Refugees - Charles_Kemp & Baylor School of Nursing

This is the home page that will allow you to access information on refugee health issues. It covers issues such as mental health, women and health, infectious diseases that health service providers can expect to encounter and it gives practical guides on various religious practices and their impact on health. It also offers cultural synopses on 20 different cultures in relation to health. It is well written, easy to navigate and worthy of recommendation with the proviso that it is written for the American health service. ۞ ۞۞ ۞۞

Child Refugees - European Council

Good Practice Guidelines for Child Refugees 2002 This document originated from a project on Refugee Reception and Integration as part of the work of the European Council on Refugees and Exiles (ECRE). Ireland was not part of the study. It is a 68 page document.

Ch 1 covers a number of legal issues with regard to child refugees and gives a limited cross European glance at how refugee children are variously treated. However this has relatively little for health care providers

Chapter 2 is more relevant in that it gives advice on best practice with regard to dealing with children in families where the parent has suffered trauma. This advice could be invaluable for social workers dealing with refugee families especially where PTSD and family reunification are factors.

The following chapters deal more specifically with treatment and education for unaccompanied children who have suffered personal trauma and should be valuable to therapists and teachers rather than general health service providers. It is fairly wordy and repetitious having been produced by several different researchers across different European countries. ۞ ۞۞

Refugee Healthcare - American Family Physicians

This report is directed at physicians whose patients are refugees. It explains - in a very accessible format - what the barriers to accessing health care might be for refugees. It provides practical strategies for the health care provider aimed at improving access to appropriate health care for refugees. ۞ ۞ ۞

Torture and Trauma

The following account has been reworked from extracts of an unpublished article by Greg Straton and Michael Begley 2005 "A Guide to Working with Refugees for Adult Guidance Counsellors"

Practical Suggestions for Working with Refugees

The experience of SPIRASI in working with refugees in the context of torture and trauma relates to not only the treatment of health related symptoms but also to the physical environment in which to appropriately operate [1]. The following are suggestions for the health care provider:

Relating to the Client
Torture or trauma affects the ability of the person to develop relationships of trust with people, and organisations, in authoritative or statutory type positions. Most refugees who have experienced trauma and torture will have passed through a stringent asylum application procedure that at times gives the impression that they are not to be trusted. The health care provider should acknowledge the past of the individual and give them a sense of being understood and believed. Where the person's past is not revealed it is nevertheless important to remember that the person has a past full of experiences external to their reality in Ireland that play a role in their way of approaching their health care. Additionally, it is important to prevent any possible re-traumatisation. Therefore, past experiences should never be replicated in any interaction; an example is any interview session which may seem reminiscent of interrogation. The Health Care Provider should remain aware of their own cultural background and that of their client. Cultural short-sightedness [2] can entrap the Health Care Provider into a way of thinking that resists adaptation and rejects alternatives. The Health Care Provider cannot ignore that they themselves are perceived in a cultural context as much as the client's cultural context cannot be ignored.

Boundaries and Referral
The Health Care Provider should maintain firm but flexible boundaries as a member of a minority ethnicity will often present with multiple issues and difficulties. In many instances the Health Care Provider may feel that they are doubling as a psychotherapist. In these cases referral to specialised services, such as the Centre for the Care of Survivors of Torture at SPIRASI, a local Rape Crisis Centre or other appropriate services, is vital. Psychotherapy and the process of dealing with the past will help the person to develop personal coping mechanisms or skills, raise self confidence and start the process of coming to terms with loss and grief. Often when working closely with clients from a background of trauma, care supervision for the Health Care Providers themselves may be required, to prevent secondary traumatisation and ultimately burnout. Self-care should never be underestimated.

Where less severe difficulties are presented it is good practice for the health care provider to bring in the services of a suitably qualified cultural mediator. Cultural mediation is a collaborative process in which both the health care provider and the client agree to the process and also agree to put into place the mediated healthcare related plan. Cultural mediation is a two way process of communication between the heath care provider and the client conducted through the cultural mediator. While the cultural mediator may offer some culturally important knowledge where necessary to either or both parties, it is in a spirit of open communication rather than of acting merely as a cultural translator.

The Interview Session
The interview session with the client is significant in understanding their needs and how to make effective interventions to enable the client to receive optimum health care. Provision of a safe environment is a priority and at SPIRASI this has been achieved through ensuring that the physical environment is as non-threatening as possible. Considerations about lighting, space and colour may seem trivial but are valuable. Spatial considerations go as far as placing the client near the exit door with a view out of a window during counselling sessions. Throughout the process, from appointment to session, clients are treated with respect by all of the staff at SPIRASI. It is important not to trigger past experiences of being subjected to ill treatment by someone in a position of power.

