Practitioner: Andrew Starr, primary mental health worker.
Field: Child and adolescent mental health services (CAMHS).
Client: Homayra Ibrahim is a nine-year-old girl who recently came to England with her mother Ameena, a midwife, and her two sisters seeking asylum from Somalia.
Case history: The family had suffered greatly in Somalia. The father had been abducted by militia men. The grandfather had been killed in front of the family. Although told to look away by her mother, Homayra could not help herself and turned to see her grandfather brutally murdered by a machete. Following these events, Ameena, who had suffered repeated rapes, took her children and fled to Kenya, a journey which took three months. From there they flew to Britain. Housed in temporary accommodation while they appealed the decision to refuse them asylum, a tenants association support worker concerned at Homayra’s behaviour, referred her to the child behaviour intervention initiative (CBII).
Dilemma: Engaging Homayra with an alien mental health system might prove more damaging than helpful.
Risk factor: Would the risk of not pushing the family to get Homayra assessed by a child psychiatrist be in her and her family’s best interests?
Outcome: Homayra’s mental health symptoms, while still involving flashbacks, have decreased and her confidence is growing. The family have been granted asylum and await housing options.
One of the aims of Community Care‘s 2002 campaign to improve services for child and adolescent mental health services (CAMHS), Changing Minds, was to secure a proper focus on prevention.
One such service is the Leicester-based child behaviour intervention initiative (CBII) – a preventive partnership between social services, education, voluntary services and health services. And its benefits are highlighted in the case of Homayra Ibrahim.
Following appalling experiences in their home country Somalia, Homayra, her mother Ameena and her two sisters escaped to Kenya and came into contact with people who, for a price, would get them out of Africa. Thinking that she was heading for the US and travelling on false passports, the family were picked up by UK immigration officials.
“At first the family were dispersed to Glasgow,” says Andrew Starr, primary mental health worker. “They were placed in a tower block where the following week a Kurdish asylum seeker was murdered.” It must have seemed that they had escaped one environment of random killings for another. “They were then placed on a council estate in Leicester. Again their experience was traumatic. Youths broke into the house at night wielding knives,” he says.
However, the family wanted to remain in Leicester because of its significant Somali population, so they moved to another estate in the city. This move, despite the verbal abuse and occasional stone or egg-throwing at the door, was a comparative improvement.
The estate’s tenants’ association had a support worker for asylum-seekers who was soon concerned about Homayra. She seemed anxious and frightened and refused to go anywhere on her own – including the toilet. The worker referred her to the CBII.
Starr and his social services colleague Zubeda Esat, a family support worker, were allocated the case. “I felt that the degree of anxiety Homayra was showing, and her scary flashbacks, were probably related to post-traumatic stress,” says Starr. “And her stress was not related to incidents in Somalia alone but to ongoing incidents in Britain.”
They recognised that Homayra’s behaviour might need psychiatric or psychological input, but believed this would be counter-productive. “If she were to receive a service from CAMHS, there was a serious access issue,” says Starr. “Her mother, who would need to bring her to appointments, would need to trust that she would get her money back for the travel. But that would be very difficult. She then has to believe that the service will be helpful. I didn’t believe that Ameena did have faith in the mental health services,” he adds.
While not thinking this insurmountable, Starr believed it to be more a matter of timing. More time was needed to help build up understanding. There was also the possibility, albeit remote, that the family could be deported. This meant, of course, that they could not plan for the future – with all the anxiety that ferments.
So the support put together was largely centred around their wishes: that the girls be able to mix with other children. Esat, a Muslim like the family, helped them to use swimming pools, sports centres and libraries. Going swimming with Homayra in a female-only session was particularly valuable: “This was really helpful as she was able to observe Homayra’s anxious behaviour and repeatedly reassure her. And she had some success in that,” says Starr. The support was grounded in the practical and everyday.
Ameena, despite her own mental health difficulties, was very clear and reassuring that none of the incidents in her children’s lives were their own fault. However, she did worry that Homayra and her sisters were not having religious education. Fortunately, Esat has strong links with the Muslim community and was able to get in touch with a Somali man who could provide religious education for Somali children. “It’s interesting what a parent’s priorities are compared to what I’d expect them to have. It’s important that parents feel they are meeting their parental duties,” Starr says.
And in so doing Starr and Esat have begun to soothe the anxieties that this family have endured so resolutely, and with asylum since approved, it can be hoped that roots and stability can help them make sense of their lives.
Arguments for risk
- It was doubtful if the family was ready for a therapeutic service – more time was needed to build up trust and a relationship. Trust was not something that could be obtained easily given the family history and experiences.
- As with many people it was thought that setting and keeping appointments would not be the best way to engage. Services needed to come to them – again as part of a trust-building exercise.
- The family had a good relationship with the volunteer support worker from the tenants’ association, who was concerned and wanted to help. Starr was able to provide her with useful information about mental health issues, and she could monitor progress.
- Homayra was getting on well at the local school, which had a sound awareness of her needs. “The school gives a clear message that asylum seekers are welcome,” says Starr.
- There was good communication between all those involved with the family.
Arguments against risk
- It was the family’s right to access therapeutic services and, given the terrible traumas suffered in Somalia and continuing bad experiences in Britain, it could have had long-term detrimental effects not to take this path.
- Although displaying admirable resilience Ameena, Homayra’s mother, had her own mental health problems, not just from memories of the abduction of her husband and execution of her father but of repeated brutal rape by militia men. It could be argued that it was simply asking too much for her to cope with such memories and trauma through a natural healing process while expecting Homayra to deal with her own post-traumatic stress in similar way.
- If there were cultural issues to be addressed, more intensive support might have successfully bridged those difficulties. More work might have been put into making therapeutic services, in this case, more flexible.
Work with asylum seekers and refugees can be described as a holistic process which includes assessment, protection (that is the right to safe care), health, housing, welfare provision, rehabilitation and therapy, writes Jocelyn Avigad.
Application of this model to the work of the CBII team shows how skilfully they dealt with the needs of the Ibrahim family and, in particular, those of Homayra. This included helping the family integrate into their local community and addressing their asylum, housing and child care needs.
The risk of not attending concurrently to the specialist assessment and therapeutic needs is that recovery from the impact of torture is for a significant number of cases not “a natural process”. It might, for instance, be that a parent is so traumatised that they are incapable of meeting their children’s physical and emotional needs. Often, it is only when leave to remain has been granted that the full impact of the horror begins to surface.
CAMHS seems the appropriate agency to provide specialist assessment and treatment for the Ibrahim family. The government’s dispersal policy will exert increasing pressure on mental health services to provide a culturally sensitive, flexible and multi-faceted service.
Failure to address cultural issues denies clients the opportunity to say: “I don’t understand the language, the concept of therapy and the asylum system.” It also fails to allow the practitioner to reflect on their cultural prejudices and practices.
Jocelyn Avigad is co-ordinator, family therapy team, at the Medical Foundation for the Care of Victims of Torture.