Copyright 1984 by Spectrum Publications, Inc.

Handbook of Psychiatric Consultation with Children and Youth.

Edited by N. R. Bernstein and J. N. Sussex.

Pages (271-289)

 

17

Consultation in Disasters-

Refugees

 

Raquel Cohen

 

 

 

The emergence of mental health consultation in relocation settings offers a new opportunity in child psychiatry. Mental health specialists are beginning to be more visible and more welcomed within relocation camps and other programs for displaced persons to the extent that they now have an enlarged base of knowledge dealing with uprooted and displaced individuals who may be fleeing political or natural disasters. It is the intent of this chapter to formalize the documentation of child-psychiatric consultants working in relocation camps and thereby add to the data base of this new field in child psychiatry. A consultant is herein defined as a child psychiatrist with consultation skills who is asked to participate inside an organized relocation system and assist the staff in finding adequate approaches to deal with families and their children or unaccompanied children. The consultant is further defined to be both aware of and sensitive to cross-cultural issues presented in these types of groupings. This is especially true when a refugee population migrates from a country other than its homeland.

Camp will be defined as the temporary geographical site where individuals will be given shelter, food, medical care, and recreational opportunities. This setting is organized and managed by the government-federal, state, or local.

It is a transitional setup and the staff's goal is to resettle the population as rapidly as feasible into the communities.

Camp staff, herein referred to as consultees, are workers who have specific responsibilities and tasks to perform in order to negotiate the objective of relocating the refugees/victims. How the consultee discharges these responsibilities is dependent on both his sensitivity and knowledge of human behavior under stress and his awareness of problem-solving techniques using mental health principles. The emotions, attitudes, and behavior reactions of these consultees can either facilitate or hinder the coping, adaptability, and acculturation of the anguished refugee/victims.

Refugees/victims are herein defined to be individuals in life transitions. They are displaced adults and children who are victims of forceful migration or disaster. They suffer from the most traumatic, dehumanizing, and painful circumstances that can befall a population. They have been moved by foot or transported by vehicles across long distances, generally without explanation, preparation or planning. The circumstances that accompany these trips can be uneventful or as traumatic as capsizing, losing a parent (escaping from Saigon, 1975) or being bitten by dogs (Mariel, 1980).

Emergency relocation procedures are defined to be the resettlement activities practiced by a group of camp workers whose job is to find a sponsor for every refugee or a housing site for every victim of disaster.

The psychiatric consultant needs to be aware of the following areas of knowledge affecting the children and their resettlement experiences:

 

1. Antecedents

a. circumstances in which family units left home

b. experience of travel

c. identifying characteristics of family/child

1. economic

2. social status

3. employment skills

4. physical health of all members

5. mental health of all members

2. Conditions of entering the transitional, temporary location (camp)

3. Coping and adaptation approaches to the camp conditions over time

4. Circumstances and conditions of leaving the transitional setting (camp)

 

Some of the above issues merit special discussion. The antecedent conditions that surround the experience of the relocation of the child have a bearing on the child's social and psychological reactions to the camp. The crisis climate of most camps does not lend itself to being sensitive to the needs of frightened, anxious, vulnerable children. Particular children will be noticed and singled out because of their "acting out" behavior (infraction of rules, destruction of property, excessive use of medical facilities).

 

The consultant was asked to advise how to handle the situation of Henry, a ten-year-old Haitian refugee who kept stealing food from the camp kitchen. In spite of the fact that all meals were provided for the families, Henry was caught several times in the process of hiding and carrying out food. On mental status examination it was found that Henry was an anxious child who had lost his father on the boat trip to the United States and who believed he would have to provide for the future of his mother and four younger siblings. The camp staff was assisted to understand the meaning of the behavior and help Henry with his need to mourn his father's death, allay his anxiety for the future, and help the mother to rely less on him as "the head of the household."

 

As the family and child become comfortable with the camp routine, the different phases of adaptation to the relocation will proceed. A portion of the population (approximately ten percent) will begin to show early patterns of mal-adaptation. Many of the signs and symptoms can be considered and classified under the DSM III diagnostic categories of conduct disorder, reactive disorder, depressive disorder and posttraumatic disorder.

