10 Clinical Applications With Refugees Oksana Yakushko and Indhushree Rajan FLEEING RELIGIOUS PERSECUTION: THE STORY OF...

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10 Clinical Applications With Refugees Oksana Yakushko and Indhushree Rajan FLEEING RELIGIOUS PERSECUTION: THE STORY OF LARISSA The following case focuses on the experience of a religious refugee from Eastern Europe. The case highlights distinct challenges faced by refugees based on their religious affiliation, national origin, and refugee background. Case Description Larissa is a Russian refugee woman in her late 40s. She moved to the United States with her husband and six children during the early 1990s under the religious refugee relocation program. Prior to migration, Larissa, a member of conservative evangelical Baptist church, experienced numerous instances of prejudice and discrimination. She was denied access to higher education and fired from her jobs because of her religious affiliation. Her children reported bullying at schools and their community. Similarly, her husband was allowed to hold only menial jobs. He was also imprisoned for severa months for his participation in "religious proselyting," illegal under Sovie 141 142 CASE STUDIES IN MULTICULTURAL COUNSELING AND THERAPY laws. When her oldest son was hospitalized after being physically attacked on his way back from a church function, Larissa actively pursued relocation options she knew were available to religious minorities. of discrimination and prejudice. Her appearance made her stand out from Since moving to the United States, Larissa struggled further with feelings others; because of her religious convictions, she did not cut her hair or use makeup. She always wore long skirts. Although she has been in the United States for several decades, she was never able to learn English. She resided in a community with other Russian-speaking Baptists. She worked alongside her husband and others from her community at a meat-packing plant. She devoted much of her time to her church: She sang in a choir during several weekly services, made meals for the needy in the community, and led her women's prayer group. Larissa was referred to counseling at the employee assistance program counseling by her supervisor at work. She initially refused to speak with a counselor, stating that "only God and her church" can help her. Fearing she would lose her job, she decided to "try it" for only few sessions. Her super- visor noticed that Larissa appeared sad, numb, and confused when spoken to. During conversations at his workplace, her husband explained to the enough and letting God heal her." in and no ing a national 272 char multip autise he for her Sametime antial sessio and her inter hased supervisor that he believed that Larissa was "falling into sin" by "not praying us min During the initial session, the counselor, working through an interpreter. learned that Larissa's difficulties began when her oldest son announced that he was moving away to live on his own. The counselor also learned that the son began to abuse alcohol. Larissa stated that it was "all her fault," because she did not do her duties as a Christian mother. She expressed an intense worry over decisions made by her other children. Although they attended a church-based school, she was aware that they had access to other "ungodly" influences. Having her children "leave God for Satan" felt devastating to her. She experienced her husband as frequently angry with her for not doing well her "wifely duties." During counseling, Larissa shared that she has unusual physical sensa tions in her abdomen. She prayed about them and sought "prayer help from her church members, but these sensations seemed to intensify over the past several months. She expressed reluctance to seek medical help be cause she believed that "God alone" can heal and that doctors "should not take God's place." However, she felt physically uncomfortable most of the The de ach a session buur het str Larissa h her. She HERAPY y attacked relocation h feelings out from ir or use United esided in ongside ant. She several led her ogram with a ng she uper- oken o the ying eter, hat the use se la T. T Clinical Applications With Refugees 143 ime and was worried that her declining health would influence her ability to be with her family or serve her church. Larissa initially refused to sign a consent form. In several discussions with ber counselor and interpreter, she disclosed that as a religious minority in the former Soviet Union and now a religious refugee in the United States, she felt tremendous distrust of all authorities. She especially doubted that information in the counseling sessions will remain confidential. After several discussions regarding a rationale for the consent form and reassurance about confidentiality in treatment, she agreed to fill out and sign documentation. However, she felt that multiple assessments as part of the initial paperwork to confuse her and to expose her to others. She also shared that it was difficult for her to answer questions "not as God wants her to were designed think" but as she "sometimes feels." During the initial sessions, Larissa was reluctant to open up. She trusted her counselor and her interpreter only when she perceived that they were sup- portive rather than judgmental of her religious beliefs. During a therapeutic intervention that focused on rapport building, the counselor and interpreter processed with Larissa her fear that counseling is intended to "Americanize and secularize" her. She was reticent to speak about her past or current experi- ences as a religious minority. However, she appeared relieved to discuss her relationship with her son and other family members, a topic she felt ashamed to bring up with others in her community. A family session was offered. She refused such a session because she did not want her children or her husband to hear about her "struggles." She did agree to receive a medical screening with a local medical provider who was a member of an English-speaking Baptist church. The medical provider requested that the counselor attend with her. Reflection and Discussion Questions 1. What further information about Larissa's case as a religious refugee would you need in order to proceed with therapy 2. What rapport-building strategies would you use with Larissa, given that she is both unfamiliar with the process of counseling and reluc- tant to engage in treatment? How could the intersection of Larissa's cultural values and religious influence the rapport building? 