Good Practice Team day I Training 17/10/2010
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On the 17th of October 2010, URVT Associates gathered at the Future Worlds Center's premises in Nicosia, Cyprus to discuss self-evaluation method as part of project Good practice (Torture Victims).
Introduction
Follow up - brief presentation of the EU ERF Project to the URVT staff by Vicky Germanakou: cooperation with the partner European organizations: Baff from Germany, Primo Levi Association from France, Zebra from Austria, Equator from Netherlands, ICAR Foundation from Romania.
Presentation of the different stages and general timeline of the Project – expectations
Distribution of the explanatory readings regarding Team Day I to URVT staff Brief orientation by Andria on the Team Day I - context/ expectations – discussion Presentation of the relevant points made at the Kick off Meeting in Graz
A general discussion followed in order to conclude on the most suitable cases for the study. The choice was based on the needs, complications and length of the cases. It was generally agreed that the most important for the study is to manifest in the largest possible extend the culture, methodology and structure of URVT services.
Then it was decided that all staff should work as one group, with Andria and Constantina leading the conversation, reflecting on the actual operation of the Unit.
Plan for the day
The day would first discuss thoroughly the two case studies, one after the other, guided by the structure that was provided through the Framework for Assessing Quality document in combination the Inventory of Working and Treatment Methods document, in harmony with the clarification/comment/guidelines provided by the internal evaluator/researcher and coordinating organization of the Project. Then adjust them in the relevant documents.
Case 1
Male around 40years old/Country of Origin: Iraq/Marital Status: married, 3 children/minors - all in Cyprus/Date of Entry to Cyprus: May 2009/Date of Application: May 2009/Claim: Iraqi abducted and tortured in 2006 for two days, by people belonging in a Religious group (Shias) controlling the area he lived in.
Conflict Analysis: Individual/Family level, Cultural, Political participation, Economic level
Individual/Family Level:
• Experiencing high anxiety regarding lack of status.
• Feelings of mistrust; sadness; guilt towards immediate family members (bringing them to Cyprus away from their lives); depression; and worthlessness.
• Clash of the male’s traditional role in Iraq – feeling embarrassed (in need of social welfare and unable to provide for his family).
• Feeling isolated as he was not in contact with his extended family as much as he would like to.
• Felt pressured by his eldest son’s attitude towards him.
• Felt pressured by not being able to meet his wife’s and sons’ needs.
• Feelings of agitation and anger due to his ongoing medical problem and due to having to wait for long periods of time in order to be examined at the hospital.
• Being distant from the immediate family members due to being highly emotive because of experiencing all these difficult circumstances.
• He and so his family has a temporary residence permit which allows them to have access to basic needs, until their case is examined. A fact which further contributes to the feelings of insecurity and lack of safety for him and his family - present status is limited and future status uncertain.
Cultural Level:
• Not belonging in the host culture was a major issue for him.
• He did not speak the language – in need of interpreter depended on his wife and children, created difficulty to attain services and to attend his and his family’s needs
• Difficulty in making friends and relationships with locals or others from his other countries, as well.
• Ignorance of Laws and rules and mentality of the host culture making it hard for him to achieve what he was aiming for.
• Felt inadequate in regards to his traditional role as the head of the family.
• His eldest son started to adopt the western type of mentality and he was against that.
• Feels that some people hold racist attitude towards him
Economic Level:
• Lack of transportation (could not buy a car) public transportation in Cyprus is not adequate for their needs.
• Unemployed and as an asylum seeker he is only allowed to do specific types of work which he could not do due to his medical problems. He was in constant need of Social Welfare to provide for his family which caused him anxiety and embarrassment.
Political/Participatory Level:
• He was in need of legal consultation regarding his rights as an asylum seeker.
• The asylum seeker’s status is inhibiting him to be active regarding his political convictions feels afraid to express his ideology openly
• Local Authorities do not treat him with the proper respect when he is requesting assistance and/or services
• Not integrated in the host culture and local society therefore he does not feel being a member of this society, thus he cannot participate on a political level in the community. And even if he wanted as an asylum seeker has no access to political participation in the hosting country’s affairs.
OBJECTIVES:
To help him with his overall problems and to provide Psychological, Social and Medical services to him and his family members, as well.
Psychological: Decrease the intensity of depressive and PTSD symptoms; teach him to apply coping mechanisms; rebuild relationships with immediate family; and to assist his adjustment in the host culture. Help him to deal with his youngest son’s disorder (AHDD) and his family members’ anxieties and dysfunctions.
Social: Making sure that the client is fully aware of his rights regarding his social needs, securing availability of appropriate housing for him and his family, access to health care, Welfare benefits, registration at Labor Office; ensuring children’s access in education; helping to assign the child with the AHDD at a school where they offer special education services; learn the Greek language in order to be integrated in the society.
Medical: Being properly examined at the hospital; receiving the appropriate treatment regarding his health issues; receiving the appropriate treatment regarding his son’s disorder; to be examined by the Medical Board regarding his torture experience and obtain the medical certificate in order to support his asylum claim. Legal: Explanation of his rights as an asylum seeker in Cyprus – point out to the authorities that he is a victim of torture – his case should be prioritize – medical examination to confirm claim
METHODS:
Psychological: Psychotherapy: Individual one-hour sessions on a weekly basis. The therapist used the Cognitive Behavioral Therapy (CBT) and Person-Centered Approach (PCA).
