Psychological Therapies for Survivors of Torture: A Human-Rights Approach With People Seeking Asylum

Following an online event with Jude Boyles and colleagues we received several questions and comments from viewers. Here Jude and colleagues respond to those questions.

The world of therapy is now heavily affected by the holy grail of evidence based practice, RCTs, time-limited work - what would you say about how that fits with working with survivors of torture?

It is indeed! – in terms of time limited work, it is a challenge for all therapists that we are responding to complex distress within short-term timeframes for many of our clients! – let alone in our work with refugee survivors of torture. Sitting alongside this, longer assessments are usually needed for survivors and engagement may take longer. In short term work, it can feel as if survivors are just learning to use and trust the space, then we are preparing for ending...and they are facing another loss and often have little support elsewhere. However, for many people 12-16 weeks of therapy can still help a great deal. In my experience, a thorough assessment and therapy and/or stabilising work, often weaving some casework in-between sessions can be extremely helpful.

In terms of research, it is so important that organisations working with survivors undertake research so that we can equip those of us in the field to do the best we can as well as listening to what clients tell us helps them. Refugees are such a diverse group however and we know that not one approach or model stands out as being the most helpful. The key for me is a flexible approach and a willingness to adapt our models to ensure that what we offer is accessible and culturally congruent.

Somehow we must achieve the balance of ensuring that there are a range of models and approaches in any team/organisation and that therapists feel equipped to work with trauma, and have a tool bag to draw from. I must admit that I have a concern around applying any fixed approach to working with any group, so for me diverse teams and approaches are what’s important. When we say that this approach works for people seeking asylum who have been tortured, we can stop listening and working effectively with the client in front of us, as it can be easy to retreat to manualised models or approaches when we are feeling overwhelmed by the work. More research with survivors is important, as long as the research has survivor involvement in the planning and delivery of it.

Any thoughts on the Home Office and the culture of disbelief and how that damages people seeking safety here?

I think the most challenging part of the work for me is working with the impact of the Home Office decision making on clients. Amnesty’s research on HO decision making exposes a badly administrated system that makes poor decisions and I have seen how harmful such decisions are and the potential they have to re-traumatise many survivors. As activists and therapists, we must speak out about the impact of this culture of disbelief on our clients. I am outraged daily by some of the decisions I see, and by the threatening language contained in some of the HO letters. We have tried to reflect this aspect of work in the book, as supporting survivors to recover from the impact of the asylum process can be at the heart of the work.

I am now working part time for a refugee organisation and am planning to become more involved in campaigns against detention, as the threat of detention hangs over our clients from arrival and is so harmful to a survivor’s mental health and impedes recovery. There is some great campaigning at the moment around ending indefinite immigration detention.

Thank you for buying the book and for your kind words. You are right that the work can have a significant impact on us as therapists, both positive and negative. Regular supervision, opportunities for training and clinical reflection are so important. Equally important is informal day to day support. I know that what made the difference for me was not just good clinical supervision, but the chance to come out of a difficult session and know that a colleague would be there to hear my outrage and sadness. We must create organisational cultures that enable this form of informal support to flourish, where staff feel valued day to day and can lean on each other during the various crises that form part of this work.

I’ve got the book and I love it and am so pleased that the client's lives and stories are so central to each chapter. it's not a distant academic book. we know some staff burn-out from the pressure of the work. I hope the book will help them and raise the quality of support for survivors

Thank you for buying the book and for your kind words. You are right that the work can have a significant impact on us as therapists, both positive and negative. Regular supervision, opportunities for training and clinical reflection are so important. Equally important is informal day to day support. I know that what made the difference for me was not just good clinical supervision, but the chance to come out of a difficult session and know that a colleague would be there to hear my outrage and sadness. We must create organisational cultures that enable this form of informal support to flourish, where staff feel valued day to day and can lean on each other during the various crises that form part of this work.

I'm also thinking that to work appropriately/helpfully it must surely be of vital importance to understand something of the culture and lifestyles of the people you work with?

It is important to prepare ourselves for this work by reading up on the country, its culture and its socio-political history as well as the situation for women/LGBT people etc. I have worked with survivors now for a long time and have learnt so much from my clients about their countries/cultures and can sometimes sense the reassurance survivors feel when I know about torture in a country or seem familiar with a country’s culture/structure etc. We have, of course to balance this with being comfortable with not knowing, and learning about the very particular world of the client in front of us. It can be a difficult balance to achieve. It is tiring for a survivor to find themselves explaining to their therapist about the situation in their country and it can create a barrier and slow down engagement.

So what training/info do you feel is crucial in order to work appropriately for each person in this client group?
Is it necessary to know the client's refugee/asylum status in order to work with them? If so, is this an ethical requirement?

I think therapists need to have researched about the asylum process and know what support is available in general for people seeking asylum, both in terms of Home Office support arrangements but to also know what services are in your area to offer advice/destitution relief/legal services.

I think it is important to know when an individual came to the UK, but vital to know where they are in the asylum process. It is interesting that you ask whether it should be an ethical requirement and it’s a good point! I advise in the book that it is important to ask this question before embarking on working with someone. The therapist needs to know if their client is safe. If the therapist is not aware their client is seeking asylum, it also means that the therapist is unaware of the huge challenges and stresses in that individual’s life. It is hard to imagine how a therapist could be effective if they were not aware of the vulnerability of any individual who is seeking asylum in terms of upcoming HO or Tribunal decisions/housing/separation from family etc. 

There aren’t many agencies where the long-term work that is needed can be provided. Any thoughts on this and on funding for this work?

It is shocking how we have reached a position in the therapy sector where long term therapy in both the voluntary and statutory sector is increasingly hard to find. Often it can be found in third sector services, but in many cases, these organisations do not have the funding to provide interpreters so may not be accessible to refugees. Fundraising for long tem therapy is also getting harder as funders like to see recovery rates and seem to want more for less, so we are in culture where long term work with survivors with complex needs is less available. I think we need to reclaim the field, as what we know as therapists is that for many people, medium – long term work is required, although of course not always. Many survivors will benefit from short term support, but should have the right to rehabilitation, which should include access to long term therapy.

I imagine that the support and encouragement and learning you all find within your group is vital to this work. and to your well-being working in this field. It must be very positive and a great feeling of mutual commitment.

It was and is! – I managed a dynamic and skilled team at a rehabilitation centre for 14 years and we created an environment of mutual support, and found opportunities regularly to reflect together as a team and ensured that we had the right structures in place to support therapists in their day to day work. There is something very special about embarking on an endeavour where you all feel passionate about the work and share similar values and beliefs. The refugee sector is an inspiring place to work and I am experiencing the same feeling of solidarity at my current refugee org as I did in my work with survivors in the North West.