Disorders of sleep, eating, bowel, and bladder appear regularly in young children. The clash between cultural child-rearing customs and camp life shows its most dramatic impact at these stages.

 

Juan, a seven-year-old boy, only son of an older couple who had lost their home after an earthquake, was refusing to be separated from his mother. He couldn't be persuaded to get undressed to go to bed at night and wanted to sleep on the floor of his parents' temporary camp shelter in a camp setting. He refused to play with other children and was preoccupied with noises and the weather. It was helpful to explain to the consultee the concept of cumulative trauma and its effects on the child's ego.

 

Issues of attitudes, prejudices among ethnic groups (U.S. staff and refugee), and expectations of how children should be disciplined and reared surface quickly. Regression in habit, maturity, or behavior of children under stress (such as loss of bladder and/or sphincter control) adds a complex dimension to the problems of the child in his interaction with the new environment.

Patterns of acculturation also emerge during this stage of adjustment to the camp. Different rates of adaptation will occur and influence the interaction between different members of the same family. Also, processes of acculturation differ. Some families show patterns of withdrawal; they turn inward, tend to reject the norms of the camp, are unable or unwilling to ask for advice or guidance from the host population. Other families reach out continuously and develop healthy, interdependent bonds with individuals around them.

 

 

BACKGROUND

 

Although acknowledging the importance of and need to document the history of refugee migration and recent disaster-assistance programs, the system established by the United States to deal with refugees/victims, and the many governmental and voluntary agencies that assist them, this chapter will focus on the role, skill, and procedures that are needed by the child psychiatrist who chooses to become a consultant to a camp professional staff. Several appropriate techniques will be described and categorized so that the work of the consultant with displaced individuals, and children in particular, can be conceptualized.

Among the historical and experiential processes that are cited in mental health literature, the following are singled out to delineate those which a consultant must understand to work with refugee populations:

 

1. Adaptation (Hamburg, 1967)

2. Acculturation (Szapocznik, 1978)

3. Value systems (Kluckhohn, 1961)

4. Coping mechanisms and their relation to:

a. culture, ethnicity, roles, status (Padilla, 1980)

b. age of child and developmental states (Freud, 1965)

c. health (integrity of CNS) and vulnerability (Nagera, 1981)

5. Social support systems (Caplan, 1974)

6. Maternal and child bonding theories (Bowlby, 1969)

 

 

RATIONALE

 

It is hoped that this chapter can assist the child psychiatrist to plan and implement a mental health program within a refugee camp.

First, attention is directed to the conditions within the setting of the camp where the consultant will participate and share his expertise. Then procedures and techniques are prescribed that will be helpful to the consultant in develop

ing a cooperative, coprofessional role with camp staff (Cohen, 1973). Finally, guidelines are developed to map out the specific areas, both concrete and conceptual, in which the consultant might participate and intervene.

The central assumption is: Planned and programmed incorporation of mental health principles within a refugee/victim camp is necessary not only for a child's healthier adaptation and eventual successful relocation, but also to support and enrich the consultee's function.

There are some effects of successful consultation which will enhance the psychological well-being of the consultee and help prevent the serious problem of bum-out that is pervasive in this type of work.

 

 

SETTING

 

The camp exists within a socially chaotic environment in which there is a sense of emergency at all times.

The following factors contribute to this crisis climate:

 

1. There is minimal time to gather data to investigate the reliability of data

2. Staff members and policy change constantly

3. Decisions are made rapidly with little regard for clear concepts, objectives, or tasks

4. The staff and client populations are stressed, irritable, and tired

 

Change is the essence of the camp setting. There is fluctuation in all levels of personnel, regulations, policies, and standards. As a result, the camp organizational structure is loose and a strong sense of identity is lacking. Also, the inconsistency that exists adds to problems of miscommunication and misinterpretation. The psychiatric consultant to the camp must be particularly sensitive to all information about change. This environment of the refugee camp is characteristic of all rapidly formed, transitory settings for displaced or uprooted populations.

