.

Hence, providing psychological aid to refugees and asylum seekers requires unique professional knowledge and skillset to address their special psychosocial needs, alongside familiarity with the appropriate language and cultural competence. The recommendations presented in this article are based on the UN and the World Health Organization (WHO) guidelines for working with people in need during a humanitarian crisis.  They are also based on the authors' years of clinical experience in psychological and psychiatric treatment for refugees and asylum seekers. This article is divided into two main sections. The first part outlines models for mental first aid, intended for mental health professionals and aid workers or volunteers, who do not necessarily have professional training, and who are in the field as first respondents. The second part reviews strategies for therapeutic work centered on crisis intervention delivered by mental health professionals. The mental health models presented are suitable for intervening in a crisis with different populations, but in this article, we will address their application specifically with refugees and asylum seekers.

נמשכת ההרשמה למחזור לימודים חדש (מחזור שמיני)
של תוכנית הכשרה בפסיכותרפיה ברוח פסיכולוגיית העצמי

A. Models for Providing Mental First Aid by Helpers With and Without Professional Training

The WHO recommendations for helpers in humanitarian crises are based on the Psychological First Aid Model (PFA). The PFA is a common and well-accepted model used worldwide in crises situations. Preliminary models of PFA began to form in the 1950s in response to humanitarian disasters (Kantor & Beckert, 2011). Although the approach has evolved over the years, its principles have remained broadly consistent. The PFA model is a structured, evidence-based intervention applied immediately after exposure to life-threatening emergencies. It was developed with reference to developmental, ecological, and cultural perspectives (Ruzek et al., 2007; Vernberg et al., 2008).

The model’s core actions are provided in a series of steps that target: 1. Contact and engagement with the client; 2. Enhancement of sense of safety; 3. Stabilization; 4. Information provision; 5. Addressing current needs and concerns; 6. Providing practical assistance; 7. Increasing mobilization of support; 8. Teaching coping strategies and connecting with additional existing services.

Manuals of international organizations have divided these eight core operations into three action principles that can also be implemented by aid workers and first respondents who do not hold specific professional mental health training. These action principles include: Look, Listen, and Link (see figure 1). They are designed to provide emotional support and help people address immediate basic needs, and find information, services, and social support. In addition, they may serve as an avenue for approaching a person in distress, assessing the help they need, and assisting in obtaining this help.

Figure 1: The three core action principles of the PFA model.

These principles are designed to promote key resilience factors and strengthen the person's coping mechanisms, mainly: a sense of security, relaxation, a sense of self and community competence, communication and connection to the environment (connectedness), and hope (Hobfoll et al., 2007). The goal of these interventions is to promote coping and adaptation to immediate circumstances, to enhance the person's long-term adaptation potential and promote immediate and future mental well-being (Akoury-Dirani et al., 2015).

Based on these factors, the PFA approach is based on four key principles (WHO, 2011):

1. The safety and rights of refugees and asylum seekers must be respected.
2. It is necessary to adapt any intervention to the cultural background, age and gender of the client.
3. It is necessary to be familiar with the other assistance activities that are taking place around the crisis, and to connect or refer to them, in order to maximize the treatment and resources directed to the benefit of the refugee(s).
4. It is important to maintain the self-care of the helper or aid worker, as to prevent burnout or secondary traumatization.

1. The LOOK phase

The observation stage takes place immediately after the initial meeting with the asylum seeker (and possibly also in the process of preparation for this meeting) and continues throughout the entire assistance process. As part of the “Look” phase, aspects of safety and risk must first be actively reviewed and screened, and one must examine whether there are basic physical needs that need to be met (e.g., food, health, sleep, shelter, clothing). If the asylum seekers need help in sorting their legal status, they should be referred to legal assistance.

