Working with forced migrants: therapeutic issues and considerations for mental health counselors.
Article Type: Report
Subject: Forced migration (Psychological aspects)
Forced migration (Care and treatment)
Psychiatric counselors (Practice)
Authors: Akinsulure-Smith, Adeyinka M.
OHara, Maile
Pub Date: 01/01/2012
Publication: Name: Journal of Mental Health Counseling Publisher: American Mental Health Counselors Association Audience: Professional Format: Magazine/Journal Subject: Health; Psychology and mental health Copyright: COPYRIGHT 2012 American Mental Health Counselors Association ISSN: 1040-2861
Issue: Date: Jan, 2012 Source Volume: 34 Source Issue: 1
Topic: Event Code: 200 Management dynamics
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 282741233
Full Text: The number of forced migrants arriving in the United States continues to increase. To provide effective therapeutic services and interventions for them, it is important for clinicians to understand the unique role that mental health professionals can play in improving the mental health of this diverse population. This article draws attention to the mental health needs of forced migrants and highlights considerations, such as medical, social, legal, cultural, and linguistic factors, that providing services to this population may entail. It also suggests ways in which counselors can actively, competently, and ethically address the social justice issues that impact forced migrants.

**********

In recent years, the number of conflicts, human rights violations, and disasters around the world has increased, leading to the forced migration of innumerable people. These vignettes represent the growing number of individuals who have endured devastating experiences. According to the United Nations High Commission on Refugees (UNHCR, 2009), at the end of 2008 there were approximately 15.2 million refugees and 827,000 asylum seekers worldwide. The United States is among the world's largest resettlement countries (UNHCR, 2009), with the vast majority of forced migrants arriving from developing countries (Sue & Sue, 2008).

This sad reality is reflected in a significant increase in the number of refugee resettlement programs and specialized treatment programs for torture survivors. In the U.S. alone, there are 20 specialized treatment programs for torture survivors and nine voluntary agencies, comprising a network of more than 400 affiliates, that help arriving refugees settle into local communities (Blanch, 2008). These programs offer medical, psychological, legal, and social services.

Mental health counselors (MHCs) need to be prepared to provide clinical treatment to individuals who have immigrated to the U.S. from other cultures and countries. Although they may share similarities, the experiences of people who come to the U.S. voluntarily and those who come involuntarily are distinctly different (Drachman, 1995; Paulson, 2003; Ryan, Kelly, & Kelly, 2009; Wilkinson, 2007). It is important for counselors to know whether the client is a voluntary immigrant or a forced migrant (refugee, asylee, or asylum seeker). An understanding of the core differences between forced migrant groups and other immigrants can sensitize MHGs to the unique aspects of the forced migrant experience and help them provide effective clinical services.

According to the United Nations Refugee Convention (1951), a refugee is a person who, owing to well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable to or, owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence [as a result of such events], is unable or, owing to such fear, is unwilling to return to it. (Article 1, The 1951 Convention Relating to the Status of Refugees, Center for the Study of Human Rights, 1994, pp. 57-58)

Typically, refugee status is determined while the person is still outside the U.S. An asylee, on the other hand, is an individual who has traveled to the U.S. and has applied for and received a grant of asylum. Asylee status acknowledges that the individual has met the definition of a refugee. This allows the asylee to remain in the U.S. and to become eligible for refugee assistance and services. Eventually, refugees may be eligible for citizenship (Blanch, 2008; Drachman, 1995; Sue & Sue, 2008; Wilkinson, 2007). Unlike refugees or asylees, who have official legal status in the U.S., asylum seekers are embroiled in the long and emotionally grueling process of receiving asylee status. They face daunting challenges. For example, they are often denied access to work, education, and social welfare benefits, and they live in constant fear of deportation (Drachman, 1995; Paulson, 2003; Ryan et al., 2009; Wilkinson, 2007).

Forced migrants differ distinctly from other new arrivals in the U.S. in several important ways. Not surprisingly, a voluntary immigrant and a forced migrant have very different experiences in terms of planning the journey, the journey itself, and the conditions of their arrival in the U.S. Unlike immigrants who choose to leave their homelands in search of better economic or educational opportunities and who embark upon planned journeys, forced migrants typically are driven from their countries due to armed conflict, civil and political instability, persecution, or torture. Their departures are often abrupt, unplanned, and carried out in life-threatening circumstances. Forced migrants may flee with few or no belongings and may not have the chance to say goodbye to family and friends (Akinsulure-Smith, 2009; Akinsulure-Smith, Ghiglione, & Wollmershauser, 2009; Bemak & Chung, 2007; Blanch, 2008; Drachman, 1995; Gorman, 2001; Pope & Garcia-Peltoniemi, 1991; Sue & Sue, 2008; van der Veer, 1998).

Along with their forcible displacement, many of the forced migrants with whom the authors have worked have experienced a host of unexpected challenges and devastating losses as well as been deprived of basic needs. Sources of their trauma include atrocities experienced directly or witnessed during armed conflict (e.g., sexual violence, the death or disappearance of family and friends, or the use of force and torture by a repressive regime; Chung, Bemak, Ortiz, & Sandoval-Perez, 2008; Pope & Garcia-Peltoniemi, 1991). The trauma is likely to have been repeated and prolonged and is often purposefully created and perpetuated by other nationals. Forced exile serves to further exacerbate the trauma (Bemak & Chung, 2008; Drachman, 1995; Sue & Sue, 2008; van der Veer, 1998). Additionally, many refugees have had to live in camps for several years before settling in a host country. Finally, the lengthy and traumatizing refugee and asylee experience may be further compounded by the same post-migration stressors that voluntary immigrants face, such as learning a new language and culture, adjusting to new gender and familial roles, accessing services, and learning new skills (Akinsulure-Smith, et al., 2009; Blanch, 2008; Drachman, 1995, Miller, Worthington, Muzurovic, Tipping, & Goldman, 2002; Sue & Sue, 2008; van der Veer, 1998).

