Feature Article:

Jan Williamson has worked as a consultant for children's issues at the emergency level for years. She has co-authored a field guide for Save the Children/US, compiled an annotated bibliography on alternative care for children orphaned by HIV/AIDS, and completed consultancies to develop ethical standards for information gathering with children and adolescents. She is featured as this month’s VAPT Playmate (see “Meet A VAPT Playmate” for more information about Jan.)

Children and the Refugee Experience: What Play Therapists Need to Know
by Jan Williamson

“We cannot waste our precious children. Not another one, not another day. It is long past time for us to act on their behalf – the impact ofconflict on children is everyone’s responsibility and it must be everyone’s concern. Graca Machal

There are an estimated nine million refugee children worldwide. While we have long understood that children are profoundly vulnerable in such situations, it wasn’t until the late 1970’s that the United Nations High Commissioner for Refugees recognized children’s needs as distinct from those of adults in terms of care. The ratification of the Convention on the Rights of the Child, (with the exception of Somalia and the United States) guarantees the humanitarian rights of children including the importance of play and their right to a safe setting for play even during large scale emergencies. Despite having these safe guards in place, the experience of a refugee child with or without family members is one of loss and displacement.

International organizations recognize three distinct solutions for families once they become refugees. These are referred to as “durable solutions”. The majority of refugee children by far will experience two possibilities; they will either return to their country of origin or settle locally (within the region or neighboring countries). A much smaller percentage of refugees will experience the third durable solution of resettlement to a distant country. This article will present a brief overview of the flight experience for families, list the issues of resettlement for refugee families and children and the more specific issues of children’s ongoing adjustments, and conclude with treatment interventions through play therapy.

Who is a Refugee?

The United Nations High Commissioner for Refugees (UNHCR) defines a "refugee" as a person who has fled his/her country of nationality (or habitual residence) and who is unable or unwilling to return to that country because of a "well-founded" fear of persecution based on race, religion, nationality, political opinion, or membership in a particular social group. This definition of a "refugee" excludes those who have left their homes only to seek a more prosperous life. The term “child” is defined as being 18 years old or younger. They may be with family members, separated from family members, or unaccompanied (family whereabouts are unknown).

What is the refugee experience?

To understand the mental health needs of children, it is important to have an understanding of what refugee families go through long before they reach a country of resettlement such as the United States. Fundamental to this journey is the realization that for each child and each family, their arrival is not necessarily a happy conclusion to being a refugee, but one phase out of several dangerous and sometimes lengthy journeys.

We can discuss the framework for previous life experiences as a sequence of stages that will vary tremendously in length of time, levels of personal danger, and ongoing losses:

Pre-departure – usually a situation of life threatening political unrest or open armed conflict.

Departure – families are faced with “Sophie’s choice” style decisions in deciding who will depart and who will stay behind. Often elderly relatives refuse to leave their life-long homes, teenagers may be sent alone, or very young children are left in the care of others in the home country.

Flight – Often the most dangerous period as the family or child depart from the home country, usually leaving most of their belongings behind and, often, without any knowledge of how long they will be displaced or where they will end up.

Refugee phase - Before obtaining refugee status, a family may end up in a camp within a country of first contact after departure, for a period of weeks, months or years. This takes a tremendous toll on adults and children as they flee the danger of their home country, survive the dangers and uncertainty of the flight itself, and often have no knowledge of where they may be offered a place to resettle.

Resettlement – After a typically lengthy and stressful process, only then do they enter the phase of being selected for a country of resettlement. This might result in further losses and family separation depending on who is in the family and what the family relationship is that they share. For example, a life long “auntie” may not qualify to travel with the family if she is not legally related to the family.

Post-resettlement – There are distinct phases that families experience once they have arrived. There is the “honeymoon” phase where everyone is relieved to finally complete this portion of their journey along with the excitement of exploring a new home. This is followed by a “slump” or depression as the daily adjustments continue and energies flag. It is this crucial phase that determines whether families successfully negotiate this slump and begin to rebound and experience a phase of settling well and are successful over time, or continue to fail and slowly slide further into a depressed and uncertain life, marginalized by an alien culture and struggling for economic stability over time.

What are the main treatment issues?

A review of the literature identifies four primary mental health issues for resettled refugee children: exposure to trauma, gaining access to mental health services, receiving culturally competent treatment, and the on-going stress of [acculturation] issues. This leads us to the corresponding interventions to address such issues through the provision of trauma-informed treatment, strategies for providing access and engaging refugee children in mental health services, approaches to providing culturally competent services, and strategies for helping refugee children and families cope with the stresses of resettlement.

What are the ongoing resettlement issues for children?

The need to acquire a new language and support yourself and your family in an unfamiliar setting is a task that would bring most of us to a standstill. Parents are in what is referred to as “survival” mode as they try to learn a language, find employment to support their children, find a home and transportation, and adjust to a new country simultaneously. This results in little time for family life, time together, or leisure activities.

Rapid language acquisition is a necessity. However, children typically acquire the new language much faster than their parents or adult relatives do, creating a gap in cultural integration. This can lead to children acting as interpreters and making important family decisions in the new language without the maturity to do so.

Reversal of family roles is frequent. In many families resettling, the women in the family are able to find non-language based employment before the men can, creating a reversal in traditional family roles where women are going out each day and men are left at home. This leads to women learning the new language and customs more rapidly than their partners.

