The Haven Project Hull 2002-2007

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					     The Haven Project Hull 2002-2007: Final Report   1



  The Haven Project
                       Hull

A Therapeutic Service for Refugee
      Children and Families.

             Hull 2002-7

               Gill Martin
                The Haven Project Hull 2002-2007: Final Report                  2




Forward.
                            Destroying Lives
It was a spring afternoon and the last watery rays of the sun shone down on
our ancient stone cottages which had been in our family for generations.
We had put the chickens in the hen house for the coming evening and our
sheep and cow were safe inside their shelter, protected from the wolves
which sometimes roamed down from the mountain.

The snow started to melt from the mountain tops, filling the rushing stream
where we collected the pure icy water for our little farm.

Dusk began to fall: we had completed our outdoor chores and were getting
ready for our evening meal. I was tired after having walked our sheep back
from the high pastures where they were grazing all day and looking forward
to the delicious warming vegetable stew that my Mum was about to serve
along with chunks of her freshly baked bread. My older sister, Zana, was
reading by the log fire and my sister Irene was playing with her toys. Dad
was washing the day‟s sweat and grime from his hands while whistling a
folk tune. We all moved to the big wooden table, ready to eat our meal.

Suddenly there was a violent banging at the door and it burst open. I jumped
with fright and the jug of milk I was carrying smashed at my feet. My heart
started pounding like a steam train and I felt it would burst out of me.

There they were: six Serbian soldiers with rifles pointed at us, the bayonets
gleaming wickedly.

For a few seconds everyone froze. My little sister‟s face was drained of
blood and her hands shook. Our petrified silence was broken as Irene‟s
favourite doll slipped out of her trembling hands and crashed to the floor.
Their thuggish leader pushed his way forwards, bellowing orders at us in
Serbian, which we didn‟t understand, rounding us up with the ugly spike of
his bayonet.

Dad pressed forwards, trying to protect us but one of the soldiers thrust his
bayonet into Dad‟s thigh. Dad‟s face was a picture of pain and humiliation
as he realized he was powerless to protect us.
               The Haven Project Hull 2002-2007: Final Report                  3



The soldiers then burst into action, trashing everything in sight. Our
furniture was hurled at windows, smashing the glass. Our favourite
possessions were broken to pieces under their big stamping feet. Precious
things we had treasured for years were destroyed in minutes as they stormed
through our home. We watched with horror as all the things we held dear to
us being demolished in front of our eyes.

After this, we were rounded up and marched outside into the cold night air. I
could hear my heart thudding in my chest as I trembled with fear, wondering
what they were going to do next.

As soon as we got outside, we walked up some hills not too far way from
our home and the Serbian soldiers vanished for a few minutes. During this
time, none of us was able to talk as we felt paralysed by the shock of what
had just happened. But after a while, we heard a loud, strange, thundering
noise coming towards us. It was a big green truck filled with Serbian
soldiers. Each one of them came out of the truck looking as if they had a
mission to accomplish. I dreaded to think what this mission was going to be.
Their fierce, arrogant, repulsive leader started giving them orders and
directions. Two of the soldiers walked towards me and my family and the
rest of them walked into our old cottage. We could not understand what was
happening, but we all sensed that something was wrong. Even though we all
feared something bad was going to happen, we didn‟t admit it to each other
because we were scared of tempting fate.

The two Serbian soldiers reached us and started shouting and bellowin
orders which we were unable to understand. My little sister screamed out of
fear but my dad managed to calm her down by singing her favourite song to
her. Then he took her in his arms and we all started walking down the hill
towards our cottage, which the soldiers had ransacked. When we arrived
near the cottage, one of the Serbian soldiers pulled Irene from my Dad‟s
arms and the other pushed my Dad to the ground. They tied him up with
thick rope and hurled him into the back of their truck. My Dad tried to
retaliate and stop them but soon realized that there was nothing he could do
to stop the soldiers.

We heard the loud thundering noise again as the green truck was driven
away by some of the soldiers. We felt devastated by what had happened, but
little did we know the worst was yet to come. Feeling sick with worry about
               The Haven Project Hull 2002-2007: Final Report                4


where they were going to take my Dad, and what they were going to do to
him, I felt unable to cope any more and screamed with fury. I wanted them
to stop and somehow save my Dad. I couldn‟t understand how people were
able to destroy the lives of other people. Who gave them the right to do this?

My Mum and sisters panicked as they feared what the soldiers would do to
me for screaming. I turned round and saw the anger in Mum‟s eyes and
stopped screaming immediately. My Mum‟s eyes told me that I wasn‟t the
only one who felt angry and unable to cope. I went to my Mum and she held
me close. We all were sitting on the grass watching the clear sky and the
glowing stars, when, suddenly, a blast of flames burst out of the cottage and
struck us by surprise. The soldiers had set out cottage on fire. My Mum
started shaking and trembling and shouting, “Jo, jo” (No, no). She seemed
terrorized by seeing the red hot flames coming out of the cottage, which she
had spent all her life repairing and making into a home for us. Her whole
past and her hopes for the future were burned, along with the cottage.

Unable to put out the fire, we stood on the hill for three hours watching the
cottage burn. Everything burned to the ground and vanished as though it
never existed. Our photos, memories, precious and practical, things were all
destroyed in the fire. Our hearts, feelings and emotions were ripped apart, as
the fire flared higher.

(Jola, aged 15 from Kosovo)

                    Life Ain‟t Easy
                 Sometimes you laugh,
      sometimes you cry but you don‟t know why
               sometimes you have war
               sometimes you have peace
      Don‟t care when people stare or what people think.
             Be strong, believe in yourself
            don‟t believe what others say
         don‟t let people cheat you or deceive you.
        Look at yourself in the mirror – you‟re beautiful
          don‟t think you‟re ugly, enjoy yourself
            trust yourself, be a good person.
                       Life ain‟t easy.           Saha. 14 years from Iran
              The Haven Project Hull 2002-2007: Final Report     5



Contents
Page
   2   Forward. Writing by two refugee children

  6    Aims and history of the Haven Project

  8    Who are we?

  9    The Early Stages

  11   What do we do and why do we work in the way that we do?

  12       Key elements of the therapeutic work.

  25       Networking

  27       Problem Areas

  32       Successes

  34       Conclusion

  35       Acknowledgements

  36       References.
               The Haven Project Hull 2002-2007: Final Report                  6


The Haven Project Hull 2002-2007
“In order to treat me equally, you may have to treat me differently”



1:   What are our aims?