At this stage, one must be aware of potential risk factors and dangers, such as exploitation and human trafficking. Signs of human trafficking may include one or more of the following (the Israeli Ministry of Justice, 2022):

• The person does not have any identification documents or passports (if they are foreigners).
• The person appears to be ill or suffering from visible infections, bruises or signs of violence.
• The person’s behavior expresses a visible difficult psychological state, for example fear, suspicion, depression, restlessness, lack of orientation in time and place, or extreme apathy.
• The person is accompanied by another person who seems to control him or her and does not allow them to speak freely or in private

If the helper is sent to help a group of asylum seekers and not a specific person, it is important to screen and locate those members of the group that need an urgent response, according to their level of distress and risk factors. Vulnerable populations who are at increased risk include (WHO, 2011):

• Children and adolescents, especially if they are separated from family members.
• Persons with physical and mental disabilities.
• Persons in complex health conditions, including pregnant or postpartum women.
• Persons belonging to minority groups and therefore at risk of experiencing violence or discrimination, for example women or people of persecuted ethnic minority groups.

2. The LISTEN phase

During this phase, one should listen empathetically and non-judgmentally to the distress and worries of the refugee, without assuming in advance what is the source of the distress. Calm the refugees down, guide them through and explain that they are currently in a safe place (if indeed they are safe). To facilitate communication, the information should be conveyed using simple, non-technical language. Also, remind them that the helper is there to support and assist them as much as possible. Promises that are not within the helper’s authority (for example, unsubstantiated statements, such as: "Don’t worry, we will take care of your status. You will not be expelled from here!")

מבקש.ת לעצמך טיפול?
כאן תוכל.י לשלוח פניה לטיפול ולקבל התייחסויות ממטפלות.ים חברי פסיכולוגיה עברית

In this stage, grounding techniques can be used if the refugees experiences extreme stress or panic. One possible grounding technique is placing their feet on the floor, instructing them to pay attention to specific objects in their environment (for example, cars, suitcases), focusing on breathing, or drinking cold water. One helpful technique for grounding is "stop-grounding-breathing". The clients are  asked to stop and identify their level of anxiety, to ground themselves by using one of the above techniques, and then to use a slow breathing technique; the air is breathed in through the nose, and breathed out through the mouth, in 3-5 seconds cycles (Tomlin, Dalglesish, & Lamph, 2020). Another common and relatively simple grounding technique involves the following steps with the recipients of the assistance:

1. Ask them to take a deep breath and assess the level of stress they are feeling.
2. Ask themt- o look around and count (preferably out loud) five objects they can see, five things they can hear, and five objects they can touch. If the them have difficulty distinguishing five items, they can be instructed to repeat certain items as long as they can sense them through the relevant sensory modalities. Next, they areasked to count four items, then three, two, and finally one item.
3. Ask them to take another breath and reassess their stress level.

If necessary, consider referring the person to receive sedative-hypnotic medication. To minimize the risk of subsequent development of PTSD, and in light of limited effectiveness, the research literature recommends avoiding or restricting benzodiazepines use in acute stress (acute stress reaction or disorder), shortly after the traumatic exposure (Guiena, 2015). Other alternatives to sedation and sleep induction should be considered, including histaminergic medication, anti-depressants (e.g., mirtazapine, trazodone) or, in cases of overwhelming anxiety, low-dose antipsychotics.

It is essential to find a quiet place where the person can speak in privacy and relatively freely at the listening stage. Mental first aid interventions in humanitarian crises are usually not given in an orderly and designated area for assistance, such as clinics, but at the disaster sites, at the border or airport, in detention and custody facilities, or other public spaces, as well as by telephone or social media. During this conversation, one should maintain a suitable distance and avoid physical contact. A calm and confident demeanor should be maintained, and the available and relevant information should be provided. As for details the aid provider doesn't know, it should be acknowledged and stated clearly that this information isn't available to the helper.

