Therapeutic Engagement with Unaccompanied Asylum-Seeking Minors

For this podcast, for Refugee Week, we are joined by Dr. Hayley Rajpal, a child and adolescent psychotherapist with a specialism in working with looked after children and their networks. Hayley’s thesis research explored the challenges of therapeutic engagement with unaccompanied asylum-seeking minors, and this will be the focus of the podcast.

To set the scene, Hayley provides a brief overview of psychotherapy before turning to detail how she came to be interested in child and adolescent mental health as it relates to refugees and asylum seekers.

Turning to Hayley’s studies, where she explored the experiences of care networks providing therapeutic support to unaccompanied asylum-seeking minors, Hayley shares some of the main takeaways from her thesis.

Furthermore, having touched on the impact of difference and diversity, plus racism and media perceptions, Hayley also shares what issues have arisen around difference and diversity when it comes to the provision of care for unaccompanied asylum-seeking children and young adults.

Subscribe to ACAMH mental health podcasts on your preferred streaming platform. Just search for ACAMH on; SoundCloud, Spotify, CastBox, Deezer, Google Podcasts, Podcastaddict, JioSaavn, Listen notes, Radio Public, and Radio.com (not available in the EU). Plus we are on Apple Podcasts visit the link or click on the icon, or scan the QR code.

If you are interested in hearing more about therapeutic engagement with unaccompanied asylum-seeking minors, check out Hayley’s recent lecture on the topic, presented at the ACAMH Southern Branch online event ‘Service improvement and research: Innovation and new challenges in CAMHS’.

Dr. Hayley Rajpal qualified as a Child and Adolescent Psychoanalytic Psychotherapist from the Tavistock and Portman NHS Foundation Trust. Whilst studying and since qualifying Hayley has worked in various CAMHS teams within the Southwest. She now works for Sussex Partnership Trust in Eastleigh and has a private practice in Southampton and Salisbury. Hayley’s specialism and main interests lie in working with looked after children and their networks. This contributed to the focus of her thesis research which explored the challenges of therapeutic engagement with unaccompanied asylum-seeking minors

Transcript:

[00:00:31.935] Jo Carlowe: Hello, welcome to the In Conversation podcast series for the Association for Child and Adolescent Mental Health or ACAMH for short. I’m Jo Carlowe, a freelance journalist with a specialism in psychology.

June 20th to the 26th is Refugee Week 2022. And I have with me Child and Adolescent Psychotherapist Dr. Hayley Rajpal, who has a specialism in working with looked after children and their networks. Hayley’s thesis research explored the challenges of therapeutic engagement with unaccompanied asylum-seeking minors and that would be the focus of today’s podcast.

If you’re a fan of our In Conversation series, please subscribe on your preferred streaming platform. Let us know how we did with a rating or review and do share with friends or colleagues.

Hayley, thank you for joining me. Can you start with a brief introduction about who you are and what you do?

[00:01:24.607] Dr. Hayley Rajpal: Yeah. So as you said, I’m Hayley, a psychotherapist, and I work within the Southwest region of the country within the NHS as well as private services as well. I thought, maybe, just also a brief overview of where and how I got into what I’m doing and a bit of an overview of psychotherapy might be helpful.

So during my undergraduate time of education, we were asked to explore children’s literature. And I came across a book written by a lady called Hilary McKay, the title is called ‘Indigo’s Star’. And within that, there was some great depictions of how one of the children in the family were drawing on the wall about the family dynamics at home. So dad wasn’t at home and he featured behind this thundercloud. And I thought, this is fascinating, you know? This drawing on what’s going on here. So I wanted to find out a bit more about what goes on behind behaviours. So I then came across therapy. Yeah, I went through the rest of my educational endeavours to then go on to my training.

So psychotherapy, in a nutshell really, is built upon the notion of conscious and unconscious processes within the mind. And that we keep the feelings and memories that are too painful, ready to be addressed consciously in our unconscious.

So a large part of my work is building up trust with young people and families to explore that part of their minds and at a gradual pace. Looking and exploring difficulties and problems and behaviours. You can have a look at the Association of Child Psychotherapists website, the ACP, if anyone is interested in learning some more information about that.

[00:02:52.288] Jo Carlowe: And how did you come to be interested in child and adolescent mental health as it relates to refugees and asylum seekers?

[00:02:59.955] Dr. Hayley Rajpal: So I worked within a generic CAMHS team in the Southwest, and when I was linked with the looked after children’s team, I noticed that, over a couple of years, we were receiving more referrals from unaccompanied minors regarding the mental health concerns of these individuals. There was a lot of multi-layered stuff going on and comorbidity as well. As those levels of referrals were increasing, we weren’t necessarily giving direct therapeutic sessions to these young individuals. It was more medication or review meetings and I was curious about that because there are several examples across the UK where direct work is happening and quite successfully. I wanted to find out really why that was happening within the service. So I then thought through my studies and having the opportunity to do some research that that would be an area of focus that seemed to be requiring some attention, really not just out of my own curiosities but for the services and young people in general.