Along with navigating “two worlds” culturally, children and adolescents may find themselves in the role as the” head of the household”. Most children are immersed into the language immediately through the school system, learning to speak, read, and write the new language at a rapid pace. Parents may ask them to translate important documents, convey emergency information, accompany them to doctor visits or hospitals, or assist in other adult settings. This can lead to reversal of roles in a different way, as children assume an important gate-keeping position as the receivers and communicators of critical family information. They become the main source of information for their parents about the new culture.

At the least, children talk about living in two worlds culturally, leading one life outside the home after rapidly assimilating to the new culture and an entirely different one within the family system of the old culture. Over time they must attempt to integrate their own two versions of life: the old version of past experiences that may include trauma, as well as the customs, language, and family values of their parents, along with the new culture with different values, beliefs, and social norms.

What are appropriate interventions for resettlement issues?

While it’s not possible for us to be a specialist in every culture we encounter, it is possible to build a cultural framework for work with a resettled child. The following are areas to address before engaging children in treatment:

Develop a culturally competent practice by compiling a list of culturally important questions related to the family or caregivers of the child. This is done by gathering information from the family on child care practices, discipline, family customs and traditions, cultural practices the family engaged in before the emergency that displaced them, and what they are doing now that is different from before. Be curious about how they’ve managed to adapt to their new life and what advice they have for newly arriving refugees.

Find out if there are bilingual therapy or play therapy services available and, if not, are there translators available, either to attend the sessions or to work by telephone. It is important that a therapist be trained to work with translators as well. Often family or community members are asked to act as translators. If this is the case, it is important to work together beforehand to insure they are translating verbatim what is being said and not altering, abbreviating or “filling in the blanks” in the translations offered.

As parents are frequently in survival mode, it is important to focus on strengthening families, family ties, and family activities whenever possible. Because of the many demands on the time and energy of parents, it is important to give careful attention to whether families have access to services (transportation, time off of work, access to low cost services, etc.) Are there community-based services within the refugee community that will support and encourage families to utilize the services you are offering?

Work with parents in tracking their acculturation process over time. John Berry’s model of acculturation illustrates the process of families attempting to integrate into the new culture. He does this by describing the different degrees by which a minority family is “absorbed” by the majority community. In one instance, families may rush to assimilate the culture and lose their own values and culture in the process. In another, families keep themselves isolated from the culture, do not assimilate over time, and find it difficult to function within the new community. The ideal experience is when the family can maintain their own cultural identity and values, while integrating the aspects of the new culture that are necessary (language acquisition) and useful (social activities).

Be aware of the political issues that caused the family to flee their country in the first place, and be aware of the differing sides of conflict for each situation. In resettlement, families from both sides of an armed conflict or differing political or religious groups may be resettled in the same area but are distinctly separate political factions.

If discussion with newly resettled parents is limited due to language and time constraints, seek out others in the community familiar with their culture. Look to the more established refugee community (those who have lived in the US for a longer period of time) to put you in contact with religious leaders, traditional healers, storytellers, or other means of support for the children and their families.

What play therapy techniques support interventions for resettled children?

As with other child-based treatments, play as narrative is the key. How can we as therapists provide the culturally appropriate setting for children to tell their story?

Use traditional folk tales to strengthen cultural ties and culturally familiar pathways for overcoming obstacles or loss. This also allows parents a way to support and share values.

Create memory books for multiple aspects of the child’s history, as a way to:

Compile and keep memories of his or her former childhood. If the family has lost family photographs, find photos of places, festivals, or other activities that can substitute as a visual presentation of the country of origin.
Chronicle the family’s journey through the various stages from pre-departure to post-resettlement experiences through journals, drawings, or sand trays.

Create a personal ritual for the child, adolescent, or family over time that honors the many losses and supports the grieving process.

Invite parents or relatives into sessions to learn how they played as children and to invite them to recover this playful aspect with their children.

Let the families teach you traditional songs and games, as well as identify play objects that are different than those found in our culture.

In past sessions, the parents have been asked to fill an imaginary toy box with the appropriate toys from their home country.

Ask families to create family trays and narrate stories using objects similar to the toy box mentioned above. Ask them to bring objects from home for use in creating the story if you don’t have what is needed.

Employ additional care in establishing a safe process for approaching traumatic memories Give special attention to how you will open and close a session with enough support in place to contain the traumatic content. In working with children in refugee camps, traditional dance activities and plays were often used with children. They afforded a repetitive activity with a known beginning, middle, and end, allowing for mastery of tasks.

Conclusion

It is hard for us as therapists to imagine the magnitude of loss a refugee family undergoes. How do we comprehend the loss of everything we once held as familiar or loved? Refugee children lose not only language, culture, and family, but the very toys they played with, the familiar places where they played or attended school, the very friends they played with. There is the loss of so much that we take for granted in the course of a day: the weather and seasons we are accustomed to, the smells and taste of local foods, the type of clothes we wear, and the homes we live in. Many of these everyday things may seem unimportant, but added together they provide the comfort of our ordinary day to day existence. While play therapy is just one aspect of a recovery plan, it can play a crucial role in the healing of children who literally find themselves as strangers in a strange land.

What does the refugee child have to lose? Those very things which give us hope to continue, reasons for believing in ourselves, and the qualities that allow us to experience joy, tenderness, security and a belief in the future, reasons for living and hoping.
Refugees Magazine 1988