Case Study 14

The following case study illustrates a collaborative intersectoral approach to mental health care for children from refugee backgrounds. The case study provides a question for viewers to consider and reflect on.

Case Study 14: Collaborative mental health care for refugee children (Sri Lankan)

(Adapted from Rousseau, Measham & Nadeau, 2012).

This cultural consultation involved three meetings over a two-year period between the public health nurse (PHN), Mary, who visits schools and day care centres in the area where the CAMHS clinic is located, and a child psychiatric consultant. Mary is the main health professional providing care for Shiva, a young boy who arrived in New Zealand at the age of four with his mother Anna. Shiva was born into a happy, wealthy, well-educated family in Sri Lanka. When Shiva was three, his father was kidnapped for political reasons and subsequently killed. Shiva and his mother were called to the hospital where, instead of finding Shiva’s father alive as they expected, they had to identify his tortured dead body. Anna, who was pregnant, was unable to protect Shiva from the horrific sight. Soon afterwards, Shiva and his mother were abducted and tortured, and Shiva witnessed his mother’s mistreatment.

Later, relatives smuggled them out of the country and they arrived in New Zealand where they applied for refugee status. On arriving in New Zealand, Anna had to be hospitalised because the torture had provoked a miscarriage. For an entire week, she lay between life and death in intensive care. Shiva sat quietly on a chair by her bedside (very surprisingly, he was not placed in a foster care setting). It is not clear whether Anna was discharged without a referral for further mental health care services or whether she did not attend follow-up appointments.

The family’s next contact with health and social services was established through Shiva’s day care. The day care workers were worried about Anna’s distrustful and avoidant behaviour. They reported that Shiva was extremely withdrawn, hid under tables and appeared to be terrified. They suspected physical abuse and severe neglect. Before reporting him to Child, Youth and Family (CYFs), they decided to consult Mary, the PHN who was their designated primary health care resource person. Mary’s work with Anna involved supporting her in organising a survival network in her neighbourhood. She taught her about food banks and helped her find furniture and appropriate clothing. Mary also helped Anna continue with her application for refugee status. In the process of helping Anna fill out her immigration papers, Mary found out about Shiva’s traumatic background by reading the written narrative that Anna had had to provide for her refugee application – Anna never spoke about this. Mary also became increasingly aware of the ongoing physical pain that Shiva and his mother continued to experience, and was concerned about its relationship with their past traumatic experiences.

Concerned about Anna and Shiva’s experiences, Mary encouraged the mother to consider mental health and medical support for the family, but Anna refused this. At this point, Mary requested a first consultation during which she discussed the situation in the absence of Anna. Mary explained how she had been working to change the daycare workers’ perceptions of Shiva’s mother from a paranoid and potentially dangerous person to a severely hurt woman who, in spite of her fragility and emotional unavailability, was deeply attached to her son. During the consultation, a thorough review of all the services involved revealed that in spite of Anna’s reluctance to see a mental health professional, she had been seeing several doctors for both herself and for Shiva due to medical complaints and had been taking a number of psychotropic drugs, without significant results. Mary was unsure whether or not she should directly address the family’s traumatic story with Anna, stressing the mother’s massive avoidance behaviours and the fragility of their alliance. Moreover, she remained worried about Shiva’s anxious behaviour; although she felt that since her involvement with the family he was showing some signs of improvement. Mary also felt overwhelmed by the story that had been indirectly revealed to her when she helped Anna fill in the immigration papers. She turned to the consultant to obtain confirmation that her work on the alliance between the mother and the day care, trying to increase the level of empathy of the care providers, was effective. Mary felt a sense of emergency, which had led her to do a lot and to become exhausted. In spite of her intensive involvement, she felt helpless. The anger of the day care workers was framed as a misunderstanding. The consultation provided comfort and helped her shape more realistic expectations. Mary was supported in her continued efforts to help Anna set up a safe and supportive environment for the family, which included helping the mother to continue with her refugee status application. Art therapy was also offered for Shiva, and his mother agreed to this, although she shared that she did not have the energy to take him to the clinic. She did agree to this being provided at the day care by a CAMHS clinic trainee, which offered significant support both for the day care and for Shiva. The consultant also underlined the survival strengths of Shiva and Anna. This helped Mary to break out of the extremely stressful emergency mode of intervention which was burning her out, and helped her understand the feelings of helplessness engendered by her role as the only care provider who Anna would trust.