Despite the natural need for helpers to share their experiences with their network, it is essential to maintain medical and client confidentiality and privacy of case details, and to share only what is necessary with the representatives of aid organizations. While listening, one should validate and acknowledge the feelings that the person is experiencing, for example: "I'm so sorry; I can imagine how hard it must have been for you to see your home after everything that has happened." It is worth noting that different cultures may vary in reference to the need or acceptability of expressing emotions. There are cultures in which it is not acceptable to share feelings, specifically with strangers. Therefore, asylum seekers shouldn't be coerced or pushed for emotional sharing, and the lack of expression of emotions shouldn't be regarded as a defense mechanism of dissociation, resistance, or avoidance. In addition, the asylum seeker doesn't have to express feelings in a way that seems appropriate to the helper. Gaps and silences should also be allowed and not avoided.

It is important to note that the meaning of first aid is not necessarily related to encouraging the persons to tell their story or conducting debriefing (which includes encouraging them to repeat the details of the traumatic events and remembering them or feelings that arise). It has been previously found that this technique isn't effective in preventing PTSD (Rose, Bisson, Churchill, & Wessey, 2002). During the crisis itself, it may overwhelm the person (flooding) and induce feelings of helplessness and emotional pain. These emotions can be processed in follow-up treatments by mental health experts and after achieving some stabilization, which doesn't necessitate acute and ongoing functioning and coping.

The crisis situation naturally invites helpers to feel capable and competent in the face of extreme human suffering. However, one should be careful about positioning oneself as a “savior” or a “problem solver”. The refugee should be allowed to express difficulty and worry (including financial, physical or health concerns) and the helper should also mirror strengths and resources ("I imagine how much courage and strength it took to escape your city and embark on a journey") (WHO, 2011).

As part of the listening phase, it is worth mentioning two models for first aid intervention, both developed in Israel. The first is the SIX C's Model (Farhi et al., 2018), which is currently used by many different governmental authorities in Israel. The model is designed to allow people in the field in times of crisis to provide mental first aid, without the need for extensive professional background or experience.

The model is based on four main principles, translating into practical action. The model is based on the hypothesis that it is preferable to facilitate cognitive over emotional functioning during acute crises situations. The helper encourages the asylum seekers to use cognitive communication, frames their chain of events chronologically, remaines committed to them and providing them with challenge and control. These are the practical actions:

מטפל בשיטות NLP,CBT,EMP
מטפל בדכאון,חרדות,OCD,טראומות

1. Reduce isolation – Make a connection with the persons and a commitment to their safety: The helper develops a connection and conveys a commitment that provides a sense of safety to the recipient of the assistance. For example, the helper may tell the asylum seeker: "I am with you now." If the helper knows the asylum seeker's name, it is helpful to use it.
2. Reduce helplessness – Challenge the persons and give them control: The helper encourages the recipients of the assistance to perform simple, effective actions while moving them from helplessness to an active state. For example, the helper can aid the recipient in deciding on a sequence of simple actions: "Now you are responsible to take your family to this address, where they will host you; there you will organize and arrange your things in the room, and call this volunteer to show you around the neighborhood."
3. Reduce emotional flooding – Cognitive communication: Helpers should manage cognitive and not emotional thinking by activating thought instead of emotion. Thus, expressing feelings in stressful events should not be encouraged, but rather cognitive-logical thinking: "Try to count the number of gray cars you see on the road or count how many bags you arrived here. Let's count."
4. Reduce confusion – Encourage continuity: This aspect is aimed at helping the help recipients understand their own story by constructing the sequence of events. For example, the helper may say, "You were in your city when it was bombed, and you embarked on a long journey to the border, and now you have arrived in the host country, and you have a visa. Now you are safe, and you can stay here safely."

