ongoing y to the new country, and post-migration in the new country. The experience of political violence and exile poses unique vulner- ability in the new cultural context, where individuals struggle with concerns about safety and trust. Psychotherapists working with immigrant clients with such histories are often faced with challenges to traditional diag nostic and treatment considerations. The following vignette i issues in psychotherapeutic work with a refugee client. Case Description illustrates s these relatively Paul is a man in his 30s who fled his home country in East Africa. He arrived in the United States a year prior to my (Diya Kallivayalil) first meeting with him. Paul recounted growing up under an oppressive regime in his country, and he became politically active at a young age. He attended a deeply split and politicized high school and grew up in what he described as a affluent and middle-class family. He also spoke of his belief that it was the role of the middle class in his country to work toward political change, even though political activity was deeply repressed and dangerous. He learned English in his secondary school and spoke it fluently. He reported having no psychiatric difficulties prior to the incidents leading to his fleeing his country. In response to an upcoming local election, Paul began to increase his visible political activity. One night when he was returning home to his mother's house where he lived, he was ambushed and kidnapped. He was kept in confinement in a room for over two weeks and was interrogated and tortured. He was told by his captors that they would never let him go that his family would be tortured as well. He was deprived of food, beaten into unconsciousness, forced into ice-cold water, given electric shocks, and and THERAPY For Nadia donging and and friends he would be PAUL new he arranged at a religious function. es of origin, in the ique vulner ith ongoing immigrant itional diag astrates these a. He arrived meeting with his country deeply s a relatively at it was the Change, nes He learned orted having fleeing his increase his home to his Ded. He was rogated and and him go Good, beaten shocks, and Clinical Applications With Immigrants 133 forced to listen to the screams of other prisoners. He believed he would be killed. Eventually he was put into a van and dumped on the side of a road and warned that his life would continue to be in danger. He was hospital- ized for over a month for his injuries. Realizing that he had no other option, I to flee to the United States and apply for political asylum. His family continues to receive threatening phone calls demanding to know where he is. He was referred to treatment by his primary care physician whom he saw for continued pain related to his torture injuries. He lived in the basement of a house of a family from his home country whom he met Paul received a diagnosis of posttraumatic stress disorder (PTSD) and major depressive disorder. He endorsed repetitive flashbacks of the traumatic events he experienced: "The thoughts of what has happened are always in my mind. The wounds are always there." He suffered with chronic insomnia and experienced nightmares and intrusive memories during the day. He de- veloped a fear of the dark due to his confinement and could not take show- ers without the bathroom door open. He felt alternately overwhelmed and anxious and emotionally numb. He also felt irritable and angry when he was around others and would say, "I feel out of touch with other people." He lost interest in normal activities and experienced great fear and anxiety about the future: "How will my life be meaningful again? My dreams are crushed." He was extremely hypervigilant and was very fearful of the police: "When I see them, I hold my breath." He felt he would never call the police if he were in trouble. He worried about his family in his home country and felt guilty and responsible for the harassment they were suffering. He also felt guilty that he could not support them financially. He had depressed mood and his sleep and appetite were erratic. He reported low energy, anhedonia, and psycho- motor retardation. He did not report suicidal thoughts, but he felt hopeless at times and felt an acute sense of loss, loneliness, and displacement. Three treatment issues were identified: dif- 1. Trust. Paul had a deep mistrust of authority figures in general and of health care providers. He was wary of providing information about himself and tended to experience questions about his history or symptoms as an interrogation. He would often ficult to open up-I feel bad and sick all over again." He lived with a pervasive sense of vulnerability and felt anxious when he saw security say, "It is very herapist the issue therapist hel troduc work with P acions do problems 134 CASE STUDIES IN MULTICULTURAL COUNSELING AND THERAPY officers at the clinic. The severity of his intrusive symptoms made it difficult for him to "forget" his torture experiences. He felt easily trig gered and would often lose time, "coming to" with severe headaches. He avoided news about his home country and stayed away from members of his community for fear that there would be some reprisal against his family. As a result he felt very isolated and lonely. 