 

 

TECHNIQUES AVAILABLE TO THE PSYCHIATRIC

CONSULTANT IN REFUGEE CAMPS

 

Consultation

 

The mental health consultation is a technique that is helpful in relocation camps to assist agency staff. The following conceptual principles underlying consultation in these camps are noteworthy to identify:

 

Focus: Consultation in relocation camps can be defined to exist for

 

a. personality or conduct disorders of the refugee/victim;

b. emotional disorders of the refugee/victim; and

c. staff interpersonal relations.

 

Level of responsibility: The camp staff members who meet with a consultant do not give up responsibility for the outcome of the individual's resettlement program nor for his mental health adaptation. The freedom of the camp worker to accept or reject what the consultant says enables him to take quickly as his own any idea that appears to him in the current situation.

 

Quality of relationship: The basic relationship between consultant and consultee is collaborative. There are no bureaucratic hierarchy levels between them; instead, they work as two colleagues who join their efforts to problem solve. A coordinative relationship is fostered by the consultant's usually being a member of another profession and entering the camp for a specific time frame.

 

Site: Consultation is usually offered during meetings which take place in response to the consultee's awareness of problems with children. It takes place in the camp setting.

 

Time of commitment: Consultation is expected to continue until the camp closes. Through the period that camp programs exist, many types of consultation objectives can be identified. For example, a consultant can be dealing with a case consultation and also consulting on some major policy problem at the same time.

 

Content: The consultant responds to that segment of the consultee's issue which the latter presents, but he does not seek to remedy other areas of inadequacies in the consultee's expertise or some of the camp programs which are working ineffectively. The consultant must, therefore, be prepared for continuous changes of focus, in regard to both the content and scope of consultation problems and the identity and hierarchical position of his consultees within the continuously shifting organizational structure of the camp.

 

Objective: Consultation has both an immediate goal-to help the consultee understand the underlying causes of the problem he is trying to solve-and a long-term goal to increase the consultee's capacity to master other types of problems. This increased sense of confidence will tend to foster the consultee's feelings of self-esteem and personal worth which will, in turn, strengthen his job performance. Although the focus of the process is on the work issues and not on the personal problems of the consultee, the consultant does observe the feelings of the consultee and respects his privacy and confidentiality.

 

A young male staff member asked for consultation in dealing with a female, sixteen-year-old Cuban refugee living in one of the federal camps. The problem that he identified in dealing with the adolescent was that she kept breaking the curfew established by the authorities. He wanted to help her so that she would not be punished. As he described her behavior, it was clear that he was containing his anger at her rebelliousness but was not aware of it. The consultant didn't deal with these feelings but empathized with the difficulty of dealing with adolescents and proceeded to focus on the methodology to anticipate her behavior and set limits within the cross-cultural communication barriers. The problem of cross-culture is a constant theme in most refugee camps where staff or one culture is expected to live among and assist traumatized populations of another culture.

 

Limits of consultation: Since a relocation camp setting rarely provides the psychiatric consultant with a clear set of expectations for defining the role to which he has been accustomed in his traditional clinical work, he must develop a new conceptual map that he carries within him into this field.

This conceptual map must indicate the limits of the consultant's professional domain. Although his role may not be pre-structured, he is not, in fact, free to do anything that comes into his head or to respond completely to all requests from consultees. He is constrained by the policies, both formal and informal, of the camp setting. These policies do not allow him to move on to other major areas of camp problems which may not have a clear connection with the mental health of a refugee or victim but which he believes might improve the quality of life in the camp.

 

A consultant was asked to help a group of camp staff to deal with the aggressive acting out behavior among young Cuban males living in a barracks within a federal refugee camp. The consultant met with the group in the barracks and was able to realize that the design of the living arrangements precluded any possibility of privacy, fostering instead a need to "protect" areas belonging to each adolescent. Although these issues were discussed, the consultant had no access or power to change the physical living accommodations in the barracks.

He is also constrained by the camp's laws and regulations as well as by its formal patterns of communication and authority. His intervention is not likely to be welcome if he takes sides in informal power struggles among staff, or if he suddenly disrupts the orderly process of decision-making that the official, bureaucratic system has developed in the camp.