Another model, that was developed in Israel at the Donald J. Cohen & Irving B. Harris Resilience Center and adopted by the Ministry of Education, is called SMBS-GO (Stop-Muscles-Breathe-Self talk-Go; Laor et al., 2014). This strategy is useful in situations of prolonged and chronic anxiety as well as in crisis interventions, providing first aid. It includes the following steps:

• Step One: I take a time-out. I put the brakes on my current thoughts and order myself to stop.
• Step Two: I shift the focus to my body and mainly to my muscles. I flex my fingers into a fist (or contract any other muscle group) while I am taking a deep breath, and then relax them and slowly exhale.
• Step Three: I breathe slowly (mainly slow exhalation) two or three times.
• Step Four: I motivate myself by speaking to myself (self talk) using a key sentence I've prepared in advance, such as "I can calm down and respond properly now", or "I don't know what to do so I'll stop now and respond later". I may identify here my emotions and remind myself my values and why I should resist to except my default response.
• Step Five: Now I can go forward and handle what I need to handle, or else put it to the side and go back to it if possible and necessary.

The model is one of the most useful interventions in working with children, adolescents and adults. It was also examined in the context of humanitarian disasters and wars in Israel and around the world and was found to promote resilience and as effective in the prevention of anxiety following a mass crisis (Wolmer et al., 2011a, b).

3. LINK phase

The third phase of the PFA model refers to helping asylum seekers connect with internal resources of resilience, hope, spirituality and faith (if appropriate for the persons and their background), abilities and skills. In addition, the person should also be referred to existing external and social support sources, including family members and friends in the host country, and to institutions and organizations that can assist with various issues. If the aid providers don’t have information and answers for specific questions and needs raised by the asylum seekers, they should take the necessary actions in order to acquire this information, and to contact the asylum seekers later on, in order to provide them with the needed information.

Ethical issues in providing mental first aid to refugees

In humanitarian disasters and crises, first aid providers are usually not professionals but work on behalf of humanitarian organizations, speaking the required language; they are sometimes the first to deliver essential aid. Although not professionally trained, these people can be a vital resilience and support source in the community. Therefore, it is important to provide these workers and volunteers with the appropriate training and guidance required to provide initial assistance.

One of the problems that may arise in working with volunteers in emergencies is related to the fact that things happen in the field very quickly, and the crises necessitate flexibility. Sometimes there is no sufficient time for sorting, training and supervising these volunteers. This challenge may pose a risk to vulnerable populations, so it is very important that any organization that employs volunteers provides rapid training and introduces ethical guidelines, mandatory for every helper to refugees and asylum seekers. Here is a summary of some critical rules for maintaining the safety of refugees receiving assistance from these workers. The complete list of rules appears in the WHO guide for aid workers (WHO, 2011).

DO

• Be honest and trustworthy.
• Respect the right of people to make their own decisions.
• Be aware of yourself and put aside your biases and prejudices.
• Respect the privacy of service recipients and maintain confidentiality of their life story.
• If you suspect that there is a person at risk, share the details with the organization's official representative.
• Be respectful and polite, in a way that is compatible and sensitive to the culture, age and gender of the person.

DO NOT

• Do not take advantage of your relationship as a helper.
• Avoid physical contact with any person you assist or deliver service to.
• Avoid physical or sexual relations with refugees.
• Do not ask the person for money or a favor for your help.
• Avoid religious conversion of refugees.
• There is a severe prohibition on physical or emotional harm of any kind.
• Do not share information, stories or location of refugees.
• Do not make false promises or give false information.
• Do not overdo your skills.
• Do not force help on people, or offer it intrusively.
• Do not pressure people to tell you their story.
• The person should not be judged on their actions or feelings.
• Do not collect any information about refugees unless requested to do so by an official organization and with the informed consent of the refugees.
• Do not take pictures or videos of refugees, or post stories or pictures on social media unless the refugee has explicitly asked to share them.
• All accommodation offers to refugees must be made through official organizations so that the hosts can be screened in advance.

These guidelines are self-explanatory and self-evident to professionals, but keep in mind that as with treating people in extreme crisis and stressful situations (and similar to basic life resuscitation practice), it is important to repeat the basic principles of treatment. This is especially true when it comes to volunteers and aid workers who are not professionally trained. Ongoing monitoring, guidance and supervision of aid workers, especially of clinical and ethical aspects, are important in these sensitive crises situations.

