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Last Updated on September 19, 2023 by It’s Complicated

In this episode of It’s Complicated, we speak with US therapist, Jesse Harbaugh about the nuances and challenges of therapy with asylum seekers and refugees. Jesse has worked with refugees and asylum seekers extensively in the US and since moving to Berlin she has been regularly volunteering at temporary housing shelters. From Jesse’s perspective, psychotherapy is not always compatible across cultural divides. To a person coming from a non-western background the value of therapy might not be immediately apparent and even notions such as “trauma” could be presumptuous or misleading. In this episode, we will discuss these topics to reveal some of our western assumptions in pursuit of more globally compatible psychotherapy.

Reece Cox:
Jesse, you’ve been working with the subject of mental health in asylum seekers and refugees since writing your Ph.D. thesis, is that correct?

Jesse Harbaugh:
That’s right.

To give our listeners a good idea of who you are and the work you do, can you tell us a little bit about your dissertation?

The title of my dissertation was, “Power, Multicultural Competence, and Trainees’ Preparation for Treating Survivors of Torture.” It was a qualitative study that looked at mental health trainees – psychologists, social workers, mental health counselors across the U.S. – who were working with refugees and asylum seekers in clinics designated to treat survivors of torture.

We looked at moments in their therapy where they felt they had arrived at an impasse, and we analyzed those and looked at how their training had not been adequate in preparing them for those moments and what was happening in terms of power dynamics in those moments of impasse and in trying to understand from different perspectives what was happening in their work with asylum seekers.

When it comes to your practice now, for example, what is necessary to take into account or what extra training is necessary when working with somebody who is a refugee or asylum seeker as opposed to someone who is not?

What I found in my research and while interviewing trainees who were working at centers treating people who had experienced torture or had refugee status was their difficulty knowing how to understand the gap in their lived experiences. The fact that they had come from a western embedded perspective and that they are interacting with a person who comes from a very different worldview made it difficult to know how to come across as accessible or explain what the therapeutic process was. It was difficult for the trainees to know what to do with using clinical diagnoses when working with a person who has no assumptions about what the therapeutic process was or what a therapist is.

We explored moments where they applied a medical model or clinical diagnosis to what they were seeing in the client and how that tended to shut down the person’s narrative with a refugee background or migration background, even a post-migration background. Being able to discuss that background was hindered by a heavy-handed application of clinical rubric that the clinicians were learning in school, but they weren’t really sure how applicable it actually was when they were doing the work with asylum seekers.

If I’m understanding you correctly, as a practitioner, it’s not just knowing the topical details about a culture that makes you able to interact with someone from that culture. That, in fact, there’s a lot of assumptions there. You’re still assuming that everybody knows what psychotherapy is and that it’s a good thing, and you’re pointing out that maybe that’s not actually true.

Right, and there are other modes of healing that maybe were used in the culture that the person is coming from. That’s something most don’t have the opportunity to learn about in school. In my dissertation, I was primarily interested in the western embedded trainee, their ability to situate themselves in terms of their access, in terms of their privilege, and in terms of a global perspective which accounts how what has been afforded to the therapist differs for their client who has come from across the world. This meeting between these two people is an extremely complex phenomenon with a mass of interacting factors bringing these people together. We’re just talking about individual therapy at this point.

To what extent does the trainee understand where they fit in this hierarchy of access on a global scale? What does that have to do with their meeting at this point in time, the two of them sharing this space now together, one person having the role of client, and the other person having the role of therapist?

This was an interesting question that a lot of people wanted to engage with when I was doing the research. That felt relevant in having to be able to cultivate a worldview, an expanded worldview, through their work with the refugees and asylum seekers.

And to anyone who has practiced or studied or is even very interested in psychology, it is a basic, fundamental principle that regardless of whatever school of psychology you come from, one of the most important things is the therapeutic relationship. I’m imagining that this is the key problem – that a therapeutic relationship is not possible if a mutual understanding of the value of therapy – or even what it is – is not first established.

Right. I think that’s a nice way to put that – the ability to look at the therapeutic relationship and what that’s comprised of. Depending on who you’re working with, different aspects of that relationship can be more salient than others. If you’re working with somebody who comes from a really similar background to yours or has similar privileges to yours – we’re talking unearned privileges like whiteness or cis-masculinity, etc. – to what extent you can talk about those things may be interesting. If you’re working with somebody whose background doesn’t come with the same sort of social privileges that yours as a therapist comes from, or even vice versa, if the therapist comes from a group of people who haven’t been, like a person of color or queer person working with someone who’s white or cis-hetero as the client, then that’s also a disparateness between the two individuals’ level of access – generally speaking, access to resources in and outside of the therapy room.

If those aren’t addressed, then it can be difficult to build a sense of trust and a sense that you can work with this person. From the client’s perspective, can that person really work with you and not hold judgment over you, can they understand exactly who you are and what has shaped you without pathologizing you? I see it as an ability to make space for your client by knowing what you might bring because of your social background, i.e., the intersecting aspects of our identity that we bring to our work as therapists, knowing what those are, and knowing how those can obscure our view of people who we’ve been taught to not value as much as those who look like us.

