From: Chapter 12, Practice Implications for Working with Refugee Women, in Working With Immigrant Women: Issues and Strategies for Mental Health Professionals (© CAMH 2008)
This chapter addresses ethical, moral and clinical dilemmas that mental health professionals face when working with women going through the immigration process. The chapter focuses on the care of women who, for the most part, are Spanish speaking and come from Central and South America. I discuss the experience of refugee women negotiating the health care and immigration systems, the impact of this experience on their mental health and the significant influence that the therapeutic alliance has on successful therapeutic outcomes.
Many of my observations are drawn from my experiences as a clinical social worker at the community mental health clinic of a Toronto hospital. My work is also informed by my own migration experience: I came to Canada from Colombia in 1979 and, like many of my clients, have struggled to navigate the system here as an immigrant.
At the clinic where I work, our services are offered in the several languages spoken by our staff, including Spanish, Portuguese, Chinese and Italian. We provide services to immigrants and refugees from many communities, including Latin America, Africa, the Middle East and China. Clients vary in terms of where they are in the immigration process, either as permanent residents or in the process of achieving “status.”
Our program uses the collaborative care model. Every client is assigned a clinician—who is a trained therapist with a background either in social work, psychology education or occupational therapy and who performs the initial psychosocial assessment—and a psychiatrist, who works with the clinician to complete the psychiatric assessment and develops the treatment in consultation with the clinician. We often refer clients to other clinics and services either in the hospital or in other centres, depending on the complexity of the issues they present (e.g., sleep disturbances, diabetes, neurological problems, addictions). We sometimes also collaborate with other agencies, such as community centres, settlement services and shelters, to form a “circle of care.” This model allows us to offer a holistic approach that goes beyond the medical model to helping clients deal with their concerns.
The women seeking refugee status who come to our clinic are often affected by the same psychiatric illnesses seen in the general population. This chapter highlights the social issues such as poverty, isolation and distrust that are common in this group of women and that are significant stressors that can affect treatment. Of special concern are women fleeing domestic violence, sexual abuse and discrimination based on sexual orientation in their home countries, as well as women sponsoring a same-sex partner who is also a refugee claimant. Case studies toward the end of the chapter highlight four women’s experiences of migration and of accessing services at different levels in the health care system, as well as the consequences of going “underground” with no legal status, no health coverage and no ability to work.
My review of the literature on refugee women was collected by the U.S. Department of Health and Human Services through what was formerly their Center on Women, Violence and Trauma (now the National Center for Trauma-Informed Care). This literature review indicates that while migration per se does not result in higher rates of mental disorders, both immigration and forced migration can affect the well-being and subsequent integration of immigrants into the host society. Women who do attend our community mental health clinic generally come with health issues that arise from their experience as refugees travelling through, in some cases, a number of countries to reach Canada.
Forced migrants often share a traumatic past, including exposure to war-related violence, sexual assault, torture, incarceration and genocide. (Please see Chapter 14 for more information about working with trauma.) It is not uncommon for many women and couples to have to flee their country without the resources to pay for their children’s journey, or the journey may be too dangerous for their children. Their hope is to reunite with the children as soon as possible. Many women are forced to flee their home countries due to gender violence, which in many cases takes the form of sexual assault and other forms of sexual violence perpetrated by government authorities, military personnel and/or insurgents. They may also leave due to domestic or community violence that their governments tolerate or encourage. During flight, they are often re-victimized by pirates, border guards, army personnel, resistance members, male refugees and others. Unfortunately, violence against women and children may not abate upon reaching the supposed safety of an asylum country.
In Practice Implications for Working with Refugee Women, in Working With Immigrant Women