While some forced migrants adjust to life in the U.S. without significant difficulties, others are at risk for emotional difficulties such as posttraumatic stress disorder (PTSD), depression, and anxiety, including intense grief as a result of multiple losses. Such difficulties can have serious and devastating consequences for their emotional functioning (Fazel, Wheeler, & Danesh, 2005; Keyes, 2000; Porter & Haslam, 2005). Even after resettlement in a safe environment, many refugees and asylees continue to suffer from multiple physical, psychological, and psychosocial problems (Bemak & Chung, 2008; Fazel et al., 2005; Keyes, 2000; Porter & Haslam, 2005; Sue & Sue, 2008).

Referrals for mental health services may come from diverse sources within the community and legal systems with which a forced migrant interacts. In our experience, requests for services for children and adolescents often come from school personnel. This is particularly likely when the child seems to exhibit problematic or disruptive behaviors. Other referrals come from case workers who are employed by refugee resettlement agencies or community-based organizations.

In the case of forced migrants seeking asylum, immigration attorneys or judges who perceive that an asylum seeker is unable to fully discuss and document persecution may make the referral, especially when such difficulties compromise an asylum claim. In such cases, the request may be for a psychological evaluation of the client's emotional and behavioral functioning, treatment to improve the client's overall psychosocial functioning, or both.

Although not all forced migrants will need mental health services, it is important that MHGs possess a solid understanding of this population's unique needs. This is especially true for those who have experienced devastating losses and traumatic events. To provide ethical, effective, and sustainable services and interventions, MHCs must understand how mental health professionals can help improve the psychosocial functioning of forced migrants. The purpose of this article is to identify the challenges MHCs face in working with a multicultural, multi-traumatized client population with a wide range of medical, psychological, social, and legal needs. We also challenge MHGs to expand their notions of treatment and thereby improve quality of care.

CONTEXTUAL CHALLENGES AND RECOMMENDATIONS

Often the psychological or emotional issues counselors are trained to address are not the most pressing concerns for a forced migrant. This reality can influence the treatment focus and type of intervention. A forced migrant's most urgent needs may relate to a lack of language skills, financial resources, or child care. Other critical needs may stem from stressors related to family separation and unemployment or underemployment (Akinsulure-Smith, et al., 2009; Gong-Guy, Cravens, & Patterson, 1991; van der Veer, 1998). Thus, in this context MHCs face unique challenges that can interfere with the treatment process. If such issues are not addressed, the counselor risks being seen as unresponsive, and treatment will quickly grind to a halt. It is important to note that forced migrants usually need a wide spectrum of services, ranging from housing to educational support and legal assistance. They also often require subsidized, low-cost, or sliding-scale psychological and psychiatric care.

Given the multifaceted needs and challenges of forced migrants, MHCs must familiarize themselves with referral sources within their agencies and other community-based organizations as well as with paraprofessional adjunctive treatment providers. Key referral sources for MHCs are medical, dental, legal, social work, case management, and educational. To heal the whole person requires integrated systems (Smith, 2007).

Medical Challenges

Initially, it is crucial that a medical provider evaluate these clients. They often come from countries with weak healthcare infrastructures and have therefore had limited access to medical and dental services. They may also have sustained injuries due to torture, such as traumatic brain injury as a result of beatings or infections and sexually transmitted diseases due to sexual trauma (Goldfeld, Mollica, Pesavento, & Faraone, 1988). With clients who have so many potential medical problems, it is important for MHCs to have ready access to nearby low-cost or free health providers.

Employment Barriers

Because illegal status precludes the legal right to work, asylum seekers and undocumented persons are often unemployed. Like undocumented voluntary immigrants, forced migrants may encounter difficulty continuing in their chosen careers because of the need to re-credential, or their professions may be obsolete in new cultural circumstances. For example, a yak herder from Tibet will need to find different employment in New York City. These challenges also vary with immigration status. While refugees are given documents for work upon arrival in the U.S., asylum seekers often have to wait through the lengthy asylum process before they are granted work documents, so forced financial dependency on family, friends, and strangers is often an additional stressor. On the one hand, the MHC may be able to help these clients to find new work by connecting them with agencies that offer such services; on the other hand, with clients who are prevented from working by very real legal restrictions, the challenge is to help them work through the long and frustrating process.

Language Barriers

Language barriers contribute to economic hardship, limit acculturation and socialization, and may impede general functioning. Specifically, they interfere with the ability to socialize and to obtain work, food, shelter, health insurance, and transportation. Therefore, MHCs must be aware of free or affordable English as a second language (ESL) courses from beginner to advanced. They must also be knowledgeable about the availability of free or low-cost preparatory classes for the Graduate Equivalency Diploma (GED).

Language barriers can also significantly complicate treatment (Akinsulure-Smith, 2007; Gong-Guy et al., 1991; van der Veer, 1998). The selection of interpreters who are both linguistically competent and able to maintain appropriate boundaries in a mental health setting is crucial. It is essential to support interpreters with a host of tools, including competence assessment screening, training to orient them to clinical work with forced migrants, in vivo feedback, regular written and oral formal assessments about their work as interpreters, and venues in which to process their experiences. Training is essential to cover common issues that arise related to language, setting the therapeutic frame, and addressing boundaries. Training must also acknowledge the role of culture, transference and counter-transference, and vicarious trauma (Akinsulure-Smith, 2004; Haenel, 1997; Marcos, 1979; Paone & Malott, 2008).

Social Services

A social worker or case manager can immediately connect the client, regardless of legal status, to a network of services, such as shelters, food pantries, clothing donation centers, and language programs. Social workers and case managers can also refer clients to job training programs and assist with Medicaid and Medicare applications. In fact, some treatment centers for forced migrants refer to meeting daily client living needs as "social treatment," which they consider integral to physical and psychological treatment (Shrestha & Sharma, 1995, p. 32).