Working with Interpreters
Language barriers pose the single most significant obstacle for non-English speaking immigrants in need of health care provision. Even those who can speak English may not be able to fully comprehend what is being said or communicate to the most effective degree for their needs. In such circumstances of language discordance, service providers need to ensure that, wherever possible, trained interpreters are used in consultations. For many health care providers in Ireland, triadic communication as mediated through an interpreter will be a new experience and consequently will impose a different and perhaps initially difficult dynamic in the client-provider relationship[3] as well as adding to demands for support and training. The website of Diversity Rx [4] is a valuable electronic resource for information on ethnic diversity in the healthcare context. It also includes an array of material on the language and cultural needs of minorities.

When using interpreters with survivors of torture, it is important to provide safe space, choice and consistency. Sexual violence is commonly reported and is used as a method of torture and persecution, so therefore the gender of the interpreter is a primary consideration. Additionally, some clients may feel that an interpreter from their own country of origin compromises their ability to speak openly due to political or ethnic divisions that may exist between the client and the interpreter. For further and more detailed information on good practice guidelines and issues in working with interpreters in the broad mental health field, it is recommended that the text written by Tribe and Raval (2003) [5] be consulted. Tribe and Morrissey (2004) [6] offer a very useful summary of the various models of interpretation: linguistic, psychotherapeutic, advocate and cultural broker modes. They also give a practical overview of good practices which are particularly relevant to the circumstances of health care providers when working with refugees and torture survivors.

Due to the various barriers that refugees encounter the Health Care Provider will at times be called upon to advocate on the client's behalf. This could include making phone calls to officials on the client's behalf to get information or clear up misunderstandings. It is important when doing this to be clear that what you are doing on behalf of the client does not raise false expectations, nor dis-empowers the client. The experience of the refugee may be that of encountering obstacles at every turn, thus the Health Care Provider must always be realistic about what can or cannot be achieved. The Health Care Provider therefore needs to be informed about the various avenues that are open which includes knowing the welfare system as it relates to the various legal statuses that their clients will be in Ireland under. Where possible, the Health Care Provider should endeavour to share or shift advocacy responsibility to the client.

Currently training in cultural competency for Irish health care providers is at an early stage of development. It is only since 2000 that practitioners have had to deal with a minority ethnic clientele on a scale that has demanded comprehensive in-house training support. However, there are well developed training programmes available and a growing number of web based resources to consult - although no comprehensive web based resources relating to minority ethnicities in Ireland have been developed as yet. Furthermore, there is a commitment from the health care sector that training is a priority for all staff. In the meantime, those practitioners who deal with these issues in their daily work were initially unprepared but have developed practical knowledge on the basis of experience alone. This experience should be incorporated into the training experience - both as examples of practice and - where applicable - as solutions. Many health care providers have not as yet seen the importance of training in this field. Many will tell researchers that 'there are no problems at this health centre'. This response is in conflict with research studies that have been carried out separately both by Cáirde [7] and SPIRASI [8] where members of minority ethnicities explained their difficulties in achieving adequate health care provision. These research studies show that many people are not accessing healthcare provision because of failed attempts in the past and as such are not presenting and thereby coming to the attention of health care providers. Training will go a long way to change this.


[1] Please consult
[2] O'Rourke, M. (2002). Interculturalism and Intercultural Counselling, Dublin: TCD.
[3] Blackwell, D. (2005). Counselling and Psychotherapy with Refugees. London & Philadelphia, Jessica Kingsley Publishers, 85-90.
[4] See
[5] Tribe, R. & Raval, H. (2003) Working with Interpreters in Mental Health. London & New York: Routledge.
[6] Tribe R. & Morrissey. (2004). Good Practice Issues in working with Interpreters in Mental Health. International Journal of Mental Health, Psychosocial Work and Counselling in Areas of Armed Conflict, 2(2), 129-142.
[7] See Cáirde website for the work that they do
[8] Unpublished report 2005 'Pilot Project in Roselawn Health Centre to Improve Access to Services for Clients from Minority Ethnic Groups' by SPIRASI's Centre for Health Information and Promotion (CHIP)

The Effects of Torture and Trauma - Queensland Health

This is an excellent Australian site that explains the effects of torture and trauma in a very concise and approachable way. It gives practical advice on how to approach patients who have arrived as asylum seekers and refugees who may have suffered from torture or trauma. It also explains the stress indicators connected to the asylum seeking process even for those who not suffered from trauma or torture in their country of origin. Recommended ۞ ۞۞ ۞۞

SPIRASI does not necessarily agree with the facts and opinions presented in this guide or any linked websites.