אנליזה בתעריף מיוחד
אנו מציעים טיפולים פסיכואנליטיים למבוגרים, ילדים ונוער. הטיפולים ניתנים בדרום ומרכז הארץ

(B) A Model for Intervening in A Crisis for Mental Health Professionals

The following is an abbreviated model based on our experience, and is a simplified model of the Rogers and Ottens crisis intervention model (Rogers & Ottens, 2005). The original intervention includes a seven-stage roadmap, of which we will review three main ones. In our experience, these outline the useful steps in the work of crisis intervention with refugees and asylum seekers: 1) Assessment of the situation; 2) Intervention; 3) Continuous evaluation of risk factors and changes in mental and functional status and ongoing emotional support as needed.

It is important to emphasize that in every aspect of the intervention, one must work with cultural sensitivity and humility and evaluate clients’ perceptions of their traumatic exposure, the meaning they attribute to these traumatic events, and factors they consider to promote resilience. If Western psychology jargon and concepts are used, they should be made accessible by explaining the meanings we as therapists attach to these terms. The therapist must invest time and effort in building a bridge of shared meaning and understanding that can help and promote communication and trust. In addition, one must recognize different intercultural communication styles and invest in getting familiar with the culture of the asylum seeker’s background.

1) Assessment of the situation:

At the beginning of a psychological or psychiatric assessment (intake), the therapist must introduce herself or himself clearly, including: full name, profession and position. If the therapist was sent by an organization or a third party, this should also be presented and explained to the client, as well as the purpose of the assessment and/or providing assistance and support. Oral or written consent for the assessment or intervention must be obtained before this process can begin.

During this assessment session and psychotherapy, clients may face memory gaps regarding details of the traumatic event(s), with a wish to avoid stimuli associated with those events. Episodes of dissociation may appear. The client may feel detachment, emotional distancing or an inability to explain or convey emotional distress, as this constitutes a natural and common defense mechanism in these situations. This emotional distance may also characterize certain cultures that don’t focus on emotional discourse or personal exposure. Clients may have trust issues and experience difficulties in decision-making processes. They may recount a confused, fragmented, or contradictory version of their stories, and the therapist should be patient and understanding of these struggles. The interview by itself constitutes re-exposure and thus impairs the avoidance mechanism, therefore presenting a risk of flooding and reactivation of the trauma. Intrusive questions should be kept to a minimum as much as possible, and the therapist should focus only on critical questions for the assessment or treatment process. Remember that the client has probably gone through several such assessment interviews and may go through additional ones. Therefore, it’s essential to get only the information relevant to the field of specialty and not necessarily dive into the overall life story.

Another characteristic of this therapeutic encounter is the clients’ difficulty connecting with the therapist, who may be perceived as an authority figure. The meeting may be threatening or paralyzing for them. Intercultural differences should be taken into account. Therefore, the use of culture-specific humor and cynicism should be minimized unless the therapist has prior knowledge of the language and environment, and feels safe using such nuances. Refugees who undergo status determination interviews, whether at the border or afterward, are likely to experience a worsening of their psychiatric symptoms. This may affect the way they behave and answer questions of the authorities. Therefore, if a client is expected to undergo such an interview, mental and emotional preparation should be provided, and the accompanying attorney on the case should also be consulted.

As with any mental examination, and as a part of good clinical practice, it is mandatory to document the interview. The documentation should include the mental situation, existing and non-existent symptoms at the evaluation time (with quotes), mental/psychiatric status examination (if the therapist is qualified), and construction of a working or treatment plan. Keep in mind that this document can be the baseline for future treatment and interventions and will also be included in a legal-procedural process, for example- in status determination. The situation should be documented correctly and truthfully. Deliberate documentation of a more severe state or condition than is presented by the client should be avoided. More severe circumstances will not necessarily improve the cleint’s case with preferential treatment from state authorities, international bodies (e.g., the UN), or aid organizations. This may also mislead future therapists.

