ShifaME Trauma Systems Therapy adapted for Refugees (TST-R) - - PDF document

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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

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• 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

Immigrant vs. Refugee vs. Asylum Seeker

• Distrust of Authority
• Linguistic and Cultural Barriers
• Stigma of Mental Health and Diagnosis
• Primacy of Resettlement Stressors
• Parent and Family Engagement

BARRIERS TO CARE: 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.

7/17/19 3 WHAT IS A TRAUMA SYSTEM?

A traumatized child who experiences survival-in-the- moment states in specific, definable moments A social environment and/or system of care that is not able to help the child regulate these survival-in-the- moment states

Social-Ecological Model

School Peer Group Neighborhood Culture Family

Individual

REFUGEE CORE STRESSORS

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THEN

• Loss of family members,

loved ones and a country

• Lack of food, water and

the basic necessities

• Prolonged, brutal

violence

• Displacement

NOW

• Loss of status
• Separation from

family/country

• Acculturation

challenges impacting familial and peer relationships

• Poverty
• Community Violence
• Isolation

TRAUMATIC STRESS

• Difficulties finding

adequate housing

• Difficulties finding

employment

• Loss of community support
• Lack of access to

resources

• Transportation difficulties
• Lack of familiarity with

school system

RESETTLEMENT 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

ISOLATION STRESSORS

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• 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

• rigin

ACCULTURATION STRESS TRAUMA SYSTEMS THERAPY TRAUMA SYSTEMS THERAPY

TST-R: A Model that Addresses Barriers to Care

7/17/19 6 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).

7/17/19 7 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

• Is sudden, unexpected, or non-normative,
• Exceeds the individual’s perceived ability to meet

its demands,

• Disrupts the individuals frame of reference and
• ther central psychological needs and schemas.

(McCann & Perlman, 1990)

*Not all people who experience trauma develop PTSD

An event is traumatic when it:

7/17/19 8 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, continuous emotional state and is well engaged with his

• r her

environment. Child has been triggered by a provocative stimuli and is engaging in coping skills to manage emotion and behavior. Child’s coping skills have been

• verwhelmed. He
• r she has entered

into a state of extreme emotion and behavior. Child’s state of emotion has

• diminished. Child is

using existing coping skills to manage emotion 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%

7/17/19 9 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)

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THE IMPORTANCE OF SHARED EXPERIENCE

• 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.

• The role of the Cultural Broker

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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.

7/17/19 11 CULTURAL HUMILITY

• A commitment to self-evaluation and self-

critique.

• Recognize, acknowledge, challenge, and

change power imbalances in relationships.

• Develop mutually beneficial partnerships

with communities.

• Work towards institutional accountability.

Effective teams:

• A commitment to self-evaluation and self-critique.
• Recognize, acknowledge, challenge, and change

power imbalances in relationships.

Importance of teamwork and cultural humility…

Non-Western Expectations/Values Western Expectations/Values

Help is given when asked Roles and limit setting Things are implied Expect shared understanding and knowledge Shared context, thus no need to verbalize Verbalizing feelings and thoughts Clearly stating positions Not assuming shared knowledge Verbal communication: Narrative, non-direct Verbal communication: Informal, to the point Eye contact as disrespectful Eye contact as respectful Close personal space as rapport building Distant personal space as professional Relationships-historical Relationships- objective/distance Collective identity Shared experiences and shared feelings Are important to the relationship Individualistic identity Focus on self-reliance and autonomy Community talk Boundaries Individual interests are subordinate to the family needs Individual interests are valued and encouraged Concept of Time: Flexibility Concept of Time: Efficiency

Cultural Dynamics Influence Interactions

7/17/19 12 THANK YOU

Contact Information: shifameinfo@spurwink.org