The second meeting with the consultant took place one year later. This time Anna, Shiva and Mary attended. Mary requested this second consultation to monitor Shiva’s progress and to address family dynamics, as Anna had re-established some connections with relatives in New Zealand. Anna refused the services of an interpreter, even when offered a choice in the interpreter’s gender and ethnic origin, so the consultation took place in English, a second language for all parties involved. Anna shared that Shiva’s fearfulness, including fear of hospitals, had diminished somewhat. In preschool, though still withdrawn, he was clearly a talented and caring little boy. For the first time, Anna was willing to discuss the possibility that her own physical symptoms and Shiva’s numerous somatic complaints could be linked to their traumatic experience. She also began to talk about karma as a means of understanding her past. Finally, with regard to family relations, she alluded to the burden associated with her status as a widow. ‘Is it possible to escape the fate of widows?’ she asked. At the explanatory level, the Western model of trauma causality coexisted with traditional cultural models (karma and the role of the widow) to give meaning to the family’s suffering.

After the second consultation, Mary discussed her feelings of isolation. Anna was refusing to let other people (an interpreter or family members) help or support her. Very invested in the therapeutic relationship, Mary felt protective of Anna and while she did not feel she was angry, she felt overburdened and wanted help to re-establish social links for Anna. Anna finally gave Mary permission to contact their various doctors and to look for one family doctor who would be willing to coordinate all their medical needs. This consultation helped Mary to understand Anna’s ambivalence towards her relatives, opened the door to discussing both the protective (religious) and threatening (the role of widowhood) aspects of tradition and supported the co-ordination of services.

The third consultation took place 10 months later. Mary asked their new coordinating family doctor, Anna’s physiotherapist, Shiva’s art therapist and Anna to attend the meeting. Anna showed up briefly and informed all the professionals that she could not stay. The ensuing discussion revealed splitting processes among the family’s various caregivers. Anna’s anxiety about her son’s and her own medical problems was being transmitted to all with a sense of urgency, along with strong feelings of anger at the inadequacy of treatment and the unfairness of the system. Anna was simultaneously asking for help and portraying the health care providers as aggressors, thus reliving her memories of the hospital scene in Sri Lanka. For her, the health care system had become a theatre of traumatic re-enactment. The consultation helped to resolve the splitting by addressing these issues and changing the perception of the mother among the caregivers. During this third meeting the family’s caregivers argued among themselves about who was not doing enough, contesting the saviour role they each wished to claim, but also share. They projected their feelings of moral obligation onto others and channeled their anger and frustration into the collaborative relationship. The consultant pointed out this splitting, noting that the effect of trauma had influenced the family’s interpersonal relationships. Since Anna’s arrival, the splitting had been shifting from the day care to the extended family, and was finally being replayed among the caregivers themselves. The plan of action proposed a way to coordinate the physical and psychological care of Anna, who now agreed to enter psychotherapy, reframing the conflict as a symptom of the trauma. Mary remained the key player, with the child psychiatrist available to provide support.

Shiva remained very involved in his art therapy sessions. He endlessly built fortresses that were always attacked by monsters and armed men. He also portrayed hospitals as scary places. Gradually, he introduced scenarios that ended in less catastrophic ways, as protection became possible to envision. In the last session, he spoke directly about his father for the first time. The therapist thought that the end of the sessions reminded him of his earlier loss, but also felt that he was offering her a gift, entrusting her with his most cherished memory before leaving.