Legal Challenges

In addition to their physical and mental health care needs, many forced migrants must deal with extremely complex legal issues, such as applications for asylum, family petitions, and work visas. Asylum seekers in particular face an arduous legal process. These clients hope to be granted asylee status because meeting the definition of a refugee would make them eligible for refugee assistance and services and allow them to remain in the U.S. and become legal residents (Wilkinson, 2007). When interpreting a client's legal status, it is vital to have an expert referral source who is familiar with the different application processes. Referrals to pro bono lawyers are also important.

While MHCs must possess a working knowledge of the legal aspects of immigration, there is no single source from which to gather this information. To ensure that an asylum-seeking client fulfills all requirements and meets all deadlines throughout this complicated process, it might be useful for MHCs to obtain permission from clients to speak with their attorneys. Important questions to ask a lawyer would be: Has the client filed an Affirmative Asylum Application with the Bureau of U.S. Citizenship and Immigration Services within one year? Has the client had an interview with the asylum officer and what was the outcome? For an individual who has been referred to immigration court, what is a Master Calendar Hearing and when is the client's hearing? Has the client had an Individual Merits Hearing? Was the client denied and, if so, has the client appealed to the Board of Immigration Appeals?

It is also important to be aware of any expectations clients and their attorneys may have of the MHC by asking: Am I expected to prepare a psychological affidavit testifying to the client's emotional and behavioral functioning? If so, will I be expected to testify in court as a fact or expert witness? If so, will the judge presiding over the case allow me to testify over the telephone? Will the client's attorney prepare me for cross-examination by the government attorney?

In these legal interactions the MHC often takes on the roles of client advocate and attorney educator--educating the attorney about the client's psychological experiences. As court dates near, regular communication with the attorney may become part of the treatment but may also take the treatment hostage: The therapeutic process may be pushed aside if the attorney, in preparing for the hearing, asks the client repeatedly to provide detailed accounts of past traumatic experiences. The attorney may not understand that when clients have experienced life-threatening and overwhelming trauma, there is the potential to retraumatize and overwhelm them, intensifying symptoms of PTSD, anxiety, and depression. In such cases, the MHC's role is twofold: help the attorney to better understand the client's experience, and help the client to deal with what may seem an overwhelming reluctance to continue with the immigration process. In our experience, it is important to be aware of the fact that asylum seekers may experience mood swings and symptom intensification not only as the asylum hearing approaches but also afterward (e.g., a sense of disappointment). Offering concrete coping tips drawn from cognitive-behavioral models, such as psychoeducation, trauma education, stress management skills training, and progressive muscle relaxation can help relieve symptoms (Akinsulure-Smith, 2009).

COUNSELING CHALLENGES AND IMPLICATIONS

Working with Interpreters

The use of interpreters is integral to working with an asylee and refugee population whose primary language the counselor does not share. In such a case treatment is filtered through another person's understanding, linguistic skills, and emotional composition, which can make working with an interpreter challenging and complex. There are several effective interventions that help lay the foundation for an effective working relationship. Meeting with the interpreter before the initial client session is the first step in setting the frame for the interpreter (Paone & Malott, 2008). It is important for the counselor to request verbatim interpretation; this approach normalizes the need to break language up into manageable lengths. The counselor should set some boundaries, normalize that there is likely to be feedback from the counselor to the interpreter during a therapy session, and communicate recognition that the job of interpreter is both cognitively and emotionally challenging (Akinsulure-Smith, 2004; Marcos, 1979; Shleinger, 2005). Meeting to discuss these matters before clinical work begins can set a warm, welcoming, and grateful tone that paves the road for a smooth working relationship that tolerates boundaries and mutual feedback in an emotionally charged context.

After that pre-meeting, the first session with counselor, interpreter, and client offers an opportunity to clarify the interpreter's role with the client. Transparency in terms of seating arrangements, eye contact, confidentiality, and the expectation that all speech will be interpreted instills a sense of safety and control for the client (Paone & Malott, 2008; Pentz-Moller & Hermansen, 1991a; Pentz-Moller & Hermansen, 1991b).

In sum, counselors who work with forced migrants must be willing to engage with the complexities that arise when working with interpreters. To assess and process the effects on treatment of using an interpreter, it is essential to reinforce the therapeutic frame in the pre-session meeting, the initial session, and regularly throughout therapy. Screening, training, and supportive and evaluative mechanisms must be in place to ensure that the interpreter's needs and interpreting standards are met. Acknowledging the role of culture when working with forced migrants must apply to all people in the treatment room (Haenel, 1997). There are a number of resources for guidance to MHCs who are unfamiliar with working through interpreters (see, e.g., Akinsulure-Smith, 2007; Farooq & Fear, 2003; Paone & Malott, 2008; Pentz-Moller, 1992; Pentz-Moller & Hermansen, 1991a, 1991b).

Counseling Interventions

Many forced migrants come from collectivistic cultures that prioritize interpersonal relationships and social networks. These cultures may take a holistic approach to mental health. Most forced migrants are unfamiliar with the Western concepts of psychotherapy and talking with a complete stranger. Rather than seek professional help, they would have gone to religious leaders, community elders, or family members for assistance or support (Akinsulure-Smith, et al., 2009; Bemak & Chung, 2008; Fabri, 2001). Now, within their new cultural context and perhaps separated from family, they may not know where to turn for help or understand how help is offered.

Counselors might consider allowing clients to teach them about what healing means in their culture of origin. What support systems would they have used in their home country? What role does culture play in the healing process, and who might facilitate that process? Partnering with local refugee community groups can offer MHCs vital resources for learning about culture and history and help to build a client's trust. MHCs might also consider integrating paraprofessionals into the healing process as adjuncts. Religious leaders and cultural healers can serve as resources, educating MHCs on how to address cultural nuances as they become part of the client's support network.

