7/17/19 ShifaME Trauma Systems Therapy adapted for Refugees (TST-R) National Child Traumatic Stress Network Initiative Sarah Ferriss DSW, LCSW, Director of Refugee Services Heidi Harrison, LCSW, Associate Director of Refugee Services Siad Shaleh, TSTR Trainer / Cultural Broker Spurwink Services www.Spurwink.org AGENDA • Introduction to ShifaME • Overview of TST-R • Review of cultural brokering Who Are Refugees? A person who is outside his/her country of nationality or habitual residence; has a well- founded fear of persecution because of his/her race, religion, nationality, membership in a particular social group or political opinion; and is unable or unwilling to avail himself/herself of the protection of that country, or to return there, for fear of persecution. -- Article 1 of the 1951 U.N. Refugee Convention 1
7/17/19 Immigrant vs. Refugee vs. Asylum Seeker • Difference in legal status: refugee vs. immigrant, documented vs. undocumented • Differences and similarities in experiences • Differences in access to services • Other special groups: unaccompanied minors, asylum seekers, temporary protected status • Asylum seeker – someone whose request for sanctuary has yet to be processed BARRIERS TO CARE: • Distrust of Authority • Linguistic and Cultural Barriers • Stigma of Mental Health and Diagnosis • Primacy of Resettlement Stressors • Parent and Family Engagement TST-R ADDRESSES THE TRAUMA SYSTEM TST-R is an adaptation of TST for refugee youth and their families. TST-R takes into account the context of the refugee and immigrant experience and barriers (e.g., stigma, language, distrust) to engaging in mental health services. 2
7/17/19 WHAT IS A TRAUMA SYSTEM? A social environment A traumatized child and/or system of care who experiences that is not able to survival-in-the- help the child moment states in regulate these specific, definable survival-in-the- moments moment states Social-Ecological Model Culture Neighborhood Peer Group School Family Individual REFUGEE CORE STRESSORS 3
7/17/19 TRAUMATIC STRESS THEN NOW • Loss of status Loss of family members, • Separation from loved ones and a country • family/country • Lack of food, water and the basic necessities Acculturation • challenges impacting • Prolonged, brutal familial and peer violence relationships • Displacement Poverty • Community Violence • Isolation • RESETTLEMENT STRESSORS Difficulties finding • adequate housing Difficulties finding • employment Loss of community support • Lack of access to • resources Transportation difficulties • Lack of familiarity with • school system ISOLATION STRESSORS • Feelings of loneliness and loss of social support network Discrimination • Experiences of harassment • from peers, adults, or law enforcement Experiences with others who • do not trust the refugee child and family Feelings of not “fitting in” • with others Loss of social status • 4
7/17/19 ACCULTURATION STRESS • Conflicts between children and parents over new and old cultural values • Conflicts with peers related to cultural misunderstandings The necessity to translate for family • members who are not fluent in English Problems trying to fit in at school • Struggle to form an integrated • identity including elements of their new culture and their culture of origin TRAUMA SYSTEMS THERAPY TRAUMA SYSTEMS THERAPY TST-R: A Model that Addresses Barriers to Care 5
7/17/19 TIER 1: COMMUNITY ENGAGEMENT • Partner with refugee community leaders to build relationships between the organization and the community needing service. Learn about the unique needs of the refugee community • • Cultural Brokers reduce stigma by providing education to the community about trauma and mental health. Develop partnerships with public schools to support • school based mental health supports and assist the schools in developing an understanding of the refugee experience and specific cultural norms/practices. TIER 2: SCHOOL-BASED GROUPS • School-based Gender-specific • Groups are co-facilitated by a clinician and a cultural • broker Open to all children with refuge experiences • Designed to be non-stigmatizing social support groups • Curriculum focuses on helping students learn self- • regulation skills and navigation of multiple cultures Acts as a gateway to Tier 3 and 4 clinical services • TIER 3: REGULATION FOCUSED & BEYOND TRAUMA Regulation Focused Treatment Teach the child & caregiver skills to help regulate • emotional states when triggered by perceived threat. Treatment often occurs in office or a clinic • Beyond Trauma Social environment is stable and child can regulate • emotional states. Treatment focuses on learning cognitive skills to address • cognitive related thought processes. Assist the family and child on gaining new perspectives • about their traumatic experience(s). 6