 To provide a community based therapeutic service to refugee and
  asylum seeking children and families.
 To develop ways of working which promote access to statutory mental
  health services for refugee children.
 To build partnerships which enable us most effectively to implement the
  first two objectives.

2:    How did the Haven Project develop in Hull
The Project has been working in Hull since the end of 2002. Until
September 2005, we were part of a national group of nine Haven Projects set
up through a registered charity, Action for Children in Conflict.
The Hull Project was funded by the Esme Fairbairn Charitable Trust.

During 2001-2 a series of training workshops, organised by Gill Martin, and
funded by Save the Children Fund and The Retreat York, was offered as a
response to the needs arising from the Government policy, originating in
2000, of dispersing of asylum seekers to the regions. A study by Andy
Dawson from the University of Hull (1) had indicated that the client group
of refugees and asylum seekers was a relatively new phenomenon to
professionals in both the voluntary and statutory sectors in Hull.

There were seven training sessions altogether, focused on aspects of refugee
mental health and varying from half a day to two days. We also drew on the
clinical expertise of the Medical Foundation for Victims of Torture in
London. There was collaboration additionally, with a series of training days
co-ordinated by Anny Woods for the North Bank Forum.

That period of identifying training needs, networking and building links led
to an invitation to Gill Martin from Action for Children in Conflict to
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develop the Hull Haven Project.


Each of the nine projects across the UK developed according to the needs
and responses in the locality. The Haven Projects in Liverpool and
Manchester were based in CAMHS and staffed by CAMHS workers for
example; in Oxford and Leicester it was University Departments of
Psychiatry which provided the staffing; in Cardiff the project was
independent as no other agency was able to manage the work, which
eventually became the situation in Hull. All were funded at this first stage by
Charitable Trusts and the finances were centrally administered through
Action for Children in Conflict.

This was an example of innovative work developed through a charity and
the methodology was developed in response to the fact that refugee children
often found school to be their „secure base‟ during the first years in the
country. Much of the work was done through schools in the various cities,
identifying the child‟s difficulties and working in partnership with Haven
project professionals.

This model has had to be adapted to the particular circumstances in Hull. We
have taken a much broader path than working only through schools, for
reasons relating to the local context. The model we have developed in Hull,
however, has a much wider application.

Our history has not been straightforward. We have suffered from the impact
of serious financial mismanagement in Action for Children in Conflict which
saw one third of our funding disappear and the nine Haven Projects end
abruptly. We came through a very difficult time, remaining committed to our
clients and, because we have always been a part-time project, we were able
to survive, albeit the staff worked unpaid for almost a year. The Haven
Projects in Liverpool and Oxford survived as independent projects, funded
through Health Authorities. The Hull Project has had to take a different path.
We were given the „umbrella‟ of becoming a project of Centre 88 for the
purposes of charitable registration and financial management and we are
hugely grateful to Jean McEwan and the Board of Centre 88 for giving us
this ‟home‟. We have had a further year of funding from a donor through
New Philanthropy Capital, together with some funding from the Local
Network Fund for a Cultural Integration Project.
               The Haven Project Hull 2002-2007: Final Report                 8


The future remains under a question mark, however, and we are in the
position of many small Third Sector organisations, facing uncertainty.



3: Who are we?
Gill Martin is the Project Co-ordinator and is a Registered Psychotherapist
with the UKCP and BACP. She is a qualified Social Worker, worked for a
number of years as a Community Development worker and was a Lecturer
and Tutor on Social Work courses at Chelsea College, University of London,
and at Brunel University. She has many years experience of working cross
culturally in London and Leeds and has worked in refugee mental health for
eleven years, initially through The Retreat York where she worked as a
psychotherapist for ten years. She has a Masters Degrees in Health Policy
and also in Psychoanalytic Studies. She has travelled widely, particularly in
Africa.

She has trained professionals in other Health Authorities in York and
Huddersfield in working with interpreters and designed a course for
interpreters who work in a mental health setting. She works elsewhere in the
region in refugee mental health, in the NHS in Huddersfield and is Chair of
Solace, a Regional refugee mental health project based in Leeds.
She is also a writer.

Rosemary Palmeira is a qualified social worker and a trained
Psychotherapist. She worked as a social worker for Refugee Lifeline before
working with the Haven Project so had several years experience of refugee
work before joining the Haven Project. She has a particular interest in the
use of creative therapeutic techniques such as drama, art and storytelling.
She has an MA in Poetry and speaks fluent Portuguese and French and has
also travelled widely, particularly in Europe and the Balkans.

Dee Kyriacou joined the project in 2007. She is Afro Caribbean in origin
and has the experience of learning as an adult. She had limited experience of
working with refugees before joining the project, but brought her own
experience of understanding racism and inequality of opportunity. She
worked in Derby, as a development worker for Early Years. She set up and
ran training for disadvantaged groups. She has recently gained a B Sc
Degree in Therapeutic Counselling at Leeds Metropolitan University. Her
                The Haven Project Hull 2002-2007: Final Report                  9


husband is a Pastor in Hull and she consequently has a particular interest in
the faith aspects of counselling


Ele Walker and Fiona Smith run the Cultural Integration Project. Ele speaks
fluent French and Nepalese and lived in Nepal for some time. She also acts
an an interpreter for the project and runs a small business. Fiona is an Art
Therapist and poet and works at The Old Parcels Centre in Bridlington with
people who have mental health problems.

We all have a depth of experience of working with people from other
cultures and share a common view about how to offer a service to people in
distress in ways which are culturally sensitive.


4: The Early Stages

The Haven Project has developed in the way that it has, in part, due to the
context in the city of Hull. When we began towards the end of 2002, some,
but by no means all, professionals in the city were beginning to become
more experienced in working with people from other cultures, but it was still
early days. In 1999 there were 137 children from minority ethnic groups in
Hull Schools and within eighteen months this figure had quadrupled. By
2006 there were almost 2000 children speaking 50 different languages and
this picture is developing all the time as migrant workers come into the city
together with two groups of Congolese families who have arrived through
the UNHCR Gateway programme.

A city which had been relatively monocultural has had to make adaptations
and develop services in a fairly short space of time.