3. What challenges may arise in working with an interpreter? What ethi- cal considerations could emerge with using an interpreter? ht All- -edge and high Tou 144 CASE STUDIES IN MULTICULTURAL COUNSELING AND THERAPY religious 4. What would be your approach to dealing with cultural or present- views and experiences that may be drastically different from your own (e.g., patriarchal norms, abusive partner relations)? 5. What do you believe are the key factors influencing Larissa's ing concerns? How would you address the presenting concerns in th She ma "related to 6. How would you manage the conflict with Larissa about seeking therapy? urgent medical care? Brief Analysis of the Case addition, if o uourdown on many i ely to distrust na consent es may be ar clients ther challeng nding the stri selors view a e seen as norm counselors e-being of the the most cultu Larissa's challe grant and ref Although popular media have highlighted certain aspects of the refugee experience (i.e., torture or war survivors), other categories of refugees typi- cally are unknown to many U.S. individuals. One such example is religious refugees. One of the first waves of religious refugees began in the 1970s with Soviet-born individuals of Jewish descent. These individuals experienced tremendous prejudice and discrimination not only because of their ethnicity but also because of their religious practices. Larissa's case exemplifies many of these struggles dis And be y primarily In their homeland, religious minorities typically are denied educational and work opportunities and are continually harassed by state authorities. Some individuals experience direct violence because of their religious affilia- tion. Religious refugees come from many countries where religious diversity is not tolerated, such as those dominated by communist ideals (e.g., China, North Korea) or those with state-supported dominant religions (e.g., Paki- stan, Sudan). wish to engage in self-education For Larissa epical cultur their childre ion (e.g The case o perienced by encing xen A culturally responsive counselor may about the ways in which refugee status is assigned. In the case of Larissa, a counselor may wish to understand the differences between a U.S.-based image of a "Baptist" church member versus the "Baptist" affiliated religious person from another country, such as Larissa (ie., small and culturally marginalized). Larissa represents a person with very traditional beliefs and practices. It may be helpful to read information about conservative and ultraconservative religious communities in the United States to understand how their religion defines their worldview and dictates their life choices. Among key challenges in working with religious refugees like Larissa is building rapport. In fact, because of faith beliefs, Larissa, like most religious udice to h be also Siggant start Larissa's interpret preter bul exp HERAPY or religious your own s present- ncerns in secking refuge es typi- eligious Os with ienced nicity many Fional Fities. filia- rsity ina, aki- on a ge 2 refugees, is unlikely Clinical Applications With Refugees 145 to seek counseling services and may view them as con- sinful weakness" related to her inability to "trust God" or "be healed through trary to her faith. She may see her agreement to seek counseling as a sign of about her participation in counseling, she may be ostracized and judged. prayer." In addition, if others within Larissa's refugee community learned In addition, many tion are individuals who experienced governmental persecu- e likely to distrust assurances of confidentiality. Like Larissa, they may a consent form. Because of legal and ethical responsibilities, refuse to sign counselors may be at difficult crossroads in approaching documentation with such clients. Another challenge of working with religious minority clients may be in understanding the strict gender and family roles to which they adhere. What U.S. counselors view as emotionally or physically abusive relational practices be seen as normal and divinely ordained within Larissa's community. Although counselors must follow their commitment to supporting the safety and well-being of their clients, they may also seek to understand how to do so in the most culturally sensitive manner. may Larissa's challenging relationship with her children is typical for most immigrant and refugee families. Intergenerational conflict can contribute to significant distress among refugee parents. Often this distress is espe- cially profound because many refugee adults opt for relocation to a foreign country primarily for the benefit of their children. For Larissa and other religious refugees, such conflicts often exceed the typical cultural rifts between generations: Conservative religious parents view their children's loss of culture and faith as a sign of their children's con- demnation (e.g., their "going to hell"). Thus, her fears may be traumatically disturbing for her. The case of religious refugees such as Larissa also highlights the realities experienced by racially White immigrant individuals. Larissa reports ex- periencing xenophobia and discrimination. Although she may assign such prejudice to her religious minority status, it is likely that negative attitudes may be also related to her linguistic difference, cultural practices, and im- migrant status. Larissa's case points to the vital importance of collaborative work with an interpreter. A counselor who has access to a trained and experienced interpreter is more likely to create a culturally safe and therapeutically suc- cessful experience for the client. 