Since Western therapeutic practices are alien to the cultures of many forced migrants, it is important to consider how MHCs might adapt the traditional U.S. therapeutic culture to help refugees and asylees on the journey toward adjustment, adaptation, and healing. Drawing from the integrative perspective described by Corey (2009), some of these adaptations might include empowering clients through pychoeducation, giving them meaningful information about the therapeutic process, and discussing respective roles and expectations in mental health encounters. Thus, clients should be given a detailed explanation of the nature and duration of treatment (Gong-Guy, et al., 1991; Smith, 2007).

While many therapeutic interventions are designed to heal or reduce the impact of trauma, it is important to recognize that very few of these models address the specific needs of forced migrants (Blanch, 2008; Smith, 2007). Although it is beyond the scope of this article to detail all the evidence-based and practice-based therapeutic interventions that can be used, the research and efficacy of treatments with forcibly displaced populations is evolving, and counselors working in the field have adapted and combined interventions to provide effective counseling. Interventions have been developed to address the needs of forced migrants at the individual (Charles, 2009); family (Porterfield & Akinsulure-Smith, 2007; Walter & Bala, 2004; Weine et al., 2006); and group levels (Akinsulure-Smith, 2009; Bolton et al., 2007; Fishman & Ross, 1990; Stepakoff et al., 2006), drawing from a range of orientations, including the psychodynamic (Drozdek & Wilson, 2004; Wilson, 2004b); supportive (Wilson, 2004a); cognitive-behavioral (Schulz, Resick, Huber & Griffin, 2006); narrative (Neuner, Schauer, Klaschik, Karunakara, & Elbert, 2004); expressive arts (Rousseau & Heusch, 2000; Rousseau, Lacroix, Bagilishya, & Heusch, 2003); and movement (Harris, 2007) therapies. Many of these interventions also incorporate such mind-body techniques as meditation (Shrestha & Sharma, 1995), deep breathing exercises, progressive muscle relaxation, and visualization to help clients find ways to control debilitating symptoms (Akinsulure-Smith, et al., 2009).

Referrals to community-based organizations may offer a way to expand the group therapy concept to a less formalized environment. For example, forced migrant clients will often join religious community groups, political activist groups, ethnic niche groups, and sexual-orientation groups, both independently and at the suggestion of treatment providers. Informal community support groups and formal psychotherapy groups have both been effective in treating forced migrants (Akinsulure-Smith, et. al, 2009; Smith, 2007).

While traditional training in psychotherapy techniques and orientations is helpful and appropriate, to address the diverse needs of this unique population MHCs must use treatment models flexibly and consider integrative methods when deciding which orientations and techniques are best suited to the presenting problems and needs of their particular population.

Complex Multicultural Issues

The major theories in counseling psychotherapy (e.g., psychoanalytic, cognitive behavioral, and client-centered) are based on White, Eurocentric, Western cultural norms (Corey, 2009; Sue & Sue, 2008). With forced migrant populations, cultural issues related to race, ethnicity, religion, gender, and social class can have very serious meaning. Through our work, we have come to learn that often these components of identity are the very factors that led to the client's forced migration. MHCs must be able to examine how important such factors are in a client's life and experiences as well as in their own lives. They must also be willing to explore thoroughly the unexpected ways such factors can impede or enhance the therapeutic process. For example, a trainee found himself invalidating the experience of an Iraqi interpreter, who had been persecuted by Americans while in Iraq, because the trainee was not open to the notion that the torture the client experienced was at the hands of the trainee's own nation. The trainee's identity generated a bias that needed to be explored in supervision to ensure that the therapeutic alliance was not damaged and to ensure that a therapeutic repair process could begin.

Although MHCs may be trained to deal with the multicultural experiences of a U.S. population, they may not be familiar with the cultural norms and values or the geopolitical experiences of the forced migrant's country of origin. Yet this information is essential to the ability to respond effectively with cultural sensitivity and competence when working with such clients. Although mental health counseling programs, internships, and continuing education courses emphasize cultural competence as an essential area of clinical training, there is still a need to train MHCs about the unique cultural experiences of forced migrants.

Transference and Countertransference

It is every counselor's duty to work continuously to understand the multifaceted, complex, and ever-changing transferential and countertransferential pulls, enactments, and boundary issues that are inevitable when working with traumatized people. Exploration should take place both in and outside the treatment room, and individual or group supervision can each prove valuable for discussing these pulls, enactments, and boundary issues.

Transference is typically viewed as the displacement of past relational experiences into the present relational situation. For example, during an individual psychotherapy session, a 44-year-old Congolese woman, who had been imprisoned, interrogated, severely beaten, and raped, talked about not wanting to discuss her trauma history. The counselor reassured her that sharing her experience would be her choice, not the counselor's. After the client disclosed her trauma she reported feeling "better." Yet, when the client returned, she told the counselor that she felt "violated" by the counselor pushing her to disclose.

The client was able to identify in therapy how her past experiences led her to feel as if she again was being disavowed of volition, control, and safety. The counselor responded to the situation with her own countertransference response and assumed that her inadequacies as a trainee accounted for making the client feel violated. The counselor's response was to apologize to the client, thus missing the opportunity to sit with and explore the client's pervasive feelings of mistrust, violation, and anger that influenced her interactions with others. In this example, the treatment would have benefited if the counselor had attended to her own feelings of ineptness and then internally explored questions such as, "Does the client feel this way because of her experience in the world? Did I misstep clinically? Or is this situation an intersection of the two?" Clearly it is crucial for MHCs to honestly explore their countertransference so they can better identify and attend to the client's transference and needs.