We tried initially to develop the „Haven‟ model in a similar way to the eight
other cities. We met with the Managers of CAMHS and with the Inter
Agency Link team on a number of occasions but both felt that they could not
enter into a partnership in spite of the fact that there was funding available to
buy staff time at that stage. Also, at that stage, the University Medical
School had barely started and therefore we could not draw on that resource,
as, for example, Leicester had. One reason given for the failure to develop a
partnership with the services was that one manager felt that it was unfair to
                The Haven Project Hull 2002-2007: Final Report               10


prioritise refugee and asylum seeking children by creating a specific service.

Apart from the work of the Asylum team, many of the services for refugees
in the city were developed in those early days through third sector
organisations, Global Friends, Arkh (Asylum Seekers and Refugees of
Kingston upon Hull). 167 Centre, Princes Avenue Methodist Church, and the
Recycling Agency in Newland Avenue. In spite of the fact that Hull was a
dispersal centre, there was only a small Refugee Council presence in the city
and it was the small third sector groups which responded to the need. Most
of those initiatives have survived but struggle to access funding.

It was clear that our only option was to become an independent service, as
partnership at that stage was not an option, and to become part of this
network of third sector organisations.

We have prioritised networking , both with the statutory and voluntary
sector as the best way to improve access to services for refugee families,
see Integration Matters. (2) for arguments supporting this approach.

We have a belief that in the area of refugee mental health it is important to
network in order to draw on the experience of others, within the city, and
also regionally and nationally. To work in isolation in the field of BME
mental health is not good practice because it is a field which is developing
and there are projects in other cities with more expertise. We also were able,
at this time, to contribute to this developing field of knowledge by running
workshops at three national conferences.

We have valued the resource offered by the Medical Foundation for their
knowledge of the political context of various countries and for the
information available from their legal department and their extensive clinical
experience.
               The Haven Project Hull 2002-2007: Final Report               11


5: What do we do and why do we work in the way we do?

We have worked with 67 families or individuals over the four years of the
project. Some of this work has been intensive, over many months or years;
with a small number, we have worked throughout. Because of funding
availability, all the staff are part time, working one or two days a week
but we have worked hard to maximize the use of time.

The families or individuals have come from the following countries:

Africa                                        Europe

DR Congo          9                          Portugal           6
Somalia           1                          Kosovo             6
Nigeria           2                          Portugal           2
Burundi           1                           UK                 5
Rwanda            1
Liberia            1
Algeria           1

Middle East

Kurdish Iraq      8
Iran              8
Turkey            2
Egypt              1
Syria             1

Asia

Afghanistan       6
Chechnya          2
Philippines       1
Pakistan          2
India             1
                The Haven Project Hull 2002-2007: Final Report                     12




The main themes of the work have involved:
 Bereavement
 Isolation
 Torture
 Rape
 Trauma
 Suicidal risk
 Parent/child relationships
 Marital breakdown
 Child/school difficulties
 Trafficking
 Conflict within the community
 Cultural transition



6: There are some key elements which we think are
central to successful work with refugee families.
6.1: Building trust and the need for a „bridge‟.

One of our priorities has been to build trust. This is one of the key issues in
improving access and one of the strengths of the Project is that it has acted
as a „bridge‟ through which refugees can access other services.
This is a crucial concept in delivering services to the BME community as a
whole. The bridge may be a community group, for example, a Refugee
Community Organisation or a Cultural Association. It is through this
networking that the Haven Project has been able to act as a bridge between
informal and formal services.

Building trust takes time, however, in the context of people who have fled
rape, torture and violence. Part of building trust is to be felt to be effective
yet when the context of many asylum seekers has been experienced as
powerlessness, effectiveness has had to take a different form. Much of the
work has been to contain, to bear witness, and to identify risk.
                The Haven Project Hull 2002-2007: Final Report               13



One of the ways in which we build trust is the unorthodox one in a
therapeutic setting, of visiting people at home. This is not always the case,
but sometimes people from other cultures are daunted by formal settings, or
too depressed to go to seek help.

Mrs G was referred by the specialist Health Visitor because it was felt that
she and her two daughters were very isolated. After the initial visit, we
received a phone call from the elder child, then 15. She asked if the therapist
could go back without an interpreter. This would mean breaking the golden
rule of not using children or a family member as an interpreter. The child
said she knew what the problem was and that she had got the information
out of her mother the day before. Her mother was insisting that she would
not speak in front of the interpreter. On this one occasion, the rule was
broken in order to build trust. Mrs G disclosed rape during the conflict in her
country and came from a culture in which shame was overwhelming for her.
We had long term contact with that family, making referrals to an NHS
counsellor; a voluntary sector organization offering some practical help;
at a later stage, CAMHS; and had an active role in the choice of school for
the older child. We had a phone call this month, five years later, asking us to
contact them to talk through some choices the younger child now has to
make about her violin course! At no point would Mrs G have discussed her
difficulties with the GP, for both gender and cultural reasons. Trust was
central to the work and the project was a bridge into other services


6.2:Referrals

In the early months we focussed on the general Haven project model of
using schools as the source of referrals. The relationship with schools has
always been important but schools vary in their openness to joint work, and
what may be a fruitful collaboration can come to an end with a change of
teacher or change of head.

In broad terms, children tend to externalise or internalise their problems. On
the whole, refugee children tend to internalise their emotional experiences.
They have good parental attachments, and the strain they manage is not
obvious at school.

One of the most complex families we have worked with came to the project
                 The Haven Project Hull 2002-2007: Final Report                      14


because a teacher noticed that a six year old was quiet and sometimes looked
sad. This sensitive referral led to long term intervention with a family which
has needed the support of several agencies over three years because of the
trauma experienced by the single parent.

It is easier when a school has a particular staff member or members working
with refugee children and a room which the children identify with as their
own space. Some children have come from areas of conflict and find the
noise of secondary schools stressful and they welcome a place to which they
can retreat.

A number of refugee children have done well academically and it is possible
for their underlying distress to be overlooked. Their behaviour may not be a
problem and so their difficulties may not come to the attention of the
teachers.

We have used, as a referral tool, the SDQ (Strengths and Difficulties
Questionnaire) but whether staff complete it has been rather uneven.

Some of the primary schools have had refugee children for some time and
have given families great support, and we are building relationships with one
or two which have only recently taken refugee children.

There are relatively few unaccompanied minors in Hull, in comparison with
a city like Leeds. However, we had a good referral network with the Student
Support Service at Hull College, although since a key staff member left this
network needs rebuilding.

Referrals have also come through voluntary sector agencies, advice bureaux,
and individuals.