 

Types of mental health consultation: The consultant is aided by a system which allows him to categorize each situation, process the flow, and predict what the most promising methods of dealing with it are likely to be. There are many useful ways of classifying mental health consultation for this purpose. The most classic distinctions are made by Caplan (1965) and are based upon two major divisions:

1. Between a primary focus of the consultant on an individual case problem and attention to an administrative problem related to a program or policy of the camp.

2. Between a primary focus of the consultant in giving specialized opinions and recommendations in regard to the program difficulty and, attempting to improve the problem-solving capacity of the consultee through the handling of a case problem.

 

Refugee/victim-centered case consultation: This is a traditional type of consultation where the consultant is asked for his opinion, diagnosis, and assessment of personality problems of an individual refugee. In addition, the consultant might recommend a plan for the most effective approach to resettling the refugee/victim.

The primary goal of the consultation is for the consultant to communicate a method to the consultee indicating how the refugee/victim can be helped. A subsidiary goal is that the consultee will use his experience with this case to improve his knowledge and skills in working with other refugees and will be prepared to handle comparable future problems.

 

A staff member asked the consultant to help him deal with a nine-yearold Vietnamese orphan who kept returning to a family that had befriended him enroute to the camp. He had been housed with a foster family chosen by the authorities. As the situation was analyzed, it showed that the foster family was a close-meshed one with one infant and a toddler. The "friendly" family consisted of parents and two adolescents. When the consultant obtained a detailed history of how the orphan spent his day he learned that the child had to accommodate his activities to the baby's schedule. This caused many difficulties between him and his foster mother. Advice and suggestions were given by the consultant on how the needs of the child could be balanced with the household routine.

 

Consultee-centered case consultation: The consultant focuses his attention on trying to understand the nature of the work difficulties for a consultee with regard to a refugee/victim and on helping him to remedy these difficulties.

The consultee's difficulties may be due to:

 

1. Lack of knowledge about the type of problem presented by the refugee

2. Lack of skill in making use of such knowledge

3. Lack of self-confidence in utilizing his knowledge and skills

4. Lack of professional objectivity due to subjective emotional complications

 

The consultant may assist the consultee to increase his knowledge or skills; he may support and reassure him to increase his self-confidence; and/or he may help hire increase his professional objectivity so as to reduce the distortion in his perception of the refugee's condition.

The hope is always that improvement in professional functioning will enable the consultee to solve the problem of the refugee/victim and that this improvement will be maintained in the future in relation to individuals with similar difficulties. The aim of this type of consultation is frankly to educate the consultee, using problems with a current individual lever and learning opportunity.

 

Mary, a ten-year-old girl who was housed in a temporary shelter following a tornado, was brought to the medical unit for diagnosis of continued vomiting. As she was being evaluated, the child became more anxious. She lost control of her bladder and urinated on the floor. This strange behavior upset the examining physician who called in a psychiatric consultant. The consultant focused on explaining to the physician the situation in which Mary had been found under the collapsed porch of her home, after spending part of the night alone. Understanding how posttraumatic situations affect children, produce regressive behavior and weaken acquired bodily control functions assisted the consultee in dealing with his patient. The consultant was able to sort out pathology, traumatic reactions to past events and adaptive mechanisms to continuous stress.

 

Program-centered administrative consultation: The work problem in this type of consultation is in planning and administration of the camp and the concern is how to develop a new program or improve an existing one. The consultant helps by using his knowledge of administration and social systems, of mental health theory and practice, and of problem development in other areas in order to collect and analyze data about camp issues. He suggests short-term and long-term solutions for the administrative human problems of the camp organization.

The primary goal for the consultant is to prescribe an effective course of action in planning the program.

 

The recreational director of a camp complained to a consultant that he was unable to interest a group of adolescent refugees in attending organized activities. As the issues and schedules were analyzed, it became clear that attending these events produced a conflict for the refugees who wanted to be first in line to eat at the cafeteria. The recreational activities were at the end of the day and overlapped with the time when waiting lines to enter the cafeteria congregated. The adolescents preferred to go there than to the recreation, due to their anxiety that food would be exhausted before they arrived.

Consultee-centered administrative consultation: This is similar to consultee-centered case consultation. However, the focus is on problems of programming and camp organization instead of problems with a particular refugee/ victim.