2. Stigma of mental illness. Paul's difficulties were complicated by a fear of the label of mental illness and receiving psychiatric care. He found it difficult to understand the role of psychotherapy in his care; in his home country, there were few therapists and people who accessed psychiatrists tended to be severely mentally ill. His suffering compounded by his shame about his psychological decline and his symptoms, and he felt angry and frustrated with himself for having emotional difficulties, which he interpreted as weakness. He would felt like this before. What's wrong with me? Will "I've say, I ever get back to who I was?" He worried that his difficulties were often permanent. never was nalopsi a social is religio would you here are se 3. Dislocation and change in socioeconomic status. As with many immi- grants and with refugees, Paul experienced profound and sudden loss and displacement. It was never his intention to leave his home and his family and come to the United States. The decision was made under duress, and it forced him into a life of dislocation and poverty. This was in contrast to the life of relative comfort and status that he lived at home and made any kind of adjustment to the United States very difficult for him. He felt he was "begging" for help here, and this wounded his pride. He experienced various incidents of overt and systemic racism that made him feel unsafe and sometimes lost in un- derstanding racial dynamics and hierarchies in the United States. He tended to idealize his home country and his life there and talked in negative terms about America: "In my country, everyone helps each other. No one goes hungry." Reflection and Discussion Questions ed States about 1. How do you understand Paul's desire to educate his therapist his home country and the political situation there? 2. How was his cultural identity an issue in treatment? THERAPY 4. sion and PTSD? Clinical Applications With Immigrants 135 How would you think about Paul's diagnoses of both major depres- When considering the client's mistrust of authority figures, what are some ways that the therapist facilitated a safe therapeutic space? How would you address the issue of the client's mistrust in your work with ve symptoms made es. He felt easily - th severe headach stayed away from uld be some repris and lonely. mplicated by a tric care. He found y in his care, in hi a fea was 5. Paul? How did the therapist help the client manage his immediate post- traumatic stress symptoms and his concerns of safety for his family? If you were to work with Paul, how would you work address his PTSD symptoms? 6. What implications does the client's view of psychiatric illness and emotional problems have for diagnosis and treatment? ople who accessed His suffering w al decline and his imself for having akness. He would ong with me? Wi difficulties were 5 ith many immi and sudden loss we his home and ision was made on and poverty d status that he e United States here, and this s of overt and nes lost in un- ted States. He and talked in ne help cad rapist about 7. In what ways do you see psychotherapy helping clients in coping with the shifts in social identity that can occur as a result of migration, such as socioeconomic status, shifts in work and relationships, career aspirations, religious practice, and sense of place? 8. How would you address Paul's shame about his mental illness in treatment? Brief Analysis of the Case There are several important and multifaceted issues to consider in providing culturally responsive therapy to refugees and asylum seekers. While recognizing the enormous variation in asylum seekers and refu- gees on a number of dimensions including country of origin, path to the United States, pre-immigration stressors, gender, and many others, some general points can be made to inform their care. Providing culturally in- formed treatment is important with all clients and populations but perhaps paramount in working with asylum seekers because the basis for a political asylum claim in the United States is a history or fear of persecution based on identity factors such as race, religion, membership in a social group, or political opinion. Therefore, identity or identification is generally the for fleeing one's home cultural identity In this country. main reason way, is both an "identity" and a lived reality. Further, refugees and asylum seek- m frequently experience discrimination, language barriers, racism, and harassment in their journeys to their host country and once they arrive there Rape & Garcia-Peltoniemi, 1991). These experiences are distressing and also dynamics in their home countries. with the s mily he li 136 CASE STUDIES IN MULTICULTURAL COUNSELING AND THERAPY disorienting because they often do not mirror the racial, gender, or class Further, because these clients have been targets based on some aspect of their identity, their relationship to this identity and the cultural g which they belong is deeply complicated. Understanding their own construc tion of their multiple identities, both prior to and after migration, and how this may have changed can be central to proving culturally responsive c and provides a useful alternative to imposing our own notions or biases. The group to understanding can be particularly important when the therapist is from the client's home country or feels he or she has prior knowledge of it from study or travel. Attending to these issues may reduce the risk of misjudging the implica tions of cultural factors in treatment (Silove, Tarn, Bowles, & Reid, 1991). is also important to be aware of assumptions about symptom presentation- such as assuming clients who are originally from other countries will show higher levels of somatization or somatic symptoms. asy- It is also important not to consider working with refugees and lum seekers as simply the treatment of the "cultural other" (Smith, 2007). This stance can prevent therapists and others from seeing the treatment as co-constructed, and they often undervalue the implications of their own cultural background and biases. There is also the danger of minimizing or distorting how the client relates to the therapist's background (although this is often assumed or a projection). Determining the goals of treatment was straightforward: Given that fear and trust were among the most salient issues that Paul presented with, working with these two issues was paramount. This work involved psycho- education about PTSD and about psychotherapy, my role as a psychologist, confidentiality, my involvement in his legal case, the role of psychophar- macology, and concrete suggestions and resources around his immediate needs, such as food and housing. We worked together on developing skills to manage his posttraumatic response, including his intrusive symptoms, sleep strategies, follow-ups for medical care, referrals for medications, reducing avoidance, and managing his panic symptoms. In this way, there was an off- going effort to communicate to Paul that trust in a relationship with an au thority figure is something built over time and not assumed. We also talked openly about his issue regarding trust over the course of our work together. In Paul's case, the change in his class circumstances and his life in po erty in the United States was a significant issue in treatment. He struggled at least He began anities he aped with who helpe dients, it used arou overtly or dass was court case dis would built in th Paul addition self beca patient. often say his fami never re that has Fischm his role time worthle whethe should dersto Life in and b work tisks of the Feszen acial, THERAPY gender, or ca He began Clinical Applications With Immigrants. 