Reference will be made later to the issue of referral pathways, but one of the
key features of the project and one to which we are wholly committed is that
delivering services to the BME population relies on a broad spectrum of
referral pathways. We share the view expressed in „Promoting Mental
Health‟ (3), that

“The community is an important setting for delivering mental health promotion to black
and minority ethnic communities”,( 3)
                     The Haven Project Hull 2002-2007: Final Report                                     15


and „community‟ in this sense is not the same as Community Mental Health
Teams, but a much wider definition of community, which includes local
networks, small organisations, communities of interest, and so on.
We would add, „services‟ to the above quote about „promotion‟.


6.3:Assessment

We work with a therapeutic model which begins with assessment as the first
step, and in spite of working very much at the grass roots, and having tiny
premises so that we cannot offer everyone an office based appointment, we
place a high priority on a clinical assessment as the first stage in the work.

The three key elements in assessing the impact of the experience of a
refugee are

1. What happened in your country of origin?
2. What happened on your journey here?
3. What has happened since you arrived here?

Some of the work is also determined by the political context of the last
seven years within the UK, and the generally high level of hostility to
refugees

A clinical assessment of a refugee‟s state of mind has to encompass

       the length of time they have been in the UK
       whether they have NASS support *
       whether their case has been determined or not
       whether they have access to legal representation

This is why refugee mental health assessment is rather different from the
usual assessment framework. We use an assessment procedure which is the
same as for non refugees, but in addition we have to consider the political
and legal context of the person.

* National Asylum Support Service which can give limited financial, housing and other support until a
determination is made on the application for asylum.
                     The Haven Project Hull 2002-2007: Final Report                              16


What is rather different in assessing the reasons for the distress of an asylum
seeker in particular, is that the political dimension in the UK is central to
their distress in most cases. There will be changes during the next few years
as the government appointed team work through the backlog of the „legacy‟
cases who arrived before the implementation of the New Asylum Model in
February 2007. There are almost 450,00 cases which have been either not
determined in the courts, or who have been refused but cannot be returned
because of the unsafe conditions in the country of origin. Where children are
involved, NASS has continued support, but there are many individuals in
Hull and other cities who are destitute and whose plight has been described
in a recent research report, „Destitution in Leeds: the experience of people
seeking asylum and supporting agencies. (4).

Those people who are dealt with under the new model are generally having
their cases determined within a few months and deportations of unsuccessful
applications are increasing. Unaccompanied children under eighteen usually
receive humanitarian protection until the age of eighteen when they have to
reapply for leave to remain.

The assessment of someone‟s mental health state, or of the reason for
distress of a family member has to begin, therefore, with questions about
refugee status. We never offer an opinion, but try to ensure that the person
has access to legal advice, which is difficult in Hull, ** and if relevant, that
the solicitor is aware of the need to provide an expert witness report on the
person‟s state of mind. It has become increasingly difficult in the last few
years to have the person‟s mental state taken into account by the Courts,
which have been dismissive even of reports produced by the Medical
Foundation, but it is still important to ensure that this context is addressed.

The judgements in relation to asylum applications have become increasingly
based on „belief‟ as the reason for refusal. In a High Court decision given
last year in relation to an applicant seeking permission to appeal, which was
granted the Judge commented

“To use belief as the reason for a refusal is perhaps unattractive and certainly
intellectually unsound”

** Hull now has no specialist immigration law firm since the closure of the Law Centre and the
reorganization of legal aid.
                The Haven Project Hull 2002-2007: Final Report                17


In any other context, it would seem inappropriate, early in an assessment, to
ask, Who is your solicitor?” Nevertheless it is an essential question and we
have valued the help of the Legal Department of the Medical Foundation in
guiding us to give good quality information to clients about seeking legal
representation.

This context in itself, of waiting, living in limbo for years, not being allowed
to work and living with high anxiety, is very demoralising and emphasises
the state of helplessness which is so often at the root of depression.

F came to the UK with her son four years ago from Iran. She had the first
standard interview with the Home Office and not had a decision of any kind.
She has become very depressed and as a secondary feature of that has
developed anorexia which has needed psychiatric consultation.


S came from an African country four years ago with two children. She was
very traumatised but showed some resilience and competence. The Home
Office was asked for a decision two years ago with no response.
She has become chronically depressed, unable to mobilise her adult ego
functioning on some days and has very severe headaches which are anxiety
related and the family have been supported by a number of agencies.

In these situations, the project has offered long term support, and involved
other agencies who are better placed to offer support in specific ways.
Referral to other agencies is an important part of our assessment skills.
A major strength of the project has been the close working relationship we
have developed with the Clinical Psychology team in CAMHS. We have
developed a fast track referral route and now on occasion do joint
assessments and share aspects of the work with a family, so that CAMHS
may do the specific clinical work while Haven meet with a family in the
community.
                The Haven Project Hull 2002-2007: Final Report               18


6.4: Child or Adult Referral

When children are referred to us we may decide, having assessed the family
stress points, to work with the adult or with the child, or with the
relationship between them. Increasingly, as we are working more closely
with CAMHS, we may refer the family and we share the work, so that
Haven can work with the parents in the community while a Psychologist can
work with the child and the family dynamic in a more clinical setting.

In assessing refugee children, whilst many appear resilient and indeed are,
they do not show evidence of disturbance in school or in other contexts.
Some children have commented that other people cannot imagine what they
are thinking and feeling inside, because they have become so used to coping,
to getting on with life. It is a difficult distinction to make as to whether an
apparently resilient child is in need of some therapeutic support, but we have
generally found that when we have made a referral to CAMHS, far more of
the child‟s internal world is expressed in that clinical context in which they
feel safe and where they can discuss their hidden fears. They may be
preoccupied by a loss which, if they spoke of it at home, would distress the
parent. Children are, of course, good at monitoring atmospheres and making
guesses about how to keep things afloat, sometimes at a cost to themselves.

Sheila Melzak who has been the lead Clinician at the Medical Foundation
working with children and adolescents identifies the following factors which
promote resilience in refugee children, which we have found helpful.


      Belonging
      Thinking
      Active strategies for active problem solving
      Feeling part of a community of exile
      Being able to integrate your own culture and the culture of exile.




The children of single parents, especially, can develop an prematurely adult
identity and carry too much responsibility for a depressed mother.
                The Haven Project Hull 2002-2007: Final Report                19


A from Kosovo said recently,
“No-one can imagine what it was like when my mother was so depressed,
listening to her threatening to kill herself”
She was seen in school as highly successful and it was only when something
erupted in her and she took an overdose that the full depth of her anxieties
became apparent. She is still very successful and but remains highly anxious.