In addition to lack of knowledge, skills, self-confidence, and objectivity, the consutanee's problem may be the result of personnel conflicts-poor leadership, authority problems, lack of staff role definitions, communication blocks and so forth. The consultant's goal is to understand and help remedy these working conflicts. His successes will enable the consultee to develop and implement plans to accomplish the mission of the camp.

Some literature on consultation (Berlin, 1964; Cohen, 1964) uses the restricted definition that denotes a process of interaction between two professional persons, the consultant who is a specialist and the consultee who invokes the consultant's help in regard to current work problems. This differs from the broader understanding of consultation and support activities which defines the consultant to be included in the organizational and administrative responsibility for program and clients.

This latter model is more appropriate for the aims of the consultant working in a relocation camp. Observing many aspects of human behavior is necessary for the psychiatric consultant to understand the refugee. His active participation requires an understanding of the following: 1) the living conditions within the unfamiliar setting of a refugee/victim camp; 2) the community environments in which the refugee will resettle; and 3) the changes involved for the refugee in the final activities of resettlement and physical transportation to his sponsor, community house or employment area.

Psychological assistance may make the difference between success and failure for a refugee/victim. Therefore, it is essential for the consultant to have different levels of responsibility and involvement. This is exemplified by the following description:

 

A consultant who was working with the leaders of a city that had been destroyed by an earthquake was asked to participate in a series of meetings to plan the care of a large number of refugees housed in two camps. The activities to be planned included housing, feeding, child health care, and placement of housekeeping and recreational facilities. The consultant participated with all the human service systems affecting this population. After acquiring first-hand knowledge of the problems faced by the service organizations and the needs of the victims, the consultant was able to introduce psychological concepts into the design program service plans.

 

 

Collaboration

 

Another technique utilized by the child psychiatrist in the refugee camp is collaboration. In collaboration, the consultant participates with the consultee in understanding, investigating and analyzing the problems of the child refugee.

 

A counselor in a camp asked the consultant to assist him in dealing with a fourteen year-old Cuban refugee male who had three episodes of convulsion. The goal of differential diagnosis was to establish whether these attacks were organic or functional. The EEG appeared normal. The consultant interviewed the youth and learned that in Cuba his family believed in witchcraft. He had come alone to the United States and felt so lonely, frustrated and depressed in the camp that he believed he had been "punished by the devil." When he became overwhelmed by his feelings he also became frightened at the thought that the "spirits were in his body." The consultee participated with the consultant to change some of the boy's situations and to help him adapt to the difficulties of living in camp.

 

The responsibility for the refugee/victim is shared between the consultant and consultee, each of whom is expected by the other and by the refugee to carry out certain procedures. These procedures may be carried out by the consultant who will act both directly with the child and indirectly with the consultee. For instance, the child psychiatrist may evaluate the child refugee/victim in his living setting, recommend that the refugee/victim come for counseling, prescribe medication and, subsequently, discuss the case with the consultee. On the other hand, the plan of action may be sequential and may have several phases in terms of assisting the refugee/victim through the tasks that he must complete before resettlement. The child psychiatrist and consultee working in the transitional camp setting maintain continuous contact with each other during the duration of the operations and share the responsibility for successful outcome.

There are important differences between this pattern of professional interaction and the traditional type of consultation. In collaboration, the consultant determines his behavior primarily on the basis of his evaluation and diagnostic assessment of the refugee/victim, for whom he accepts direct responsibility. He works together with his colleague, the consultee, who will examine other aspects of refugee/victim life and who will participate in seeing that whatever procedure is recommended will be carried out.

Although the consultant may communicate his procedures, there are some areas of diagnostic content that are confidential and should not be shared with the consultee. This distinction between classic consultation and collaboration within the refugee camp setting is noteworthy.

It is possible in a relocation camp to combine consultation and collaboration elements. However, the following problems can occur in combining the two techniques: 1) miscommunication, 2) barriers in interpretation, 3) overstepping the boundaries of the task of the consultee, and 4) scapegoating. The behavior of a consultant who over-identifies with the refugee/victim's plight highlights issues of miscommunication and misinterpretation of cues given by staff, leading to overstepping the boundaries of the psychiatric consultant.