7/17/19 TIER 4: SAFETY-FOCUSED TREATMENT • Establish and maintain safety in the social environment • Advocate for services and supports • Home-based or community based • Cultural Brokers are partnering with clinicians • Involves partnerships with other organizations and community providers • Treatment interventions build capacity to build safety and protect the child TST-R OBJECTIVES: • Engagement of refugee children and families in services • Decrease stigma of mental health • Increase identification of refugee youth with mental health needs • Provide sustainable culturally and linguistically- appropriate school-based mental health services • Address the trauma system TST-R DEFINITION OF TRAUMA An event is traumatic when it: • Is sudden, unexpected, or non-normative, • Exceeds the individual’s perceived ability to meet its demands, • Disrupts the individuals frame of reference and other central psychological needs and schemas. (McCann & Perlman, 1990) *Not all people who experience trauma develop PTSD 7
7/17/19 SURVIVAL IN-THE-MOMENT Changes in 3A’s (Affect, Awareness, Action) over the 4R’s (Regulating, Revving, Re-experiencing, Reconstituting) Regulating Revving Re-Experiencing Reconstituting Child is in a calm, Child has been Child’s coping skills Child’s state of continuous triggered by a have been emotion has emotional state provocative stimuli overwhelmed. He diminished. Child is and is well and is engaging in or she has entered using existing engaged with his coping skills to into a state of coping skills to or her manage emotion extreme emotion manage emotion environment. and behavior. and behavior. and behavior, and to reengage with the environment. LIFETIME TRAUMA EXPOSURE: • Sum score of 24 dichotomized items: – On average 5 lifetime traumatic events – Age Range: 0 – 16 – 94.2% endorsed at least one lifetime traumatic event • Most commonly endorsed items: – Been in a warzone: 54.7% – Family member hospitalized: 54.7% – Family got into serious conflicts with each other: 40.9% – Client was slapped, punched, kicked or physically hurt: 40.4% – Client has seen or heard someone badly hurt or killed: 36.5% 8
7/17/19 TRAUMA EXPOSURE IN RESETTLEMENT: • One year in to treatment: – Clients had experienced a mean of 2.1 types of exposures in the past year (Range: 0-5) – 76% had experienced at least one additional event in the past year • Most common items experienced in the past year: – 46% had known or seen someone in the family being arrested, put in jail, or taken away by police – 31% had been separated from a primary caregiver for more than a few days – 23% had lost a family member – 23% had seen a family member slapped, punched, kicked, or physically hurt CULTURAL BROKERING & CULTURAL HUMILITY CULTURAL BROKERING IS…. The act of bridging , linking or mediating between groups or persons of different cultural backgrounds for the purpose of reducing conflict or producing change (Jezewski, 1990) 9
7/17/19 28 THE IMPORTANCE OF SHARED EXPERIENCE The role of the Cultural Broker -Cultural brokers play a huge role when a provider • is establishing trust, especially in situations where families may have had past negative experiences with providers, authorities or other people in positions of power. • -Empowers families to help them understand that they have a right to agree or disagree when getting services. • -Clarifies information given to make sure nothing is taken away wrongly. • -Beside providing language access, cultural brokers help providers understand the philosophy of life of the client they are working with and that helps the clients and families understand the services they are receiving. • Interpreters vs. Cultural Brokers: What ’ s the Difference? Cultural brokers add to information, › facilitating deeper understanding Cultural brokers add context, provide › background knowledge to enhance provider ’ s understanding of situation Interpreters pass information from one › person to another without making changes Cultural brokers are partners to › clinicians THE RISE OF CULTURAL COMPETENCE Cultural competence arose as a well- meaning response to increased awareness of the cultural, racial, and ethnic diversity of the people we serve—and a desire to responds positively to the varied needs of a diverse population. 10
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