Analysis by an MHC of transference and countertransference issues comes slowly and must be nurtured by supportive, open, and challenging supervision. Supervisors should help tease out what in the clinical setting is coming from the counselor and what is coming from the client. Approaches such as psychodynamic ones can help heighten MHCs' awareness of transference and countertransference issues (Danieli, 1994). In general, open dialogue about cultural differences is crucial to identify the "culturally determined countertransference" (Bustos, 1998, p. 342) that is inherent when counselor and client are from different cultural backgrounds. Additionally, in sessions with the counselor the supervisor can help model transferential exploration by exploring the supervisor's countertransference to the client and the counselor (Jacobs, 1991). If an interpreter is being used, it is important to expand the frame of transferential exploration to include the client's countertransferential reaction to the interpreter.

It is also important to look at the range of possible enactment paradigms that are common in working with forced migrants, such as powerful/powerless, savior/saved, victim/perpetrator, and abandoner/abandonee (Eisenman, Bergner, & Cohen, 2000). Mordecai (1991) wrote that, "It may even be wise for counselors of abused or abandoned clients to ask themselves early in the process, 'How is this client likely to involve me in an act of abuse or abandonment?'" (p. 260).

Listening for transferential pulls and enactments and then ensuring that they are addressed in supervision will heighten any counselor's awareness of therapeutic boundary violations and boundary confusion. For example, a counselor may feel inadequate about his or her cross-cultural knowledge and try to become a country expert rather than allowing clients to become teachers of their own cultural experiences, which would increase their feelings of control and mastery (Tizon, 2001). Another common boundary issue is not exploring client gift-giving because of the counselor's discomfort about the class differences that are common between MHGs and their clients. For instance, one trainee did not realize that she had accepted a dozen red roses from a client without being curious about the meaning of the gift until she explored the issue in supervision and, subsequently, with the client. Some other boundary issues include glossing over a client's discriminatory beliefs because the client has been subjected to discrimination, and working overtime during the holidays because of the MHC's guilt over the client's separation from family. Common boundary transgressions are allowing children into sessions due to a client's lack of financial resources and social support, and counselor denial and avoidance of termination because they do not want to be perceived as yet another person who has disappeared from the client's life. Clearly, this is not an exhaustive list, but it does represent common challenges to boundaries that MHCs face in working with forced migrants.

The transference and countertransference issues and the enactment possibilities are endless in that they reflect the relational experiences of the people in the therapy room. That is why investing tremendous effort in reflecting on transference and countertransference, enactments, and boundary issues is clinically rewarding and will improve care, especially of forced migrants.

Clinician Self-Care

Clearly, work with this population can heavily stress the clinician. Pearlman and Saakvitne (1996) defined vicarious traumatization (VT) as the "transformation in the inner experience of the counselor that comes about as a result of empathic engagement with clients' trauma material" (p. 25). The main symptoms of VT are disturbances in personal identity, world view, spirituality, affect tolerance, fundamental psychological needs, interpersonal relationships, internal imagery, and physical presence in the world (Jenkins & Baird, 2002). According to Pearlman and Saakvitne (1996), verbal exposure to traumatic material can cause changes in a person's cognitive schemas of self and others concerning trust, safety, control, esteem, and intimacy. People are deeply affected, both positively and negatively, by working with traumatized forced migrants.

The first step in minimizing negative effects is to acknowledge the impact of VT and understand that self-care is both prevention and cure of the possible negative effects of working with traumatized forced migrants. The three crucial layers of self-care are organizational, professional, and personal (Bell, Kulkarni & Dalton, 2003; Pross, 2006; Trippany, Kress & Wilcoxon, 2004). Organizational self-care includes being involved with supervision, a reading group, or a process group (Bell et al., 2003). In our experience, professional self-care relates to building relationships and networking through such organizations as The National Consortium of Torture Treatment Programs (http://ncttp.org) and the International Society for Traumatic Stress Studies (http://www.istss.org) through meetings, seminars, conferences, trainings, and listservs. Lastly, personal self-care focuses on individually tailored ways to support oneself while engaged in deeply challenging work. Some examples are consistently getting adequate sleep, physical exercise, and good nutrition; creating transition times (e.g., taking a deep breath, getting coffee, making a personal phone call); and scheduling time to debrief (Norcross & Guy, 2007).

Norcross and Guy (2007) also recommend that MHCs (a) ensure that they have support and time to process with supervisors and peers; (b) share needs with family and friends not just by sharing the de-identified details of the clinical work but also by getting needs for rejuvenation and physical affection met; (c) identify maladaptive coping mechanisms, such as drinking alcohol, and seek healthier outlets, such as engaging in non-work-related activities; and (d) anticipate feelings of guilt, helplessness, emptiness, and rage, as well as rescue fantasies. In such moments, Norcross and Guy further suggested, it is important to have personal support, to acknowledge the limitations of one's role, and to have referral sources for clients who need different kinds of support than what the counselor can offer. Laub (2003) wrote about the counselor as "the listener" who "has to be at the same time a witness to the trauma witness [the client] and a witness to himself" (p. 58). Self-awareness and self-care are lifelong journeys. It is important for all counselors to give priority to both and tailor what works for them in order to have longevity in this work.

For those who work with trauma survivors, Herman (1997) pointed to the importance of a support system for counselors that includes "a safe, structured and regular forum for reviewing ... clinical work" (p. 151). In our work setting, we have found that regular supervision and a peer support group offer safe places to express our reactions and discuss technical and theoretical concerns related to the treatment of forced migrants. It is particularly important to address how trainees are affected by the work, because they are often the least experienced in addressing these issues and not fully enough integrated into the institution to reap the benefits of its support. For example, trainees who are not on-site the day an after-work self-care yoga class is offered are not likely to attend. Therefore, it is imperative that training directors ensure that a continuous confidential process group is available, that all supervisors address vicarious trauma and self-care with those they supervise, that there are trainee staff meetings to assess and normalize vicarious trauma and strategize around self-care, and that didactics, case conferences, and readings also address vicarious trauma and self-care.