 

A consultant was asked to accompany a camp counselor to the building that housed adolescents who had broken a camp regulation. The camp setting was staffed by paramilitary personnel and the building served as jail for the camp. One of the adolescents who had been caught hit one of the guards and was handcuffed to his bed pending investigation. The counselor was interested in finding out what had happened and in using his expertise to help the youngster regain control.

He started asking questions of the guards and turned to the consultant to ask him to interpret the issues to the military personnel. The consultant became incensed and believed that he was being manipulated to sanction this type of punishment. He berated both the counselor and the guards for their lack of sensitivity and went to see the director of the camp, accusing the camp counselor of allowing a refugee to be handcuffed.

After an investigation, it was found out that the camp personnel had followed policy and were trying to help contain a very dangerous situation. The consultant had very few facts before he became emotionally overwhelmed.

 

 

Education

 

Consultation has an aspect of education directed to helping the consultee with his current work problems in relation to a specific refugee/victim or his program. The consultee uses consultation to add to his personal knowledge and to reduce areas of misunderstanding in order that he may deal more effectively in the future with a similar problem.

It is this educational aspect of consultation that makes it an important refugee/victim resettlement method. A goal is to spread the application of the psychiatric consultant's mental health knowledge to the many agencies that will continue working with refugee migration/resettlement.

Education as a specialized professional activity needs to be conceptualized as an indirect methodology. This indirect methodology has important merits in a relocation camp, including the widespread effect of the resettlement agencies on large numbers of refugees/victims. In order to use the limited time of the consultant effectively in helping the consultees deal with the problems of a refugee/ victim, the child psychiatrist needs to design specific boundaries with the maximum educational carryover.

 

 

OPERATIONAL GUIDELINES

 

The focus of this section is to provide consultants with common guidelines and language necessary in order to work with consultees. These consultees have the responsibility of planning, initiating, and making the resettlement program of refugees/victims operational.

A key concern for the consultant is to match the activity rhythm and professional tone of the camp worker. This tone reflects crisis, emergency, and immediacy of need.

 

Steps to Developing Mental Health Consultation

in a Refugee Camp

 

1. Proximity and Reputation: A fundamental principle in developing a positive relationship with camp personnel and gaining trust and credibility is to create proximity and establish the reputation of being trustworthy, competent, and interested in helping without infringing on the rights of the staff or endangering their approaches and programs in the camp (Caplan, 1968).

2. Offer Collaborative Services: Initial contact can be established by the offer of collaborative services to the refugees/victims referred for psychiatric diagnostic evaluation. Such referrals when accepted can be used as a cue to the needs of the camp workers. Each case is carefully observed to assess the problems that the individual presents. The consultant then offers to share information and assist in the problem resolution with the appropriate worker.

3. Initiate Simple Report System: The rights of the refugee/victim to confidentiality and competent diagnosis and treatment can be safeguarded even while relationships with the other staff are being built during the initial period. This means, however, sending an immediate written communication, followed by subsequent information on the progress and management, to the appropriate camp staff. Language must be simple and understandable. These reports can also provide opportunities for mental health workers to participate in daily meetings with as many staff persons as possible, thus initiating relationships and beginning to build a picture of the social system and culture of the camp. The opportunities to disseminate knowledge, support therapeutic attitudes, and assist in developing good team morale exist every time a consultant has to report his findings.

4. Personal Contact with Authority Figure: Another important principle is for the consultant to realize the importance of making personal contact with the top authoritative figure of the camp as soon after his entry as possible. The purpose of this contact is to obtain sanction for his exploratory and negotiatory operations in the camp. This is particularly important if the consultant is invited informally by a middle-management member of the staff.

5. Explore Organized Patterns of Camp: The mental health consultant should explore the organizational pattern and system of the camp in order to recognize its authority and communication network. He should be careful not to accept a distorted point of view by using information contributed by some people and missing others. In his explorations the consultant should learn about the camp's mission of transitional living as well as about the relief procedures, relocation values, and traditions of its workers.