It’s really just talking about these unconscious biases about people whose backgrounds are mildly different or quite different from ours, linguistically different, racially different, economically different, etc. from ours.

In the case with working with refugees and asylum seekers – people who come from parts of the world that, for most of us, have not been raised to value or to know or see accurate representations of – we’re working with someone from a place that we have very scant information about. We might have picked up our knowledge of their culture unconsciously from popular culture, from National Geographic, from all these problematic sources – to put it one way. Further, the person sitting across from us is likely unaware of all of these things.

It is important for us, as therapists, to be able to understand and own our assumptions. This entails understanding how our perspective maybe completely skewed and flawed and, in fact, that our biases could possibly even be impediments to our ability to humanize and see the person, see the human being, who is in our therapy room.

And, that, on the most basic level, knowledge is necessary for empathy, to build empathy.

Knowledge is useful and also an awareness of what you don’t know – humility. An understanding of where the boundaries of your knowledge about people in other parts of the world, where that knowledge ends.

You’ve written previously in a blog post for “It’s Complicated,” that terms we would typically hear in a diagnostic context like PTSD or even trauma, can be problematic in, say, a therapy session with somebody who is a refugee or asylum seeker. Why are terms like “trauma” or “PTSD” to be avoided in these cases?

I think for some people who are familiar with the term “trauma,” and who come from western backgrounds, maybe similar to mine, it might feel validating to have your experience described as “trauma.” But for other people who have not heard this term before, who are coming into an already western model of medicine and even psychotherapy, the application of this word can possibly eclipse the individual’s ability to authentically describe and spontaneously find words for their own experience.

Applying the word “trauma” may make it difficult to understand even the political aspects of somebody’s experiences or the cause of somebody’s flight. To some extent, trauma can obscure an important political reality that the individual was dealing with and that is, ultimately, important in their ability to, first, conceptualize what happened and, then, to even heal from it.

There is really interesting research by the psychologist, Başoğlu, wherein he compared political activists who had been tortured in Turkey with people who are not political activists but who were also tortured. He found that the political activists, because of their political analysis, had shorter-lived and less severe symptoms, symptoms that we would typically ascribe to PTSD.

I have to think that there’s something about being able to really be in charge of what happened without needing a medical narrative involved, but having a political narrative. It’s actually shown in research to aid in one’s resilience, to aid in one’s healing from torture.

I don’t think that labeling something as “trauma” is always necessary for some people outside of our western context. It isn’t as important, isn’t as integral to their healing process as it is for others.

I had never considered, especially in this context, how a word or a diagnostic word, in particular, can change somebody’s relationship to their experience

If you are traumatized from torture, and that’s the focal point then the other details fall out of the picture. That’s a much more passive way of viewing such a situation. I.e., something happened to you rather than you suffered thought something in order to strive for a goal. That’s a very, very different narrative, and I never considered the power of that in such a direct way.

Ultimately, having an understanding of the context and what’s motivating other people to do what they did to you. It’s like a means to a political end.

I think I was really struck by that research, too. The healing power of having a political analysis is compelling to me. A really interesting way that not seeing this issue of having to flee one’s country or being tortured for political, ethnic, or a number of reasons, understanding how those aren’t just the domain of psychology but much, much broader than psychology.

I think that we’re really aided in our work with refugees. We’re aided by a critical and political analysis of not just the person we’re working with but also ourselves and the way we impact one another even though we come from very different parts of the world. It goes back to the therapeutic relationship.

And another essential facet about therapy is building a personal narrative through the therapy process. I can understand that if a therapist doesn’t know how to connect on the terms of the person they’re working with, then that person’s narrative is co-opted into a western context that runs the risk of being an alienating clinical experience rather than a healing one.

Right. So, then, as the therapist, you’re going into unknown territory, you’re stepping outside of what your training has been, you’re stepping outside of understanding things diagnostically, clinically. Things are not organized in predictable ways anymore and that can be anxiety-provoking. Especially if you’re working with someone who’s feeling flooded and overwhelmed with anxiety and having nightmares and all these kinds of things. And for the therapist, it can really take them to this raw, unpredictable place.

In the case of the therapists I interviewed while writing my dissertation, ultimately that ability to step out of the medical model – the clinical psychology model – and into something that’s unknown but ultimately led by the client, it helps the survivor to feel more connected with the therapist on a human level and to feel like they can continue talking. The therapist can more easily encourage them to keep speaking and to make sense of their experiences in the context of a person listening to and caring about what they had to say.

They were able to take authorship of their own lives leading to a deepening connection with the therapist. This is one of the important tasks of therapy with asylum seekers so that they can, hopefully, start to feel connected to humanity again. For some people, that’s one of the things that was really harmed, their kind of trust and belief in basic goodness in others. To feel like a spark of that coming back, the possibility of that in the therapeutic relationship, I think, is a really huge moment for somebody.

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