[00:03:51.390] Jo Carlowe: Turning to your studies, your thesis explored the experiences of care networks providing therapeutic support to unaccompanied asylum-seeking minors. Can you share some of the main takeaways from that?

[00:04:04.352] Dr. Hayley Rajpal: I’m mindful of not wanting to give too much in the short time that we have because it’s a quite– there are quite a vast amount. But in brief, there were, obviously, differences and similarities explored between unaccompanied minors compared to looked after children. So Indigenous looked after children and the impact that they have upon placements and relationships.

In particular, also the impact upon the availability and ability to be able to offer care to these young people. And I think one of the greatest challenges was identifying and remaining in touch with a young person’s needs when there’s significant traumas and multiple layers of deprivation that you have to contend within a care network. So it’s quite well known, I think, within the psychotherapeutic community and also within those that look after looked after children that there are multiple layers of deprivation that these young people have to contend with.

And that the networks and organizations also have to navigate their ways through. And what this research did find out, really, was that there’s a fourth layer that’s quite unique to these individuals in terms of the level of deprivation that they have contend with. They’re a distinct group that entices a different response from those around them. And I think that there needs to be acknowledgment that young people have a set of pre-existing biased assumptions that are thrust upon them from society, from politics, from a media context as well, which become enacted and held by foster carers, professionals depending upon their own political associations and where they position themselves within society.

And that really does feed into a care network. And that can be one of the challenges, in particular, of providing therapeutic support to unaccompanied minors and refugee communities because there are these increased defences, if you like. That then clouds the needs, in particular, of really what they’re requiring, and it can restrict access to support.

And also authentic engagement as well with others. And just to add, I think, there are loads more, but on top of that, there were [INAUDIBLE] of institutional racism or unthinking racism that occurred. And one of the most fascinating was the language. How we use language just in general but, again, for this community. There was such a fear of getting things wrong and words that were used like influx. Words of war like minefield, bombshell, and metaphoric trapping. Susan Sontag as someone to potentially look into further if you’re interested in the idea of metaphoric trappings which is where we use words which can incite a rational fear. And I think, there’s a lot of that surrounds unaccompanied minors and refugee communities.

[00:06:32.695] Jo Carlowe: I’m wondering because in your work and in your studies, you’ve spoken to many foster carers. So I’m wondering if you can set the scene for us about the kinds of challenges that arise for foster carers. You’ve already touched on some of them. But when they are supporting minors who are asylum seekers.

[00:06:49.867] Dr. Hayley Rajpal: One of the interesting things that came out was the idea of this trauma monster that it was born out of the support group. So just to elaborate in terms of the research that the data that was gathered from support groups that were offered to foster carers over six sessions and then interviews with professionals, with five different professionals not just within CAMHS but within other areas. Yeah, within the support group, in particular, this idea of a trauma monster came about where there were a multitude of facets such as greed, emotional burden, fear, and this idea of needing to defend against something that could be quite frightening or shocking or contagious that these young people were bringing into a foster care environment.

Not necessarily that they were frightening or shocking in themselves as individuals or as young people but what they had been through, and their experiences could be quite overwhelming. And how then a family would respond to that or feel supported or not supported by social care services to engage with that was something that was spoken about. There were so many gaps in knowledge for foster carers looking after and supporting these young people. They come with very little information about their histories and where they’ve come from, their date of birth, confusion around their names, for example. And naturally what we do, as human beings, is we try to fill the gaps when we don’t have knowledge. And that led to miscommunications and misunderstandings. A lot of complexities then added to what was hoped for, I suppose, within those foster care dynamics of wanting to invite these young people in but then not really being sure of who they had and what would be right for them and supporting them with their needs.

They felt uninformed and out of touch and sometimes, as a result of that, they wanted to have more control over what the young people were doing or where they were going because they didn’t have that knowledge. There was also a real big conflict within foster carers of whether they could be mothers or were seen as mothers or whether they had to be professionals and that they were encouraged to be more maternal and accepting and having these children as their own within the family. But at the same time, being told not to get too attached because they were going– these children were going to be moving on at some point. And that was a real dichotomy for them and a struggle.

[00:08:56.560] Jo Carlowe: Did it make it harder to place the children because there’s a sense, almost that, there’s too much to hold almost for foster carers?