Social: Social Counseling Individual and family sessions and telephone conversations as often as needed. Conducting needs assessment, explaining procedures, legal rights regarding social needs. Actions taken to facilitate his integration in the local society.
Medical: Medical Assessment: Underwent medical assessment by the Unit’s Medical Director.
Legal: Legal Advice: Discussion and presentation of his rights as an asylum seeker in Cyprus.
ACTIVITIES
The Unit employed an interpreter for offering him the following services.
Psychological: For the psychological assessment: wrote down the client’s social and psychological history. Spent time in sessions for building a robust therapeutic relationship; promoted trust by using active listening, paraphrasing and summarizing. PCA’s techniques were used to provide the three core conditions (unconditional positive regard, empathy and congruence) in order to treat his depressive symptoms. CBT’s techniques were used in order to attack his PTSD and depression. CBT techniques include: explanation of the model of how Thoughts, Emotional Responses and Physiological Responses interrelate and they affect Behavior; finding realistic coping mechanisms and applying them in his life; did relaxation sessions and taught him how to apply relaxation techniques (i.e. controlled breathing); the use of many diagrams in the sessions in order to portray what the therapist wanted to emphasize on. The therapist accompanied the client’s eldest son and his mother to the meeting with the headmaster of the school in order to resolve problems which appeared to the child’s behavior.
Social: During the first meeting with the client, the social history was recorded, and his needs were identified and prioritized. Assisting him and his family to leave the Reception Center of Asylum Seekers – contacting landlords, help in the search of accommodation. Resolving problems regarding Welfare services and Labor Office through contacting the officers in charge as well as employers. Contacting and using other institutions/organization’s services in order to resolve client’s problems. Available language courses were introduced to the client.
Medical: Made an appointment with a woman gynecologist for his wife and dealt with her ongoing treatment.
Legal: recording personal details, claim and facts relating to his case. Consultation on his legal rights and advice as to his case. Letter to the responsible authority noting that he is an alleged victim of torture and his case should be prioritize/expedite procedures for case assessment – referred to the medical committee for examination. Escorted at the first instance interview conducted by the responsible authority (Asylum Service). Escorted at the Medical Committee examination.
OUTCOMES
Psychological: Helped him cope with his depressive and PTSD symptoms; Assisted him to manage with his daily anxieties and stressors and lack of confidence regarding being in a different culture; Helped him build a social network; Facilitated meetings regarding his son’s disorder (school, children’s hospital, AHDD-ADD Association, Neurological Institute etc); Helped him handle difficulties with interpersonal relationships; Gave him incentive to adjust in the host culture.
Social: Left the reception center – found a house for him and his family. Enrolled to Greek lessons; the problems with labor office were resolved after the social counselor arranged appointment with a governmental doctor and he obtained a written diagnosis of his problem, suggesting that he is not able to work – welfare benefit was granted for the family.
Legal: The client applied for asylum on May 2009. He had his interview on November 2009 and was examined by the Medical Committee on April 2010. While, process not quick enough for a victim of torture, yet for average of delays in asylum procedures in Cyprus it was relatively ok. Corina mentioned the lack of data-system set by the government, which would detect vulnerable groups upon application, in order to prioritize such cases. Also complained on the incompetence and lack of expertise of the members composing the Medical Committee, as she was present and witnessed the process with the client. There was no interpreter, no psychological assessment and almost none of the Istanbul Protocol guidelines were followed.
As the issue of the Medical Committee and referrals came about and an intense conversation as to the changes on the procedures by the government followed and it was agreed that more actions (apart from the report to the Ombudsman and UNHCR) should take place. Awareness is necessary and publications in order to put more pressure on the responsible authorities.
Case 2
Male Iranian, 35 years old, Single. Applied for asylum in 2008. Asylum Claim: He was arrested, imprisoned and tortured due to his political activities as a member of a political group against the Iranian government.
Conflict analysis:
Individual/family level: • He is in detention • Presenting Posttraumatic Stress Syndrome that reveals in repetitive phase symptoms, intense anxiety, and depression. • Sleep disturbances, flashbacks episodes. • Severe psycho-somatic symptoms such as headaches, not being able to concentrate • Intrusive thoughts and paranoid ideation secondary to trauma; lack of trust to any human being. Hypervigilant and overreactive to external stimuli. • Refused to see psychiatrist or take any kind of medication because of his past traumatic experiences • Negativistic thought pattern about the future and his life in danger. • Constant feelings of fear, insecurity and helplessness. Stressed concerning his future, getting the status, making a family etc. • Hepatitis C carrier – the client was not visiting a doctor for treating his disease. • Osteo mascular pains as a result of torture. • Limitation of choice and interest areas. • Asylum seeker • Asylum seeker
Cultural: • Pressures from his family in Iran to get married • Isolated, not involved in groups of people. He was only communicating with specific Iranians whom also didn’t trust. • He doesn’t know Greek, and he speaks only basic English a fact which deters him from becoming a member a group of people from the host country.