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2) Intervention:

The primary goal of psychological interventions with refugees is to restore homeostasis and help the patient return to a functioning state. This can assist them in dealing with immigration, including the process of acculturation and survival in the host country. The basic assumptions of the intervention relate to the fact that refugees are required to function at a certain level, given the lack of services and their limited support networks. Functioning, occupation, and adapting a routine will help acculturation and recovery from the traumatic experiences. At the same time, if possible, it may be beneficial to incorporate a long-term treatment plan that will address broader goals, such as trauma processing and reconstructing narratives. Crisis interventions can be performed by therapists working with different therapeutic approaches. The intervention must be understandable, defined, and clear - for both the therapist and the client. The therapist must convey hope and belief in the refugee's ability to return to function. The therapeutic focus is the crisis and its effect on functioning and emotional state. The emphasis is on the “here and now” and strengthening coping mechanisms and mental resilience. The therapist's position should be supportive-directive, flexible yet with clear and agreed boundaries. If possible, it is advisable to decide in advance on the duration of the intervention and its limits, and to agree on the intervention's goals.

1) Preparation for intervention phase:

At this stage, the following aspects should be considered:

• Make sure that the client's physical needs are met: food, drink, and adequate sleep.
• Assessment of the nature of the stressor - physical, mental, economic, environmental, or other.
• Observing the persons dealing with the stressor: what are the mental, social or personal resources available to them, their financial situation, what does the crisis mean for them and how it is perceived, and what are the defense and coping mechanisms used. It is appropriate to construct a dynamic or behavioral formulation at this stage if the therapist is trained in psychodynamic or behavioral therapy.
• In the assessment phase, the difficulty or problem that the treatment will focus on should be defined. As treatments of refugees may not be long-term, it is advisable to focus on a specific goal and adapt an appropriate work plan, depending on the therapist's training and perception.
• Emotional ventilation must be allowed, and emotional distress must be acknowledged. Psychoeducation may be appropriate. The persons’ cultural perceptions regarding psychiatric or psychological treatment should be examined, whether they have experienced this kind of treatment in the past, know what the treatment includes. All of these actions help and prepare the interpersonal infrastructure to allow further work. It is also possible to incorporate mirroring that consists of the normalization of the situation and an explanation of stress/anxiety responses as natural responses to a crisis (abnormal) situation.

2) Intervention phase:

• At this stage, one may choose to include behavioral aspects of constructing a daily (actions) routine and a weekly plan (behavioral activation), to help build a routine with pleasurable and motivating personal tasks.
• Existing resources can be mapped out and strengthened, including internal resources that can help adapt.
• Various techniques can be used in accordance with the therapist's training and the clients needs. For example: Mindfulness, EMDR, CBT, ACT, existential therapy, psychodynamic therapy, or couple, family, or group therapy. One of the resources developed in Israel offers mindfulness therapy specifically for refugees (Aizik-Reebs, Yuval, Hadash, Gebreyohans Gebremariam, & Bernstein, 2021).
• The client should also be referred to external resources to make the existing services accessible. For example, contact with relatives or contact with organizations that can provide various services. The therapist can also engage in solving concrete problems and contemplate together with the client how they may be approached. Within this process, the therapist provides an external perspective and familiarity with the culture and society of the hosting country. At the same time, it is essential to be careful of entering a therapeutic position of problem-solving as a central component of treatment. This position can quickly arise within the therapist in the context of countertransference in the face of the suffering and helplessness that asylum seekers encounter.
•  Also, support and encouragement may be provided if appropriate at this stage.
•  Throughout all stages of the intervention, the acknowledgment of the client's resilience alongside the emotional distress must be balanced. Hope should also be noticed and promoted.
• Throughout all stages, flexibility, listening, patience, and adjustment to the client's pace are required, while paying attention to intercultural aspects. In the intercultural context, attention must be paid to the power relationship dynamic built into the situation: a therapist of local culture and status, and a refugee client. For the client, the therapist may represent, even unconsciously, the host country government ministries. These aspects may affect the client's sense of protection and should be approached with sensitivity and consistency with the client's culture. As discussed above, in a society where there is no room for expressing emotions, encouraging this can be considered a threatening step. Therefore, it is necessary to examine how the expression of emotion is perceived in the client's culture.
• Inform the client beforehand of any time limitations. When the end of the treatment is determined, explain the support options after the therapeutic process has ended (e.g., return to the therapist for additional sessions, contacting another service).