It has been difficult to involve one or two schools with our work because of
the other pressures on the school, but also because the children do not often
present the usual array of difficult behaviour so that our clinical concerns are
not taken so seriously. Teachers often do not have the time to notice the
warning signs and prefer to believe that the children are coping well.

We have developed a good working relationship with one Educational
Psychologist in particular and have had a number of referrals through her.

One of the questions we have been asked to help with in two cases is

“To what extent is this child‟s learning difficulty related to trauma?”

In these cases, the opinion of the teacher, the Education Psychologist, the
Clinical Psychologist and perhaps a Consultant Paediatrician are all brought
to bear on the problem. The Haven Project may have a role in the assessment
stage; observing the child; building trust with the carer; finding out in more
detail what the child‟s history has been and directly making referral to
CAMHS having taken some time to explain to the carer what the value of
this might be. We try to use interpreters with whom we feel confident and
the interpreter can play a part in helping the family to build trust.

The assessment role which we have developed is important in maximising
access to services for refugee children.

6.5:Individual and Family work

We have done individual work with a number of children and also with some
adults where we have felt that that was appropriate.
There has been a limited amount of individual work with adults, but when
we have worked with children, we have often involved the parent/s also.
                 The Haven Project Hull 2002-2007: Final Report                    20


There is a debate about whether western models of counselling and therapy
are appropriate for people from other cultures. Dick Blackwell (5)
suggests that it more a question of how to make our counselling and
psychotherapy suitable for our clients.

“Most people have some form of communication available for the expression of pain and
distress”



The key elements of this therapeutic work have been to:


a) Listening to the experience.

Bearing witness is of crucial importance in the work, when people feel
understood in the depths of their loss. To share some understanding of what
human beings are capable of is in itself important to some people.

b) Not making prior assumptions about what is most important.

One man had been tortured three times, had lost three members of his family
and been separated from his son for five years. What he found most difficult
to express, what he had never told anyone, even a family member, was that
his wife had been raped before she was murdered.
His shame and anger were overwhelming, certainly as great as his pain of
bereavement, but for the clinician, provided another learning point.

c) Containing distress

Mrs and Mrs R came to this country and gained refugee status. However, her
previous experience of humiliating rape made it difficult to for her to
continue the marriage once she had the choice in this country.
We were able to see the couple individually and together and support them
both in different ways in what became clear was going to be a permanent
separation.

d) Being aware of one‟s own cultural assumptions

Mr N whose marriage had ended, needed support but in spite of his distress
at the ending of the marriage, he wanted to know how he could find another
               The Haven Project Hull 2002-2007: Final Report                 21


wife to share his life. He did not feel able to go out and meet someone before
he was divorced because of his faith but was overwhelmed by loneliness. We
helped him to find a solicitor to deal with the marriage breakdown and
explained in great detail how the system worked here in relation to the
divorce.
He eventually found his own path but needed the containment of the
sessions to help him think his way through this new life.


e)Finding Forms of Communication

A family of three were referred by an advice center; parents and a twelve
year old daughter. Two other daughters had been left with family members
in the Middle East. The parents separated after some time here.
The child was suffering from the loss of her sisters, racism at school,
from health problems and confusion about her parent‟s separation.
The project bought her a guitar; printed some of her poems through which
she had been able to express her own view of her life; advised her mother on
how to deal with the school situation, which she chose eventually to change;
suggested how she might talk with her GP about what she felt were her
child‟s special needs, and gave her information about accessing legal advice.
None of this was classical talking therapy, but was effectively therapeutic in
content and approach.

f) Working with Child/parent difficulties

H was five when his father returned after an absence of two years, having
been returned to his country and been tortured for a second time. The child
refused to acknowledge his presence, the father was deeply traumatised and
was receiving individual help through the Psychological Therapies team at
the Octagon. The Haven role was to work with the child/parent relationship,
helping the father to engage with the child through play, and through a pet
bird, which the father bought for the child and which became the
intermediary for the relationship they built.

g) Using non verbal techniques

This is always easier with children than with adults. We have a range of
games and toys, and drawing materials to help with emotional expression,
but we also used symbolic materials such as a bag of stones with adults, so
                  The Haven Project Hull 2002-2007: Final Report                             22


that they select one to represent how they feel, or a set of cards around
which they can tell a story which represents something of their experience
and feelings.


h) Working with Trauma

Some refugees have had experiences which have left them traumatised.
Most refugees are distressed, although only some are suffering from
traumatic experiences.

The reason why a clinical assessment is important is to build a picture of the
impact of someone‟s experience and to consider what might be helpful in
rebuilding their lives. People learn to rebuild their lives around a traumatic
experience. It is not a linear progression through a „cure‟ and perhaps the
trauma always re-emerges at times, for example in dreams. What is
important is to try to find a balance through speaking about the experience
and allowing it to continue to overwhelm.

“The client needs to live sufficiently in the present in order to feel secure and grounded
enough to revisit the past without being overwhelmed by it” ( 6)



The person‟s ability to regulate their emotions is central to the treatment of
severe trauma and the problem for a few people who are traumatised but
who are in the „legacy‟ group of cases is that they are also suffering from
constant anxiety. That, combined with the disregulation of the trauma from
the past makes it very difficult for them to remain stable.
Guus van der Veer (7) suggests that those who cannot do this end up

“taking leave of their senses and organise their internal world around the traumatic
experience and develop chronic PTSD.”

Again, witnessing and containing are helpful in this process.

It is also important to understand something of the physiology of trauma,
to understand the way in which someone is overwhelmed into panic, and at
the same time have a cognitive thought that the panic is not necessary at that
moment, yet be unable to control the „fight/flight mechanism‟. To be
understood in that way, even if the response cannot be changed, can be very
                 The Haven Project Hull 2002-2007: Final Report                23


therapeutic and a key moment of communication between the therapist and
the client.

The Octagon Psychological Therapies team have been able to approach this
problem through have a massage therapist as a member of the team, to
approach a body/mind problem through the body, but this is only available
unfortunately, to patients who are registered with the appropriate GP‟s.

As well as being overwhelmed by a traumatic experience, someone may be
„psychically numbed‟ (8), so that their responses are deadened.
This is an issue where children are concerned because they may seem to
cope at school very well and their difficulties masked by the ways in which
they „cope‟. One girl recently said

“Studying is like taking Prozac, it takes the edge of everything”.