Economic: • Unable to work due to the psychological problems. He is depending on the welfare allowance as his only source of money. Was facing delays in receiving the monthly welfare allowance, resulting in sometimes not being able to cover his basic needs.
Political Participation: • As an asylum seeker he has a temporary residence permit, which while allows him freedom of movement and access to basic needs and rights, these do not include any form of political participation in the local society. • Also he has great fear in expressing his political views, as he feels threatened and target of the Iranian Embassy in Cyprus. He once participated in a protest outside the Iranian embassy which later caused him anxiety and stress….
OBJECTIVES:
• Be released from the detention center. • Psychological: Reduce the somatic and psycho – somatic disturbances caused by the trauma. • Reduce sleeping disturbances. • Help the client realize that he needs medication in order to stabilize his psychological situation. • Learn coping mechanisms to deal with the trauma. • Stable treatment by the psychiatrist and the hepatology doctor in order to receive the right treatment for his disease and the paranoid ideation. • Help him develop a more adequate ability to make decisions • Encourage him to create realistic goals and remain positive. • Strengthen client’s defenses; work on PTSD symptoms and trust issues.
Social:
Legal: Release from detention, awareness that he an alleged victim of torture. Due to his severe psychological symptoms under which the first instance interview was conducted to repeat the interview, after he is psychologically stabilized. Expedite the refugee status determination procedures. Take into account URVT report on his case, in an effort to avoid go through the Medical Committee examination.
METHODS:
Psychological: Psychological support and Psychotherapy: Individual one hour sessions on a weekly basis, with the presence of an interpreter (except some times because of the client’s trust issues towards the interpreter). The therapist used cognitive restructuring.
Social: Social Counseling: Individual one hour sessions, follow-ups through phone conversations and counseling. Client’s walks-in in crisis situations.
Legal: Legal counseling – informing the client about the asylum procedures and acting on his behalf
Medical Doctor: Medical assessment – diagnosis of health problems. Referrals to governmental doctors for further examination and treatment
ACTIVITIES
Arranging interpreter to attend the sessions and to accompany the client to the governmental psychiatrist.
Psychological: Discussing with the client different techniques which could help his sleep improve.
Social: Contact with the detention’s psychiatrist, liaising to achieve his release. Arranging appointments for psychiatrist and other governmental doctors. Sending report to the Asylum Service, including the assessments of all the professionals of the Unit, in order to be taken into consideration during the examination of his claim. Being in search for available housing – contacting the landlords. Having constant communication with the Welfare officer to explain the severity of the case, resolve any issues appeared in order to avoid delays.Assistance in applying and acquiring medical card. Communication with various local organizations in order for the client to be provided with food and clothing, as well as accommodation during the periods that he was leaving his house as a result of the paranoid ideation.
Medical: Medical assessment – history. Referrals to governmental specialist doctors to address his medical problems. The medical director had contact with the hepatology doctor in order to agree on the treatment and how to proceed with dealing with the client’s health problems.
Legal: Letter to the Asylum Service and Migration requesting his immediate release from detention, as he is an alleged victim of torture and the expediting of the procedures (namely interview, assessment). Letter of complaint to the Asylum Service regarding the interpreter during the first instance interview. Letter to the Asylum Service requesting for a new interview, as in the first one the client was not in a stable psychological state.
OUTCOMES
Released from detention center. Built a trusting relationship with the professionals of the Unit.
Psychological: After being convinced to take medication, his paranoid ideation was controlled.
Social: The social counselor secured housing for the client.
Medical: Client’s health was generally assessed after being referred for specific examinations by the medical director of the Unit. Stable treatment for his health problems was managed. During the discussion of the two cases, Vicky Germanakou and Corina Drousiotou mentioned that we should perhaps discuss very quickly a case of a client whose case went through all asylum procedures and was recognized. As there was not enough time left, this was decided to be presented by Corina in short and then discussed by the staff, in relation to their involvement on the case.
Closing of the Session
Larry Fergeson summed up the day and tried to draw brief conclusion as regards the operation of URVT. While analyzing the cases it was observed that even though the therapist’s aim initially was to work on the individual’s psychological symptoms, she was ending up dealing with various family dysfunctions emphasized by the client. URVT staff in general appear to be in good cooperation amongst them – and are discussing cases thoroughly – it seems to work well this way due to the small size of the Unit and small number of cases. Several problems were pointed out as regards efficiency in dealing with delays and access of the clients to their rights during the procedures. Staff should try to put more pressure on the authorities through letters copied to all responsible authorities including the Minister if appropriate. Awareness is very weak – and that would possibly contribute to the bettering of the procedures. In the end, SWOT analysis was mentioned and shortly introduced by Andria Neocleous, however there was not time to discuss this in context. There was a brief discussion on Marie’s visit on the 21st of October and on the Study Day I. Andria Neocleous, Vicky Germanakou and maybe Constantina Christou will participate in the meeting. They will meet to prepare for it, Monday 18 October 14.00 – 17.30