CONCLUSION

MHCs who work with forced migrants are obviously challenged to move beyond traditional roles. They have to engage a culturally diverse, often traumatized population. To address diverse needs and provide care that reaches the level of best practices, they must be prepared to wear many therapeutic hats: counselor, educator, expert witness, and advocate. As MHCs we are forced to take on many roles that challenge us to move beyond the traditional boundaries of the profession. This is not to say that counselors should assume the role of medical practitioner, social worker, or attorney. However, they cannot simply sit passively and wait for clients to present their concerns once a week. MHCs have to be active participants in treatment, and that means taking on many additional roles. To work with this population, MHCs must be prepared to work not just within their offices but to engage and collaborate with professionals in the systems, such as the family, school, community, and legal system, that our clients inhabit or interact with.

Recently, in a courthouse only a few blocks from Ground Zero in New York City, a 20-year-old Ukrainian lesbian woman won asylum with the support of her counselor testifying as an expert witness. The judge stated that the client, whom the counselor had treated for three years in individual and group therapy, had won her case because of the affidavit and testimony of the expert witness. The young woman left the courtroom, gave her new wife (another asylee, from Kazakhstan) an enormous hug, and turned to the counselor and simply said, "Thank you for everything."

The client began treatment as an emergency referral due to suicidality. Through intensive psychotherapy after three years she no longer met the criteria for major depressive disorder or PTSD (American Psychiatric Association, 2000). Because of the client's experience of torture in her home country, she had been reluctant to engage in any services that might elicit conversation about her past, but eventually she was successfully referred to an attorney, registered as an international student in a local college, and was convinced, despite intense fear, to go to the LGBT Community Center, where she met her future wife. Her simple expression of gratitude upon winning asylum captures how important it is for mental health care providers to understand the multifaceted ways forced migrants need support in terms of legal, social, educational, psychological, psychiatric, and medical needs in order to make appropriate referrals.

Given the growing number of forced migrants and their complex and multifaceted needs, MHCs must learn about how best to meet the unique mental health needs of these clients. They must also be prepared to move beyond the simple counseling role and become actively involved in advocacy, community outreach, and public policy (Constantine, Hage, Kindaichi, & Bryant, 2007) to address the unique social justice issues. While we are aware that one article cannot comprehensively address the diverse and complex nature of the U.S. forced migrant population, we can begin a conversation about how MHCs can better prepare to provide effective therapeutic services to these clients. The conversation needs to be open and continuous within training programs and training institutions. By acknowledging the specific needs of forced migrants, we can pursue research to expand our treatment knowledge and, most importantly, improve our quality of care.

REFERENCES

Akinsulure-Smith, A. (2004). Giving voice to the voiceless: Providing interpretation for survivors of torture, war, and refugee trauma. The Gotham Translator, 3, 6-7.

Akinsulure-Smith, A. M. (2007). The use of interpreters with survivors of torture, war, and refugee trauma. In H. E. Smith, A. S. Keller, & D. W. Lhewa (Eds.), Like a refugee camp on First Avenue: Insights and experiences from the Bellevue/NYU Program for Survivors of Torture (pp. 83-105). New York, NY: Bellevue/NYU Program for Survivors of Torture.

Akinsulure-Smith, A. M. (2009). Brief psychoeducational group treatment with re-traumatized refugees and asylum seekers. Journal for Specialists in Group Work, 34, 137-150.

Akinsulure-Smith, A. M., Ghiglione, J., & Wollmershauser, C. (2009). Healing in the midst of chaos: Nah We Yone's African women's wellness group. Women & Therapy, 32, 105-150.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Bell, H., Kulkarni, S., & Dalton, L. (2003). Organizational prevention of vicarious trauma.

Families in Society: Journal of Contemporary Human Services, 84, 463-470.

Bemak, F., & Chung, R. C. (2007). Counseling refugees and migrants. In P. B. Pederson, W. J. Lonner, I. G. Draguns, & J. E. Trimble (Eds.), Counseling across cultures (6th ed., pp. 307-324). Thousand Oaks, CA: Sage Publications.

Blanch, A. (2008) Transcending violence: Emerging models for trauma healing in refugee communities. (SAMHSA contract #280-03-2905). Retrieved from http://www.c-r-t.org/content/research/TransViolencepap.pdf

Bolton, P., Bass, J., Betancourt, T., Speelman, L., Onyango, G., Clougherty, K. F. ... Verdeli, H. (2007). Interventions for depression symptoms among adolescent survivors of war and displacement in northern Uganda. Journal of the American Medical Association, 298, 519-527.

Bustos, E. (1998). Psychodynamic approaches in the treatment of torture survivors. In M. Basoglu (Ed.). Torture and consequences: Current treatment approaches (pp. 333-347). London, UK: Cambridge University Press.

Center for the Study of Human Rights. (1994). Twenty five human rights documents. New York, NY: Columbia University,

Charles, L. L. (2009). Home-based family therapy: An illustration of clinical work with a Liberian refugee. Journal of Systemic Therapies, 28, 36-51.

Chung, R. C.-Y., Bemak, F., Ortiz, D. P., & Sandoval-Perez, P. A. (2008). Promoting the mental health of immigrants: A multicultural/social justice perspective. Journal of Counseling and Development, 86, 310-317.

Constantine, M. G., Hage, S. M., Kindaichi, M. M., & Bryant, R. M. (2007). Social justice and multicultural issues: Implications for the practice and training of counselors and counseling psychologists. Journal of Counseling and Development, 85, 24-29.

Corey, G. (2009). Theory and practice of counseling and psychotherapy (8th ed.). Belmont, CA: Brooks/Cole Publishing.

Danieli, Y. (1994). Countertransference, trauma, and training. In J. P. Wilson & J. D. Lindy (Eds). Countertransference in the treatment of PTSD (pp. 368-88). London, UK: Guilford.

Drachman, D. (1995). Immigration statutes and their influence on service provision, access, and use. Social Work, 40, 188-197.