A sort of solution, but not perhaps a successful one for the longer term.

i) Group Work

We have organised group work for women in particular around themes
which might have some cultural relevance, such story telling, drawing an
object which reminds them of their country, or dance. These are ways in
which they can access safely the feelings of what they have left behind.
Many refugees keep alive the hope of returning if things change. The
country they have left behind, its colours, scents, sounds are all part of their
emotional life and their loss. Groups of this kind offer them a space to bring
those life giving memories to the fore and to share their significance with
others, as a way of restoring some self respect.

j) Education and information

Sometimes we have helped families in a very practical way because this
seemed to be the most appropriate outcome of an assessment. The family has
become informed of how a particular service works and in one case we were
able to inform city councilors about the context of refugees and why they
were in the city.
                The Haven Project Hull 2002-2007: Final Report                   24


Having assessed a child as not in need of a direct psychological service.
although she had had traumatic experiences, because of the strengths and
resilience of the parents, in discussion with the child we identified a primary
need as attendance at a single sex school.
Because of the distance from the school, the application for a bus pass was
refused. We attended an appeal committee at the request of the Councillors
to explain why we had this opinion and helped them to understand the
situation by providing them with articles about what people in the country
of origin suffer, without breaking confidentiality. This helped the members
of the committee to understand the particular circumstances of this request.

k) Cultural Integration Project

This work has been ongoing during 2007 as a way of helping refugees
discover more about the place they in which they live and is in the spirit of
the Home Office „Integration Matters‟ paper,(9 ) of
„contributing to the community‟ and „improving access to services‟ through building
trust.
There have been workshops on Christmas crafts, dough models,(run by a
Kurdish refugee), a Yorkshire cookery day for children run at the Zoo café, a
visit to the Deep, walking the Wilberforce trail, a trip to see „Cargo‟, a play
about slavery) and the one where, in spite of pre-organised booking, so
many people turned up on the day we had to book another bus, the trip to
Bridlington.

The purpose of the project is not simply to put on an event, but is part of
becoming known as an agency to which people can turn on another
occasion. We have also built capacity in individuals by asking people we
have known for some time to help with the project.

l) Working with Interpreters

We have a long experience of working with interpreters and as mentioned
before, have delivered training on this theme to other Health Authorities.
Working with interpreters is a highly skilled task and we have provided a
regional resource to organizations working in this field. We try to build good
working relationships, preferring a model where the interpreter is a co-
worker, not only a translator, but someone in whom we can build mutual
trust for the benefit of the client. Clearly, interpreters need to understand the
therapeutic context in which they are working.
                 The Haven Project Hull 2002-2007: Final Report                    25


We have also valued interpreters as referrers, as on occasion they have
known of an isolated family who could not access help in other ways.
We try to be aware of the stresses on the interpreter of some of the sessions
they have to interpret for. None of us, including the therapists, are
impervious to the stresses of this work and we want to stress the importance
of „good practice‟ which includes some support and debriefing for
interpreters in the field of mental health work.

7: Networking and why we consider it to be important

In Mental Health Promotion (10) it states that
“Partnerships between Health, Social Services and the Voluntary and Community Sector
are essential to the delivery of effective Primary Care Mental Health”

Much of the work in Hull in relation to refugees and asylum seekers has
hitherto been done by the voluntary sector, on limited resources and relying
heavily on volunteers. We have built a working relationship with these
organisations and for some time had a staff member on the Board of Arkh
and substantially contributed to the design of the Befriending Project which
has been funded through the Home Office. One staff member is also a
counsellor at Arkh.
The example below describes clearly why good Primary Mental Health
services for the BME population have to been seen as a spectrum.


F is a teenager who was given a befriender and who established a trusting
relationship. On an outing one day, the befriender became concerned by
comments the girl was making about people who kill themselves. The
befriender discussed her concern with the carer who contacted the Haven
project for advice about how to approach the problem. The real nature of the
girl‟s anxieties and experiences came to light and the referral pathway
to CAMHS was used. This pathway to care involved:
Arkh befriending project
The befriender
The carer
Haven Project
Social Services
CAMHS
GP
                  The Haven Project Hull 2002-2007: Final Report                          26


Some of the key organizations with which we have been involved include:

    Refugee Council Network
   The Haven Project has attended the network meetings which were
   organised through the Refugee Council in Leeds and were a useful
   opportunity to share ideas and experience. These have been currently
   discontinued and there is now no specific forum for these discussions at
   present.

    North Bank Forum
   For a time the North Bank Forum had a working group looking at issues
   relating to BME mental health. However, the discussion was, in our view,
   not consistently grounded in the experience of BME people and came to
   an end. The fact that there were no BME staff within the Forum
   promoting the work was one reason perhaps that it had limited impact
   overall.

    HANA (Humber All Nations Alliance)
   The Haven Project is a member of HANA and has played a specific role
   in helping to develop a working group through which to consult members
   of the BME community about the issues relating to mental health which
   are of concern. We have consulted with Selina Ullah, the BME lead in the
   National Institute for Mental Health in England in the North who has
   been supportive of this step. Recently we have also invited staff from the
   Humber Mental Health Trust to participate in and contribute to the work
   of the group, thus widening the partnership. Our long-term objective is to
   strengthen a user perspective.

    Gateway Project
   We have recently been invited to participate in the Gateway Project
   meetings because of our contact with families from both groups of
   Congolese. We have also worked closely with the Refugee Council Team.

    Local Strategic Partnership.
   We have contributed to the work of the Partnership concerning services
   for children. In its consultation document on the Third Sector 2007 (11)
   the Government identifies Strategic Partnerships as the main vehicles for
   developing a „vision‟ and emphasises the importance of
   „engaging the Third Sector organisations which provide a strategic voice and can
   support local action, as a bridge to smaller organisations working at grassroots level‟ .
                The Haven Project Hull 2002-2007: Final Report                  27


   The Haven Project does not in itself provide a strategic voice, but its
   participation in HANA enables it to make a contribution at this level.

    Ethnic Minority Support Service
   This group, which relates to the needs of BME children in schools has
   operated regularly for some years and has offered a route through which
   we can build relationships with schools who have refugee pupils.

    Home Start
   Recently, Home Start has built a link with the Haven Project as they also
   have a small project which relates to the needs of refugee children under
   five.

    Regional links
   At a Regional Level we have links with Solace a regional refugee mental
   health project; Jantela, an umbrella group of five organisations working
   with refugees; Leeds Asylum Seekers Support Service (LASSN);
   KRAFT in Huddersfield, and at a national level value the expertise of the
   Medical Foundation and the Refugee Council.