3) Continuous assessment and support:

This stage takes place throughout the therapeutic process, particularly toward the end of the intervention. Within this stage, special attention must be paid to risk factors, such as suicidality, aggression, and aggravation of the mental state. All of these may be affected by the client's current circumstances; obtaining an official legal status, being interviewed by the authorities, the threat of deportation, poverty, loss of shelter. The refugee's mental and functional condition must be continually assessed, as well as the support needed. Links must be made to organizations and other third parties that can provide the additional needs required for their well-being (legal assistance, health, welfare systems, education).

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Writing examination or treatment summary and letters

Sometimes, after the intake or during or following the treatment of refugees, the therapist is asked to write a summary report or a letter for the use of various bodies (beyond the usual treatment summary at the end of therapy). Here are some highlights to consider when writing such documents:

• Make sure you know to whom the letter is addressed and for what purpose. The therapist should explain the meaning of the document and provide reliable information regarding the procedure. Details cannot be delivered to any authority or organization without written informed consent of the refugee, even if the intervention was made at their request or with their funding. Everything must be done in accordance with the relevant ethical codes and laws regarding medical confidentiality and the terms in which violation of said confidentiality is permissible.
• If a psychiatric diagnosis is given, it should be supported, detailing relevant symptoms. It is also recommended to add quotes from the patient. In addition, if possible and necessary, an ICD/DSM code should be added to the diagnosis as well as a psychiatric mental status examination.
• It should be carefully considered to what extent to elaborate on details of the client's life and exposure to trauma (as described above, one of the most common defense and coping mechanisms with trauma is a fragmented memory of the events). Every time the client is asked to recount the events of the traumatic experience, there is a chance that his or her version will change. Different, or even contrasting, versions of testimonies can complicate the patient in legal procedures, such as refugee status determination or visa applications. Such cases often create misunderstandings between therapists and lawyers or law enforcement officials, who need a single, clear, coherent version. Therefore, it is recommended to minimize the background details and the sequence of events.
• The phrases "according to him" or "she reported", should be added to the descriptions provided by the refugee so that the report reliably reflects that the events were as the person described them.
• Mediate the contents of the letter to the patient, and make sure that the version of the letter is approved by him or her. A copy of the document should be given to the patient for further treatment.

Additional aspects of the treatment of refugees and asylum seekers

Self Care: Caring for the Helpers

Refugee care may evoke various emotions and reactions among caregivers, helpers, and therapists. On the one hand, they may feel a sense of meaning, mission, caring, and hope; On the other- feelings of over-identification, anger, helplessness, and burnout could arise. Two known phenomena in the context of refugee care are compassion fatigue and secondary traumatization. Compassion fatigue (Figley, 1995) refers to the physical, emotional, and psychological impact of helping others — often through experiences of stress or trauma. Compassion fatigue is often considered burnout, a cumulative feeling of fatigue or dissatisfaction from work or life. It can appear in the ongoing treatment of severe trauma situations.

Similarly, many studies indicate the effects of these therapies on therapists through secondary traumatization. The therapists suffer from post-traumatic symptoms caused by exposure to traumas experienced by others, including fatigue, avoidance of specific stimuli, increased alertness, and feeling of emotional numbness. These effects may also be linked to the robust countertransference processes that can arise in a trauma situation; these bring therapists to feel mixed solid feelings, a desire to "save," to act and be active, and in general - to get rid of the painful feelings and helplessness, all of which are characteristic of patients suffering from PTSD.