The consultant can then ascertain whether he can make a contribution that might simultaneously help fulfill the objectives of the resettlement program. Insofar as this is possible, he will foster the building of a relationship of mutual trust and respect that may form a basis for collaboration. He should actively begin to know the camp staff and help this staff get to know him. He should clarify the nature of his expert assistance. He also must clearly express his readiness and availability to work with the camp in pursuit of mutual or compatible goals.

 

The active exploration of the camp organization was used by a consultant to widen his base of sanction and intervention. When he was asked to assist with a program of daily activities for the refugees, he asked to meet with a group of camp teachers. The consultant had not participated in the educational sector of the camp program, even though many adaptation problems were exhibited by children who were learning English as a second language. He expressed an interest in observing the classroom situation. During his interaction with the teachers he shared his knowledge of the relation of stress and emotions to learning. The teachers became aware of many puzzling experiences they had had with the refugees and asked for further consultation.

 

This process may provide the opportunity to discuss a wider range of topics, including policies and problems faced daily by the camp personnel. It might also open discussion to areas of staff interest in collaborating to pursue the resettlement goals.

6. Establish Communication Patterns: The establishment of communication patterns within the conflicting, fragmented, and distorted network of a camp setting is not an uncomplicated process. The communication link person who has the power to transmit important information is a gatekeeper as well as a messenger of information across units in the camp. The director of the camp is obviously concerned with area surveillance and legal control. He needs to satisfy himself that the activities of the consultant are not going to undermine his position within the operations of the camp before he will allow messages to pass freely. Until he is satisfied, however, he is likely to exert control and to be highly selective in deciding what type of meetings and communications are to be allowed between individuals. At the beginning, he may permit consultation requests for senior and trusted staff only. Serendipity opportunities allow, at times, for crossing barriers to communication. The following example highlights this occurrence:

 

As a camp program was winding down, the need to place 150 unaccompanied minors into the community became an urgent matter to the camp director. He called a meeting of all the chiefs of services to develop a plan of action. The consultant to this camp invited himself along with the chief of mental health services. During the discussion it became evident that the manner in which decisions were going to be made would have an important mental health implication. The consultant offered his opinions and suggestions. He had only been allowed to participate in the so-called "mental health program" before this meeting. When the director became aware of the many psychological ramifications of the planning and how it would affect all the components of the camp program, he urged all his service chiefs to confer with the consultant in regard to their programs.

 

Conflicts of Interest

Conflict of value priorities between the consultant and the staff of a refugee/victim camp can easily occur. Each of the camp workers has responsibilities and may feel that a mental health consultant could encroach on his territory or oblige him to change his way of operating. It may be, in fact, that the consultant will fill functions that no staff person is equipped to undertake, and that he may help them to do better and more easily what they were already doing. However, unless the consultant learns what each has been doing and carefully defines his own role so as not to overlap with their work-and unless he succeeds in communicating this clearly to them-it is likely that some camp staff will either overtly or covertly oppose his entry into the system. The fragmentation and multiple governmental and private resettlement agencies that are part of relocation camp programs make it difficult to constantly keep in mind everybody's task.

Distortions of Perception and Expectation

Some of the distortions of camp personnel perception and expectation will be traditional or cultural; that is, they will be shared by most of the camp staff and will be based on common professional ideologies including their feelings about the cultural background of the refugees/victims. Their perception of the consultant as a person coming from a different background that may clash with the values of the camp staff or is insensitive to refugee ethnic background can promote barriers to communication.

These culturally based stereotypes are, of course, likely to be compounded by individual emotional reactions to and misperceptions of the consultant. This is especially true when the consultant is working within a climate of heightened tension and unrest characteristic of relocation camps, where the normal defensive structure of individuals responsible for solving severe problems may already be weakened.

An essential task of a consultant is to be aware of the irrational perceptual stereotypes utilized by tired, overwhelmed camp staff and existing within the crisis climate of relocation camps. He learns about them from behavioral cues, by being sensitive to the implied meaning of words and actions of the camp staff, and particularly by being aware of any defensive maneuvers toward him. He should allow the staff full freedom to manipulate him, to reveal their stereotype fears, to test and confirm their suspicions, and also to exhibit ways of excluding him. To counteract these behaviors, the consultant should then take steps to dissipate the distortions and replace them with opportunities for the consultee to examine him. He should do this by taking an active role in educating camp staff about his own value system, his feelings about religion and skin color, and his respect for the individuality of human beings regardless of background.

The consultant must be alert to both the manifest and latent content of communication. The need for camp staff to repeatedly test out fearful stereotypes must continuously be met by the consultant's methods to invalidate these stereotypes. He must talk directly and give both verbal and nonverbal messages to clear the air and establish realistic interactions.

 

Developing a Common Language

 

The removal of distortions of perception between consultant and consultee in the camp enhances an opportunity for better communication. The communication can be effective, however, only when the two sides share common values, philosophy, and language. This is a serious problem in camp settings due to the many variables already identified. The consultant must make a special effort to learn the specific modes of communication in the camp setting. This relates not only to vocabulary but also to behavior such as gestures, comfort distance between people, and levels of formality or informality practiced by military, civilian, voluntary, and religious agencies.

The consultant must constantly search for feedback from his consultees to ascertain that they have understood his point of view. Likewise, he must check to see that he has understood their verbal and nonverbal communication.

 

 

A black American consultant was having difficulties convincing an Irish camp guard chosen from the National Reserve, who was dealing with a Vietnamese family, that he could advise him in how to deal with the passive-aggressive behavior of a fourteen-year-old girl. The consultant was aware of the racial prejudice involved and had to tell the guard about his own experiences in Vietnam where he had been sensitized to understand the behavior of the refugees. After he "earned" credibility with the guard, they were able to focus on how to understand the girl who was not obeying the M.P. controls.

 

 

Ground Rules for Collaboration

 

Ground rules for collaboration include the need to work out and maintain consensus of objectives. The nature of the consultant's operation within the camp and the problems with which he is dealing varies with the type and status of the individual or organization that is seeking help.

The consultant must continuously ensure that his current role, as identified by the power-authority structure, is clearly defined. This role clarity will help the camp staff know what kinds of situations are appropriate to discuss with him and what they may expect from the collaboration.

These ground rules should include a clear awareness of the social sanction for this joint activity, especially as camps continually and rapidly change directors. There must also be guidelines for contacting the consultant. For example, a) who is and is not allowed to contact the consultant, b) where, c) in what situation, d) for how long, e) how often, f) through which group, g) for what purpose, h) what the consultant can be expected to do, i) what he must do, and j) what he will not do.

 

 

Successive Stages of Camp Specialist's Role

 

At the beginning of his contact with a camp, the consultant may be a relatively unknown and unsanctioned visitor whose operations are confined to helping a single group of staff members with a particular refugee/victim. The specialist may observe or examine in order to make a diagnosis, prescribe treatment, or refer to another component of the health or medical health delivery system inside or outside of the camp. The specialist is strictly a case evaluator.

At a second stage, the consultant may have received permission from the camp director to explore the possibility of more extensive collaboration. He may be invited to meet with staff and increase their knowledge of mental health matters by giving them short lectures, by leading discussion or by directing half-hour seminars. During such rapid, focused interactions, the psychiatric consultant will learn about the intense work problems and severe difficulties the staff encounters with the refugees/victims. Camp staff will discover whether the expert's attitude is relevant to their immediate concerns and whether he is willing and able to assist them with their urgent problems. During this stage, the consultant serves as an emergency expert whose role is that of staff instant educator.

During the third stage, the specialist may be invited on an occasional or a regular basis to talk with individuals or groups of the staff about specific refugees/victims. He will be expected to screen each refugee and make referrals to other clinics for investigation and treatment, or else he may be expected to offer advice on appropriate management within the camp. The consultant's role clearly includes full consultation during this phase.

The consultant may also be expected to act as a collaborator in certain cases and to treat some of the refugees/victims himself, either during his visit to the camp or in some other clinic in the community.

In addition, the consultant is likely to be asked to deliver messages about refugees/victims who are being treated in his clinic or other hospitals and to provide reports from his colleagues to the camp staff about the progress of these cases. During this stage, the consultant plays a liaison role.


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