146 CASE STUDIES IN MULTICULTURAL COUNSELING AND THERAPY sessment and treatment, including a multidisciplinary approach that may Larissa's case points to the importance of flexibility in approaching as include medical or pastoral care. In addition, the counselor and interpreter may choose to forgo the use of the formal assessments and include relevant questions as part of the sessions (e.g., suicide assessment, domestic violence assessment, trauma assessment). Recommended Resources Books and/or Articles Brody, E. (1994). The mental health and well-being of refugees: Issues and directions. In A. J. Marsella, T. H. Bornemann, S. Ekblad, & J. Orley (Eds.), Amidst peril and pain: The mental health and well-being of the world's refugees (pp. 57-68). Washington, DC: American Psychological Association. Hill, P., & Pargament, K. (2003). Advances in the conceptualization and measurement of religion and spirituality implications for physical and mental health research. American Psychologist, 58, 64-74- Koenig, H. G., McCullough, M., & Larson, D. B. (2001). Handbook of religion and health: A century of research reviewed. New York, NY: Oxford University Press. Levitt, P. (2007). God needs no passports: Immigrants and the changing American religious landscape. New York, NY: New Press. McCullough, M. E. (1999). Research on religion-accommodative counseling: Review and meta-analysis. Journal of Counseling Psychology, 46, 92-98. Miller, A. M., Birman, D., Zenk, S., Wang, E., Sorokin, O., & Connor, J. (2009). Neighborhood immigrant concentration, acculturation, and cultural alienation in former Soviet immigrant women. Community Psychology, 37, 88-105. doi:10.1002/jcop.20272 Journal of Miller, A. M., Sorokin, O., Wang, E., Feetham, S., Choi, M., & Wilbur, J. (2006). Acculturation, social alienation and depressed mood in midlife women from the former Soviet Union. Research in Nursing & Health, 29 134-146. doi:10.1002/nur.20125 Miller, W. R., & Thoresen, C. E. (2003). Spirituality, religion, and health. An emerging research field. American Psychologist, 58(1), 24-35. Salsman, J. M., Brown, T. L., Brechting, E. H., & Carlson, C. R. (2005). The link between religion and spirituality and psychological adjustment: 10 Clinical Applications With Refugees Oksana Yakushko and Indhushree Rajan FLEEING RELIGIOUS PERSECUTION: THE STORY OF LARISSA The following case focuses on the experience of a religious refugee from Eastern Europe. The case highlights distinct challenges faced by refugees based on their religious affiliation, national origin, and refugee background. Case Description Larissa is a Russian refugee woman in her late 40s. She moved to the United States with her husband and six children during the early 1990s under the religious refugee relocation program. Prior to migration, Larissa, a member of conservative evangelical Baptist church, experienced numerous instances of prejudice and discrimination. She was denied access to higher education and fired from her jobs because of her religious affiliation. Her children reported bullying at schools and their community. Similarly, her husband was allowed to hold only menial jobs. He was also imprisoned for severa months for his participation in "religious proselyting," illegal under Sovie 141 142 CASE STUDIES IN MULTICULTURAL COUNSELING AND THERAPY laws. When her oldest son was hospitalized after being physically attacked on his way back from a church function, Larissa actively pursued relocation options she knew were available to religious minorities. of discrimination and prejudice. Her appearance made her stand out from Since moving to the United States, Larissa struggled further with feelings others; because of her religious convictions, she did not cut her hair or use makeup. She always wore long skirts. Although she has been in the United States for several decades, she was never able to learn English. She resided in a community with other Russian-speaking Baptists. She worked alongside her husband and others from her community at a meat-packing plant. She devoted much of her time to her church: She sang in a choir during several weekly services, made meals for the needy in the community, and led her women's prayer group. Larissa was referred to counseling at the employee assistance program counseling by her supervisor at work. She initially refused to speak with a counselor, stating that "only God and her church" can help her. Fearing she would lose her job, she decided to "try it" for only few sessions. Her super- visor noticed that Larissa appeared sad, numb, and confused when spoken to. During conversations at his workplace, her husband explained to the enough and letting God heal her." in and no ing a national 272 char multip autise he for her Sametime antial sessio and her inter hased supervisor that he believed that Larissa was "falling into sin" by "not praying us min During the initial session, the counselor, working through an interpreter. learned that Larissa's difficulties began when