To help therapists to maintain their well-being, it is recommended that therapists set their boundaries.  This includes limiting the extent and scope of treatments. In addition, it is essential to keep attending team meetings, supervision, ongoing training, and considering personal, professional care (psychotherapy). The treatment of refugees often raises not only emotional but many materialistic needs, from basic needs for food, clothing, and money to housing. Therapists are advised to refer refugee clients to aid organizations involved and not try to meet these needs independently. This is to maintain the boundaries of the treatment and their ability to engage in mental and psychosocial therapy over time.

Acts of allyship and public advocacy

The term allyship exists within intercultural therapies and the treatment of asylum seekers and refugees. It refers to the need for caregivers, therapists, and aid providers to use their social position to improve the situation of disadvantaged and isolated populations and prevent human rights violations. In their work with refugees, helpers and therapists are exposed to essential knowledge. Their responsibility is also to expose discrimination and social harm mechanisms, work for systemic change and engage in policy change whenever possible (Kia-Keating, & Juang, 2022). It should be noted; of course, that, as previously mentioned, all this should be accomplished while maintaining the confidentiality and privacy of people who received help from the volunteers and without any forced or unwanted exposure.

Examples of allyship active actions that combat inequity, exclusion, and violation of the rights of refugees and asylum seekers can be:

• Sharing information on social and systemic barriers, such as lack of mental health services on social and general media.
• Active advocacy and connecting with policymakers to inform them and demand the initiation of policy change.
• Membership in organizations that promote human rights, including the health and mental health rights of asylum seekers and refugees.
• Assistance in establishing and making health services accessible to refugees.
• Protesting and taking action to promote change toward abusive acts and human rights violations as witnessed by caregivers
• Connecting organizations and individuals are working to promote mental health services for asylum seekers and refugees.

Summary and implications

In an ever-changing world riddled with wars, epidemics, and climate change, waves of forced migration are expected to continue. The care of displaced persons who have experienced multiple traumas requires a unique and appropriate knowledge and skillset. Some of these skills are cultural competence, understanding the specific ethical issues that may arise, and sensitivity to the particularly vulnerable situation in which patients are treated. It is essential for knowledge about refugees in crisis to be integrated into training programs and include intercultural trauma support skills, awareness of social justice issues, care for people experiencing forced migration, and strategies to promote coping, hope, and resilience among these populations.

הרשמה למפגשי היכרות וצפייה בהקלטות מפגשים
בואו לקבל טעימה ממגוון התחומים המרתקים הנלמדים אצלנו במרכז

Author notes:

Yael Mayer, PhD, clinical psychologist, senior lecturer in the Department of Counseling and Human Development at the University of Haifa, research associate in the Faculty of Medicine at the University of British Columbia, Canada, co-founder of the Lewinsky Garden Library and the CEC Academic Center for Immigrants and Refugees in Israel, of Mamatefet and WE organizations for immigrant women in Canada, and formerly a professional director and clinical supervisor at the MESILA Center (Assistance Center for Migrant Workers and Refugees) on behalf of the Tel Aviv-Jaffa Municipality.

Ido Lurie, MD, MPH, a psychiatrist, director of the adult clinic at Shalvata Mental Health Center, chairperson of the Israel Community Mental Health Society, Israel Medical Association (IMA). A senior lecturer at the Tel Aviv University School of Medicine. Founder and former director of the Gesher Mental Health Clinic for asylum seekers, Ministry of Health. Former UNHCR advisor on mental health of refugees and asylum seekers.

For questions and inquiries regarding this article, please contact Dr. Yael Meir, yaelmayer10@gmail.com or Dr. Ido Lurie ido.lurie@gmail.com

The authors would like to thank Tamar Dressler and Nitzan Hirsch for their help in translating the paper to English and further editing.

Notes

1. While there are semantic and legal implications to the terminology of “refugees” and “asylum seekers,” we will use these terms interchangeably for this article. Refugees and Asylum Seekers and Mental Health Implications

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