   We place a high value on networking and drawing on the experience of
   others to develop a high quality service in a specialised area of work.


8: Problem Areas

8.1:The position of the voluntary sector

Hull has undoubtedly made great strides in the last few years in developing
an improved awareness among Council services of diversity and equality
policy and practice. The BME population in the city has increased during
that period from 3% to maybe more than 8% especially if the recent inflow
of migrant workers are included.

Some core funding has been made available to the refugee voluntary sector
groups which has undoubtedly facilitated the development of those services.
However, funding is still fragile and uncertain.

Historically, the voluntary sector has had a less significant profile than in
                The Haven Project Hull 2002-2007: Final Report                 28


other larger cities. In Leeds, for example, there is an organisation
specifically to co-ordinate and promote the services offered by voluntary
sector mental health organisations, Volition.

As a voluntary sector organisation with considerable expertise, we have
experienced difficulties at times in working with the statutory sector and
have encountered a suspicion that, if we are in the voluntary sector, we are
not really qualified and our opinions should therefore carry less weight.
In reality the Haven team is highly qualified and very experienced in a
specialized area of work and could be a valuable resource to the Statutory
sector.

We have also encountered difficulties in having referrals to Social Services
accepted, although as the teams have become more familiar with refugee
issues, this is improving. We have also encountered problems in „working
together‟ with one or two social workers and feel that this again is based on
a difficulty in understanding that people within the voluntary sector can also
have expertise and be a useful resource.

8.2:Tokenism

This is an issue which is a constant problem for BME professionals and
organizations.

During the period when we were trying to establish the Haven Project in
partnership with a Statutory Service, we eventually made an agreement to
pay a sum of money to Educational Psychology for time which was given by
them to Haven related work. The collaboration began and then stopped
suddenly. What became apparent was that the Department had just had an
OFSTED Inspection and that the collaboration with Haven ticked the BME
box. Once the inspection was over, the requirement to work with the Haven
Project disappeared. This is a familiar experience for many BME people.
Although two of Haven‟s staff are not from BME groups, the client group
with which we work means that our position as an organisation often mirrors
theirs, experiencing tokenism and marginalisation. The Haven staff have
many years experience of working cross culturally in other cities which are
more multi-cultural than Hull and also abroad. Again we could be a resource
which is more widely used for these reasons.
               The Haven Project Hull 2002-2007: Final Report               29


8.3:Anxiety about delivering services differently

Also during the earlier period, a concern was expressed by the Inter Agency
link team after a series of meetings to explore collaboration,
that if this was developed, even though some funding would be available to
the team, it would not be fair to prioritise refugee children above the
ordinary population. This did not take account of their specific need, nor,
more importantly, of the need to offer a service in a different way.
Opportunities were missed to work more closely together and for the team to
use the specific expertise of the Haven project in refugee work, whilst the
Haven project might have drawn on areas of expertise from the team.
Instead, services have developed separately rather than allowing us to
collaborate and develop a model more appropriate to the needs of the BME
population.


8.4: Lack of a holistic assessment model for unaccompanied minors.

The care offered to the small number of unaccompanied minors in Hull,
while supportive in many ways, could be improved by adopting a model
developed by a Psychologist in Kent through the experience of working with
a large number of young people being cared for by Kent, an area which
received many asylum seekers before dispersal was introduced, especially
Young Separated Refugees.
The psychological needs of this group are not necessarily best managed by
referral to a counselling service which is not experienced in working with
refugees. A counselling service may be excellent for some populations, but
many counselling courses do not include a cross cultural perspective in any
depth, nor offer training in working with interpreters. In addition there is a
specific „good practice‟ model in ensuring that a young person reaching the
age of eighteen has the best possible representation, which, if appropriate
includes expert witness reports. A closer and more collaborative working
relationship which recognizes the particular strengths of the Haven Project
would maximize the quality of the service which unaccompanied minors
receive.

8.5:Development of NHS services in isolation from other services.

There are opportunities now, through the commissioning framework to
build a closer working relationship between Health and other services.
                  The Haven Project Hull 2002-2007: Final Report                       30


A failure to do this can leave specialized Primary Care health workers
working in an isolated context, and struggling with refugee issues for which
they have not had specific training. There is a greater risk of secondary
traumatisation of staff working in settings where they are not working
alongside other organizations involved with the client group.

8.6: Over-reliance on GP referral as the route into psychological care.

There is substantial literature on the extent to which people from BME
groups do not present problems related to anxiety and depression, for
example one study suggested that
„Chinese communities seem less likely to consult GP‟s, in particular for anxiety and
depression. Chinese groups tend to access their GP‟s only after long delays and less than
40% of them seek help firstly from their GP‟.

„Depression in people from African Caribbean, South Asian and refugee and asylum
seeker communities is frequently overlooked, although these communities may be at 60%
higher risk than the white population with the risk being twice as high for men than for
women‟ (12)

One woman recently referred to the Haven project had become very
depressed and on medication for three years but had never been referred for
counselling until her daughter needed a referral to CAMHS. She had been
referred by the GP to Primary Care Counselling and was on the waiting list,
but when offered the choice, preferred a referral to the Arkh counselling
service which she knew was familiar with refugee problems.

The Haven Project was contacted by HANA about an individual whose
community were very concerned about him. The GP had not referred him as
he did not consider him to have a mental illness. However, the difference in
his behaviour had become very marked to those who were familiar with him.
A CPN is available to 167 and this was the route taken in this case, but again
perhaps the GP was not familiar with cultural issues relating to his
behaviour.

Of course, a GP must retain clinical responsibility for patient care, but to
insist that GP‟s are the only referral pathway may be a barrier to patients
from cultures unfamiliar to the GP offering care.
                  The Haven Project Hull 2002-2007: Final Report                          31




S was a referral in the early days of the Haven Project. He had come from an
African country and was originally a child slave. He became very distressed
and disoriented and was in a mental health unit. He was not considered to
have a mental illness, but the Haven Project therapist considered that he was
very fearful and that some of his symptoms could suggest that he was a
fragmented personality and dissociated. He was undoubtedly difficult to
understand and to help, but working with a voluntary organization and
members of his community, he was given access to some African healers
who understood his state of mind, and who, in the end, arranged a return to
an African country to be cared for by the healers there. The problem area
was not the fact that he was not easily helped by the NHS mental health
system, but that there was an unwillingness to consider alternative routes to
offering help in this very specialized case. There was a lack of willingness to
use the cultural expertise of the members of his community.