her oldest son announced that he was moving away to live on his own. The counselor also learned that the son began to abuse alcohol. Larissa stated that it was "all her fault," because she did not do her duties as a Christian mother. She expressed an intense worry over decisions made by her other children. Although they attended a church-based school, she was aware that they had access to other "ungodly" influences. Having her children "leave God for Satan" felt devastating to her. She experienced her husband as frequently angry with her for not doing well her "wifely duties." During counseling, Larissa shared that she has unusual physical sensa tions in her abdomen. She prayed about them and sought "prayer help from her church members, but these sensations seemed to intensify over the past several months. She expressed reluctance to seek medical help be cause she believed that "God alone" can heal and that doctors "should not take God's place." However, she felt physically uncomfortable most of the The de ach a session buur het str Larissa h her. She HERAPY y attacked relocation h feelings out from ir or use United esided in ongside ant. She several led her ogram with a ng she uper- oken o the ying eter, hat the use se la T. T Clinical Applications With Refugees 143 ime and was worried that her declining health would influence her ability to be with her family or serve her church. Larissa initially refused to sign a consent form. In several discussions with ber counselor and interpreter, she disclosed that as a religious minority in the former Soviet Union and now a religious refugee in the United States, she felt tremendous distrust of all authorities. She especially doubted that information in the counseling sessions will remain confidential. After several discussions regarding a rationale for the consent form and reassurance about confidentiality in treatment, she agreed to fill out and sign documentation. However, she felt that multiple assessments as part of the initial paperwork to confuse her and to expose her to others. She also shared that it was difficult for her to answer questions "not as God wants her to were designed think" but as she "sometimes feels." During the initial sessions, Larissa was reluctant to open up. She trusted her counselor and her interpreter only when she perceived that they were sup- portive rather than judgmental of her religious beliefs. During a therapeutic intervention that focused on rapport building, the counselor and interpreter processed with Larissa her fear that counseling is intended to "Americanize and secularize" her. She was reticent to speak about her past or current experi- ences as a religious minority. However, she appeared relieved to discuss her relationship with her son and other family members, a topic she felt ashamed to bring up with others in her community. A family session was offered. She refused such a session because she did not want her children or her husband to hear about her "struggles." She did agree to receive a medical screening with a local medical provider who was a member of an English-speaking Baptist church. The medical provider requested that the counselor attend with her. Reflection and Discussion Questions 1. What further information about Larissa's case as a religious refugee would you need in order to proceed with therapy 2. What rapport-building strategies would you use with Larissa, given that she is both unfamiliar with the process of counseling and reluc- tant to engage in treatment? How could the intersection of Larissa's cultural values and religious influence the rapport building? 3. What challenges may arise in working with an interpreter? What ethi- cal considerations could emerge with using an interpreter? ht All- -edge and high Tou 144 CASE STUDIES IN MULTICULTURAL COUNSELING AND THERAPY religious 4. What would be your approach to dealing with cultural or present- views and experiences that may be drastically different from your own (e.g., patriarchal norms, abusive partner relations)? 5. What do you believe are the key factors influencing Larissa's ing concerns? How would you address the presenting concerns in th She ma "related to 6. How would you manage the conflict with Larissa about seeking therapy? urgent medical care? Brief Analysis of the Case addition, if o uourdown on many i ely to distrust na consent es may be ar clients ther challeng nding the stri selors view a e seen as norm counselors e-being of the the most cultu Larissa's challe grant and ref Although popular media have highlighted certain aspects of the refugee experience (i.e., torture or war survivors), other categories of refugees typi- cally are unknown to many U.S. individuals. One such example is religious refugees. One of the first waves of religious refugees began in the 1970s with Soviet-born individuals of Jewish descent. These individuals experienced tremendous prejudice and discrimination not only because of their ethnicity but also because of their religious practices. Larissa's case exemplifies many of these struggles dis And be y primarily In their homeland, religious minorities typically are denied educational and work opportunities and are continually harassed by state authorities. Some individuals experience direct violence because of their religious affilia- tion. Religious refugees come from many countries where religious diversity is not tolerated, such as those dominated by communist ideals (e.g., China, North Korea) or those with state-supported dominant religions (e.g., Paki- stan, Sudan). wish to engage in self-education For Larissa epical cultur their childre ion (e.g The case o perienced by encing xen A culturally responsive counselor may about the ways in which refugee status is assigned. In the case of Larissa, a counselor may wish to understand the differences between a U.S.