Drozdek, B., & Wilson, I. (2004). Uncovering: Trauma-focused treatment techniques with asylum seekers. In J. P. Wilson & B. Drozdek (Eds.), Broken spirits: The treatment of traumatized asylum seekers, refugees, war and torture victims (pp. 187-219). New York, NY: Brunner-Routledge.

Eisenman, D., Bergner, S., Cohen, I. (2000). An ideal victim: Idealizing trauma victims causes traumatic stress in human rights workers. Human Rights Review, 1, 106-114.

Fabri, M. R. (2001). Reconstructing safety: Adjustments to the therapeutic frame in the treatment of survivors of political torture. Professional Psychology, Research 15, Practice, 32, 452-457.

Farooq, S., & Fear, C. (2003). Working through interpreters. Advances in Psychiatric Treatment, 9, 104-109.

Fazel, M., Wheeler, J., & Danesh, J. (2005). Prevalence of serious mental disorder in 7000 refugees resettled in Western countries: A systemic review. Lancet, 265, 1309-1314.

Fishman, Y., & Ross, J. (1990). Group treatment for exiled survivors of torture. American Journal of Orthopsychiatry, 60, 135-142.

Goldfeld, A. E., Mollica, R. F., Pesavento, B. H., & Faraone, S. V. (1988). The physical and psychological sequelae of torture. Symptomatology and diagnosis. Journal of the American Medical Association, 259, 2725-2729.

Gong-Guy, E., Cravens, R. B., & Patterson, T. E. (1991). Clinical issues in mental health service delivery to refugees. American Psychologist, 46, 642-648.

Gorman, W. (2001). Refugee survivors of torture: Trauma and treatment. Professional Psychology: Research and Practice, 32, 443-451.

Haenel, F. (1997). Aspects and problems associated with the use of interpreters in psychotherapy of victims of torture. Torture, 7, 68-71.

Harris, D. A. (2007). Dance/movement therapy approaches to fostering resilience and recovery among African adolescent torture survivors. Torture, 17, 134-155.

Herman, J. (1997). Trauma and recovery. New York, NY: Basic Books.

Jacobs, C. (1991). Violations in the supervisory relationship: An ethical and educational blind spot. Social Work, 36, 130-135.

Jenkins, S. R., & Baird, S., (2002). Secondary traumatic stress and vicarious trauma: A validational study. Journal of Traumatic Stress, 15, 423-432.

Keyes, E. (2000). Mental health status in refugees: An integrative review of current research. Issues in Mental Health Nursing, 21, 397-410.

Laub, D. (2003). Bearing witness or the vicissitudes of listening. In N. Levi & M. Rothberg (Eds.). The holocaust: Theoretical readings (pp. 57-92). New Brunswick, NJ: Rutgers University Press.

Marcos, L. (1979). Effects of interpreters on the evaluation of psychopathology in non-English-speaking patients. American Journal of Psychiatry, 136, 171-174.

Miller, K. E., Worthington, G., Muzurovic, J., Tipping, S., & Goldman, A. (2002). Bosnian refugees and the stressors of exile: A narrative study. American Journal of Orthopsychiatry, 72, 341-354.

Mordecai, E. (1991). A classification of empathic failures for psychotherapists and supervisors. Psychoanalytic Psychology, 8, 251-262.

Neuner, F., Schauer, M., Klaschik, C., Karunakara, U., & Elbert. T. (2004). A comparison of narrative exposure therapy, supportive counseling, and psychoeducation for treating posttraumatic stress disorder in an African refugee resettlement. Journal of Consulting Clinical Psychology, 72, 579-587.

Norcross, J. C., & Guy, J. D., Jr., (2007). Leaving it at the office: A guide to psychotherapist self-care. New York, NY: Guilford Press.

Paone, T., & Malott, K. (2008). Using interpreters in mental health counseling: A literature review and recommendations. Journal of Multicultural Counseling and Development, 36, 130-141.

Paulson, D.S. (2003). War and refugee suffering. In S. Krippner & T. M. McIntyre (Eds.), The psychological impact of war trauma on civilians: An international perspective (pp. 111-122). Westport, CT: Praeger.

Pearlman, L. A., & Saakvitne, K. (1995). Trauma and the counselor: Countertransference and vicarious traumatization in psychotherapy with incest survivors. New York, NY: W.W. Norton.

Pentz-Moller, V. (1992). The ethics and techniques of interpreting. Torture Supplementum, 17-19.

Pentz-Moller, V., & Hermansen, A. (1991a). Interpretation as part of the rehabilitation. Torture, 3, 9-12.

Pentz-Moller, V., & Hermansen, A. (1991b). Interpretation as part of the rehabilitation, part II. Torture, 3, 5-6.

Pope, K. S., & Garcia-Peltoniemi, R.E. (1991). Responding to victims of torture: Clinical issues, professional responsibilities, and useful resources. Professional Psychology: Research and Practice, 22, 269-276.

Porter, M., & Haslam, N. (2005). Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons. Journal of the American Medical Association, 294, 602-612.

Porterfield, K., & Akinsulure-Smith, A. (2007). Therapeutic work with children and families. In H. Smith, & A. Keller (Eds.), Like a refugee camp on First Avenue: Insights and experiences from the Bellevue/NYU Program for Survivors of Torture (pp. 299-335). New York, NY: Bellevue/NYU Program for Survivors of Torture.

Pross, C. (2006). Burnout, vicarious traumatization and its prevention. Torture, 16, 1-9.

Rousseau, C., & Heusch, N. (2000). The trip: A creative expression project for refugee and immigrant children. American Journal of Art Therapy, 17, 31-40.

Rousseau, C., Lacroix, L., Bagilishya, D., & Heusch, N. (2003). Working with myths: Creative expression workshops for immigrant and refugee children in a school setting. American Journal of Art Therapy, 20, 3-10.