137 with the sense that he was receiving charity from others, including the ing at least initially, in jobs that he considered low status was a blow to him. Family he lived with. Once he did receive his work papers, the idea of work- to feel that people felt he was not "being grateful" for the oppor unities he did have and that they did not want him to aspire to more. He coped with this in part with fantasies of how he would "repay" the people who helped him when he rebuilt his life and became wealthy. As it is with all s important in therapy with Paul to be careful in the language used around these issues and the choices he made-that is, to not imply, overtly or covertly, that he was "better off" here or in his home country, that class was not an issue in the United States, to make assurances about his imply that he should settle for a certain job, and so on. Doing Court ould have been deeply disruptive to any tenuous trust that was being ets based on some aspect nd the cultural group to ding their own construc fter migration, and how ulturally responsive cu n notions or biases. This he therapist is from the ledge of it from study misjudging the implica owles, & Reid, 1991). mptom presentation her countries will show with refugees and as other" (Smith, 2007) eeing the treatment a lications of their own nger of minimizing or ground (although this clients, it was case, to built in the relationship. Paul's case can be looked at through the lens of loss and shame. In addition to the detrimental view he held of mental illness before he him- self became ill and the shame associated with seeing himself as a "mental patient, he also experienced his symptoms as another loss; he would often say, "I've lost everything, even my mind." He lived with the loss of his family and his community, with the painful knowledge that he could never regain his country and his old life, and often embodied this tenet that has been said of refugees: "Exile is the most painful form of torture" (Fischman & Ross, 1990, p. 139). He felt also acute loss and shame over his role as provider and protector of his family back home, something he at times discussed in terms of losing his masculine identity. The guilt and worthlessness he felt in the United States made him at times question whether he had made the right decision in coming here and wonder if he should return and risk his life: "At least I'll be facing things," he said. I un- derstood his behavior of educating me about his country and his political life in part as a wish to feel less like a "patient" for some part of the session and became instead the expert. I also understood it as a way for him to ark through validating his political activity for which he had taken such risks and that had cost him so much. This was an important component tforward: Given that Paul presented with ork involved ped role as a psychologis role of pachopa ound his immediate un developing sive symptoms, skep edications, reducing way, there was an on tionship with an med. We also talked our work togethe and his life in po mene. He song of treatment. In regard to the therapeutic relationship and transference/countertrans- part of him was comforted by my being an immigrant, the perception that I 138 CASE STUDIES IN MULTICULTURAL COUNSELING AND THERAPY was an "immigrant by choice" was troubling to him and made him feel that we were psychologically fundamentally different. Therefore, he felt, could I truly understand his plight? He would devalue therapy and therefore me at times. My own countertransference was also mixed sometimes. His devalu- ing of therapy made me feel that perhaps therapy was not "enough" and feel guilty that I had not engaged in political activity. Sometimes I would worry about how to answer his questions about whether I liked my job and why I had chosen it or whether I regretted leaving my home country. This led to discussions with him around whether "sameness" was required for therapy to work and what level of it was required for the client to feel heard and understood. Paul was able to express that much of his wish for "sameness" was related to the deep shame and guilt he felt about his choices and his mental health problems and that devaluing treatment at times was a way to step away from these feelings. He was also able to hear my admiration for his political work and the personal risks he had taken. Recommended Resources Books and/or Articles Ainslie, R. C. (1998). Cultural mourning, immigration, and engagement: Vignettes from the Mexican experience. In M. Suarez-Orozco (Ed.), Crossings: Immigration and the sociocultural remaking of the North American space (pp. 283-300). Cambridge, MA: Harvard University Press. Akhtar, S. (1996). "Someday" and "if only" fantasies: Pathological optimism and inordinate nostalgia as related forms of idealization. Journal of the American Psychoanalytic Association, 44, 723-753. Akhtar, S. (2011). Immigration and acculturation: Mourning, adaptation, and the next generation. New York, NY: Jason Aronson. Blanche, M., & Endersby, C. (2004). Refugees. In D. Olivere and B. Monroe (Eds.), Death, dying and social differences. Oxford, England: Oxford University Press. Comas-Diaz, L. (2006). Latino healing: The integration of ethnic psychology into psychotherapy. Psychotherapy: Theory, Research, Practice, Training, 43, 436-453. Leary, K. (2000). Racial enactments in dynamic treatment. Dialogues, 10, 639-653. Psychoanalytic boom