The Health Promotion report concludes:

„Partnerships between health and social services and services in the voluntary and non-
statutory sector are essential to the delivery of effective primary care mental health.
Primary care teams may have close links with Citizens Advice Bureaux, benefits and
housing agency workers as well as partnerships with voluntary sector services that
traditionally are good at engaging people from black and ethnic minority groups. (13)

There are certainly examples of this good practice in Hull, but the Haven
Project has encountered problems in relation to PCT services not being
allowed by managers to build a collaborative working relationship.
The Haven Project has not been enabled to ensure that the resource of
expertise, which it undoubtedly is, is used in partnership with PCT services,
in spite of efforts by the project to try to build links.

9:Successes
9.1:Building trust with clients

We have now worked with some families for a long time and they turn to the
project for support when needed.
One client who moved to London said that she had not really recognised
                The Haven Project Hull 2002-2007: Final Report                 32


how helpful the project was until she moved and realised that that was not
how all services worked!
We have maintained supportive and committed relationships with our clients
through some periods of great despair and some have maintained the contact
over many years when their legal status has not been determined.


9.2: Having a key role in the design of the Arkh Befriending Project

The Befriending Project is the classic example of how to offer a bridge
between cultures.

P is an eleven year old boy from the Horn of Africa cared for by a relative.
He has some learning difficulties and is quite isolated from school friends
when he is at home. A befriender visits him once a week to play football
with him, which is his passion.


Mrs N is caring alone for a six year old child. She has become somewhat
isolated within her community recently and is very distressed. In addition to
Haven Project intervention, she has been allocated a befriender who will
take her shopping and help her with her English.

A befriending project is a vital part of the spectrum of mental health
provision which is needed to offer a service sensitive to the needs of BME
populations. A befriender can be the first point of contact, and be confided in
so that a problem might manifest itself first in that context, or a befriender
can offer support to the work of other agencies by providing a link between
the two cultures.



9.3:Building a partnership with CAHMS

This partnership has been based on mutual respect and a willingness to share
information when appropriate. It has taken time to develop but has shown
itself to improve access to CAMHS services for refugee families and to
support the Haven Project in complex cases with expert clinical opinion.
It is a model which could be developed with other services.
                The Haven Project Hull 2002-2007: Final Report                  33




9.4: Working with HANA to develop the working group which focuses on
BME mental health issues.

We have worked closely with HANA to raise the profile of the debate about
mental issues among the member organizations and also worked to build
link with the Humber Mental Health Trust.

9.5: Drawing on international experience through attending an
international seminar at Pharos in Utrecht.

Understanding the experience of a number of other European countries was
an important element in helping us to think about our work .

David Ingleby (14) identifies the key elements of good practice in work with
young refugees as:

      Preventive/Early intervention
      Outreach models to improve access to services
      Culturally appropriate
      User involvement

9.6: Being part of a consultation group in the Dept of Health which guided
the authors of a training manual on refugee health
for NHS staff

We contributed to the initial meetings to assist the two writers of the guide
by outlining the key areas which should be addressed

9.7: Participating in the Local Strategic Partnership discussions in
relation to services for BME children.

The Government Third Sector consultation paper recognizes that the Local
Strategic Partnership is an important forum through which to engage the
views of both the Statutory and Voluntary Sectors on key areas of policy.
               The Haven Project Hull 2002-2007: Final Report               34




10: Conclusion

We argue that the Haven Project has provided an innovative, flexible and
culturally sensitive and effective resource, both to Hull‟s asylum seeking and
refugee population and to organizations trying to build the skills appropriate
to Hull‟s rapidly changing demography.

The model involves developing pathways to high quality care for
refugee and asylum seeking families, by:

    Using community development techniques of building trust and
     having an easy referral route with a limited waiting time between
     referral and response.

    Being experienced in culturally sensitive work.

    Understanding that good mental health care for refugees and
     BME populations relies on a spectrum of services which work
     together with trust and respect.

    Offering expert assessments

    Building positive working relationships with CAMHS, which is a
     model which could be replicated with other agencies.

    Networking with the voluntary sector in the city.

    Recognising refugee mental health as a specialist area of work

    Understanding the political, legal and personal context of refugee
     lives.

    Networking regionally, nationally and internationally to keep abreast
     of developments in the field.
                The Haven Project Hull 2002-2007: Final Report             35




Acknowledgments


Throughout this document reference to „refugees, unless otherwise stated
includes „asylum seekers‟.


We wish to thank our clients for their trust in sharing difficult life
experiences and for teaching us so much about the needs of refugee families.


We are grateful to:

The Esme Fairbairn Charitable Trust and to New Philanthropy Capital for
their financial support

Centre 88 and Jean McEwan for giving us a „home.‟

Hull Childrens Fund who gave us a small grant for equipment.

Steve Ibbetson for advice and information

Dave Knapp for advice about the Mental Health Trust

Dr Peter Campion for support on specific issues

Anny Woods for encouraging the work on Mental Health in HANA

The Local Network Fund for funding the Cultural Integration Project

All the interpreters who have worked in a professional manner with us over
the years


And in particular to Patricia Ross and the Clinical Psychology Team at
CAMHS who took the step of working closely with the project amd enabled
us to develop a model which we hope will increase access to NHS services
               The Haven Project Hull 2002-2007: Final Report              36




References.

1 Dawson A. (2000) Monocultural communities and their effect on
asylum/immigration seekers in Humberside. A Report for Save the Children
Fund
2 Home Office. (2005) Integration Matters: A National Strategy

3 Mentality 2003 Promoting Mental Health Chapter 6

4 Lewis H (2007) Destitution in Leeds: The experience of people seekinig
asylum and supporting agencies. JRCT

5 Blackwell D (2005) Counselling and Psychotherapy with Refugees:
Jessica Kingsley London.

6 Ibid

7 van der Veer. G (1992) Counselling and Therapy with Refugees. Wiley

8 Blackwell D (2005)

9 Home Office (2005) Integration Matters: A National Strategy

10 Mentality (2003) Promoting Mental Health Ch 6

11 Dept for Communities and Local Government. (2007) Third Sector
Strategy for Communities and Local Government

12 Mentality (2003) Promoting Mental Health

13 Ibid

14 Ingleby D. (2005) Bridging the gap between needs and services:
challenges for mental health and social care. University of Utrecht. Pharos
Summer Course
The Haven Project Hull 2002-2007: Final Report   37