Ryan, D. A., Kelly, F. E., & Kelly, B. D. (2009). Mental health among persons awaiting an asylum outcome in Western countries. A literature review. International Journal of Mental Health, 38, 88-111.

Schulz, P., Resick, P., Huber, L., & Griffin, M. (2006). The effectiveness of cognitive processing therapy for PTSD with refugees in a community setting. Cognitive and Behavioral Practice, 13, 322-331.

Shleinger, Y. (2005). Vicarious traumatization among interpreters who work with torture survivors and their counselors. (Doctoral dissertation). Retrieved from the Chicago School of Professional Psychology. (URL 3196278)

Shrestha, N., & Sharma, B. (1995). Torture and torture victims: An annual for medical professionals. Katmandu, Nepal: Center for Victims of Torture, Nepal (CVICT).

Smith, H. E. (2007). Treatment techniques and priorities: A psychological approach to the patient. In H. E. Smith & A. Keller (Eds.), Like a refugee camp on First Avenue: Insights and experiences from the Bellevue/NYU Program for Survivors of Torture (pp. 26-166). New York, NY: Bellevue/NYU Program for Survivors of Torture.

Stepakoff, S., Hubbard, J., Katoh, M., Falk, E., Mikulu, J-B., Potiphar, N., & Omagawa, Y., (2006). Trauma healing in refugee camps in Guinea: A psychosocial program for Liberian and Sierra Leonean survivors of torture and war. American Psychologist, 61, 921-932. doi:10.1037/0003-066X.61.8.921

Sue, D. W., & Sue, D. (2008). Counseling the culturally diverse: Theory and practice (5th ed.). Hoboken, NJ: Wiley & Sons.

Tizon, O. P. (2001). Dreams and other sketches from a torture survivor's notes. Professional Psychology, Research &r Practice, 32, 465-468.

Trippany, R. L., Kress, V. E. W., & Wilcoxon, S. A. (2004). Preventing vicarious trauma: What counselors should know when working with trauma survivors. Journal of Counseling fir Development, 84, 31-37.

United Nations High Commissioner for Refugees. (1951). Article 1, The 1951 Convention Relating to the Status of Refugees. (United Nations General Assembly A/CONF.2/2/Rev.1) Retrieved from http://unbcr.org.au/unhcr/images/convention%20aud%20protocol.pdf

United Nations High Commissioner for Refugees. (2009). 2008 global trends: Refugees, asylum-seekers, returnees, internally displaced and stateless persons. (FICSS Publication Global Report 2008). Retrieved from bttp://www.unhcr.org/4a375c426.html

van der Veer, G. (1998). Counselling and therapy with refugees and victims of trauma (2nd ed.). New York, NY: Wiley & Sons.

Walter, J., & Bala, J. (2004). Where meanings, sorrow, and hope have a resident permit: Treatment of families and children. In J. P. Wilson & B. Drozdek (Eds.). Broken spirits: The treatment of traumatized asylum seekers, refugees, war and torture victims (pp. 487-519). New York, NY: Brunner-Routledge.

Weine, S., Feetham, S., Kulauzovic, Y., Knafl, K., Besic, S., Kelbic, A., ... Pavkovic, I. (2006). A family beliefs framework for socially and culturally specific preventive interventions with refugee youths and families. American Journal of Orthopsychiatry, 76, 1-9.

Wilkinson. J. (2007). Immigration dynamics: Processes, challenges, and benefits. In H. Smith & A. Keller (Eds.), Like a refugee camp on First Avenue: Insights and experiences from the Bellevue/NYU Program for Survivors of Torture (pp. 65-81). New York, NY: Bellevue/NYU Program for Survivors of Torture.

Wilson, J. (2004a). Empathy, trauma transmission, and countertransference in posttraumatic psychotherapy. In J. P. Wilson & B. Drozdek (Eds.), Broken spirits: The treatment of traumatized asylum seekers, refugees, war and torture victims (pp. 277-316). New York, NY: Brunner-Routledge.

Wilson, J. (2004b). Posttraumatic treatments: Guidelines for practitioners. In J. P. Wilson & B. Drozdek (Eds.), Broken spirits: The treatment of traumatized asylum seekers, refugees, war and torture victims (pp. 181-185). New York, NY: Brunner-Routledge.

Adeyinka M. Akinsulure-Smith is affiliated with the City College of New York and the Bellevue/NYU Program for Survivors of Torture. Maile O'Hara is in private practice in New York City. Correspondence regarding this manuscript should be sent to: Adeyinka M. Akinsulare-Smith, Ph.D., Department of Psychology, The City College of New York, New York, NY 10031.E-mail: aakinsulure-smith@ccny.cuny.edu
Ms. Q, 26, is a single Venezuelan political activist. During her
   intake assessment for treatment, she reported numerous difficulties
   in her daily functioning. Many of these stem from a host of
   traumatic events that led her to seek safety in the United States.
   Among the experiences she described were a brutal gang rape, a
   narrow escape from members of the opposition who attempted to
   kidnap her, anonymous telephone death threats, being chased by
   masked men with guns, and witnessing the murders of friends and
   fellow students at political protests. Eventually Ms. Q's fear for
   her life became so overwhelming that she was forced to flee
   Venezuela, leaving behind family, friends, and belongings.

   Mr. J, 38, is a married Sierra Leonean. During the Sierra Leonean
   civil war, he witnessed many atrocities. After razing his family
   home to the ground, rebels abducted Mr. J. They held him captive
   for two years, tortured him repeatedly, and made him work for them.
   On several occasions, he was forced to watch rebels chop the hands
   off innocent people and rape young women. Mr. J has not seen his
   wife or their three children since the night their home was burned
   down. He struggles with the uncertainty of whether his family is
   dead or alive.
Gale Copyright: Copyright 2012 Gale, Cengage Learning. All rights reserved.