-based image of a "Baptist" church member versus the "Baptist" affiliated religious person from another country, such as Larissa (ie., small and culturally marginalized). Larissa represents a person with very traditional beliefs and practices. It may be helpful to read information about conservative and ultraconservative religious communities in the United States to understand how their religion defines their worldview and dictates their life choices. Among key challenges in working with religious refugees like Larissa is building rapport. In fact, because of faith beliefs, Larissa, like most religious udice to h be also Siggant start Larissa's interpret preter bul exp HERAPY or religious your own s present- ncerns in secking refuge es typi- eligious Os with ienced nicity many Fional Fities. filia- rsity ina, aki- on a ge 2 refugees, is unlikely Clinical Applications With Refugees 145 to seek counseling services and may view them as con- sinful weakness" related to her inability to "trust God" or "be healed through trary to her faith. She may see her agreement to seek counseling as a sign of about her participation in counseling, she may be ostracized and judged. prayer." In addition, if others within Larissa's refugee community learned In addition, many tion are individuals who experienced governmental persecu- e likely to distrust assurances of confidentiality. Like Larissa, they may a consent form. Because of legal and ethical responsibilities, refuse to sign counselors may be at difficult crossroads in approaching documentation with such clients. Another challenge of working with religious minority clients may be in understanding the strict gender and family roles to which they adhere. What U.S. counselors view as emotionally or physically abusive relational practices be seen as normal and divinely ordained within Larissa's community. Although counselors must follow their commitment to supporting the safety and well-being of their clients, they may also seek to understand how to do so in the most culturally sensitive manner. may Larissa's challenging relationship with her children is typical for most immigrant and refugee families. Intergenerational conflict can contribute to significant distress among refugee parents. Often this distress is espe- cially profound because many refugee adults opt for relocation to a foreign country primarily for the benefit of their children. For Larissa and other religious refugees, such conflicts often exceed the typical cultural rifts between generations: Conservative religious parents view their children's loss of culture and faith as a sign of their children's con- demnation (e.g., their "going to hell"). Thus, her fears may be traumatically disturbing for her. The case of religious refugees such as Larissa also highlights the realities experienced by racially White immigrant individuals. Larissa reports ex- periencing xenophobia and discrimination. Although she may assign such prejudice to her religious minority status, it is likely that negative attitudes may be also related to her linguistic difference, cultural practices, and im- migrant status. Larissa's case points to the vital importance of collaborative work with an interpreter. A counselor who has access to a trained and experienced interpreter is more likely to create a culturally safe and therapeutically suc- cessful experience for the client. 146 CASE STUDIES IN MULTICULTURAL COUNSELING AND THERAPY sessment and treatment, including a multidisciplinary approach that may Larissa's case points to the importance of flexibility in approaching as include medical or pastoral care. In addition, the counselor and interpreter may choose to forgo the use of the formal assessments and include relevant questions as part of the sessions (e.g., suicide assessment, domestic violence assessment, trauma assessment). Recommended Resources Books and/or Articles Brody, E. (1994). The mental health and well-being of refugees: Issues and directions. In A. J. Marsella, T. H. Bornemann, S. Ekblad, & J. Orley (Eds.), Amidst peril and pain: The mental health and well-being of the world's refugees (pp. 57-68). Washington, DC: American Psychological Association. Hill, P., & Pargament, K. (2003). Advances in the conceptualization and measurement of religion and spirituality implications for physical and mental health research. American Psychologist, 58, 64-74- Koenig, H. G., McCullough, M., & Larson, D. B. (2001). Handbook of religion and health: A century of research reviewed. New York, NY: Oxford University Press. Levitt, P. (2007). God needs no passports: Immigrants and the changing American religious landscape. New York, NY: New Press. McCullough, M. E. (1999). Research on religion-accommodative counseling: Review and meta-analysis. Journal of Counseling Psychology, 46, 92-98. Miller, A. M., Birman, D., Zenk, S., Wang, E., Sorokin, O., & Connor, J. (2009). Neighborhood immigrant concentration, acculturation, and cultural alienation in former Soviet immigrant women. Community Psychology, 37, 88-105. doi:10.1002/jcop.20272 Journal of Miller, A. M., Sorokin, O., Wang, E., Feetham, S., Choi, M., & Wilbur, J. (2006). Acculturation, social alienation and depressed mood in midlife women from the former Soviet Union. Research in Nursing & Health, 29 134-146. doi:10.1002/nur.20125 Miller, W. R., & Thoresen, C. E. (2003). Spirituality, religion, and health. An emerging research field. American Psychologist, 58(1), 24-35. Salsman, J. M., Brown, T. L., Brechting, E. H., & Carlson, C. R. (2005). The link between religion and spirituality and psychological adjustment: