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
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
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 (
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 (
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
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
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
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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