[00:09:04.923] Dr. Hayley Rajpal: I think– for some, I think there was a bit of a question of whether they could do it long term or whether they’d signed up for this. And also again, the image that they were sold often by the media is that these children– small children in these news images that are looking for homes and then, actually, the children that were placed with them were 15, 16, and 17-year-olds and maybe questionable if they were adults or not, again, that’s another thing that these young people have to face when they are coming in the country. There’s so many questions of who they are and where they’ve come from. So yeah, I think, for some, it was a bit of a challenge of whether they could continue fostering unaccompanied minors or whether they wanted to– looking back whether they should have gotten to that in the first place.

But on the flip side, the study did explore the challenges but there was love, there was hopefulness that came up– came within this group too. And the idea of wanting to do a good enough job. And even the question of adoption came up too. Of really wanting to accept some of these young people. And one family, in particular, one mom really wanted to adopt her child – the child that she had with her because his family had abandoned him. That, I suppose, in brief paints a bit of a picture of what it was like in foster placement and, again, what was brought to the group.

[00:10:12.445] Jo Carlowe: So there was a line from your research, Hayley that really stood out to me. It talks about the flight to normalize behaviours and for professionals to position themselves in the shoes of the other. Presumably, done in a very well-intentioned way. But you found it dulled down the ambiguity and trauma. Can you elaborate what did you spot?

[00:10:37.860] Dr. Hayley Rajpal: I think you’re right. I think in many ways, this was, perhaps, done with good intentions and to try to understand what it might have been like for a young person so that there was a level of empathy you could say. But when considering the levels of trauma that is often present, I think another viewpoint could be that by going into oneself to try and understand the situation or emotion, it prohibits us from being open to be able to listen and feel and be in touch with the individual’s experience and what it’s been like for them.

To some, this could be done completely unconsciously. As an unconscious defence, I think, and the mechanism to protect maybe from what it was– what it might have really been like and their reality. So instead, there’s a positioning of almost in a fantasy of what it might be like, which is what I mean then by the dumbing down of the ambiguity and the trauma which thus could result in a young person feeling misunderstood and not receiving the level of support that they really do require.

So it’s not to say that don’t do it or that’s wrong, I think it was just an observation that was quite striking that came out of the study, really, from the interviews. It was quite apparent that people wanted to try and understand and make sense of but at the same time, that prohibited them from really being able to get fully in touch with what was really going on and what was really being felt.

[00:11:55.480] Jo Carlowe: And of course, you interviewed professionals for your thesis. What are the challenges did they face in terms of the provision offered and also their communications with carers and also the children themselves?

[00:12:06.845] Dr. Hayley Rajpal: There was a big emphasis on the struggles with time pressures. So there was felt to just not be enough time. So paediatricians have a very short amount of time to do the health side of things. Again, within CAMHS, there were pressures to try and fit everything in an initial assessment time period, which is about an hour, an hour and a half. And on top of that, you’ve got language difficulties. So you’re having, potentially. So there’s an interpreter that would be involved. On top of that, depending upon where an interpreter is from, you could have a cultural impact conflict with the person that you’re seeing and the political difficulties in with that as well. That’s all takes time management, if you like. And on top of that, there was a feeling of trying to get it right and wanting to get it right but feeling that again because of the pressures that they weren’t doing enough or weren’t doing as well as they might like to have been. And again, back to the language, as I mentioned before, there was a worry of getting– saying things wrong or causing offense and then maybe not saying or asking what they might like to to stop getting into that model or prohibit from getting too messy. So there was quite a lot of, I think, guilt and shame that was ignorance, as well as there was some recognition of limited capacity to think and react at times as well.

I wondered if– there’s a quote that I have from the research that, I think, is just really striking and really brings this to life. And I wondered if it would be OK to share that. So this is a professional talking about their experience that they had heard from a social worker. So they’d gone to meet, I think, there were five young people who were found in a freezer truck and they’d been in a freezer truck for hours. They had loads and loads of clothes on. They said it looked like they just gone and robbed a few washing lines kind of thing. A ripe mismatch of clothes where they heard a couple of people who had come in proper ski wear, these hadn’t. They were seen by ambulance crew who had labelled them, subject 1, 2, 3, 4, and 5. Subject 5 had a very low body core temperature, life-threatening body core temperature.

But then, they couldn’t say– when the social workers arrived, they didn’t know who was 1, 2, 3, 4, or 5. So the person who needed hospitalization for the low body temperature, they didn’t ask a name. And of course, they’re all disorientated because they’ve been in the freezer truck, and they’re frozen, and they’re so cold, and they’re thinking and all of that. So nobody asked for a name.

So that was a quote there from one of the interviews. And I think, the vagueness in the account is quite striking and the unknown quantity of time, again, the individuals have been traveling in such conditions. The names, the identities of the young people, where the clothes had come from, who had arranged the transportation, all of this stuff. And I think freezer and frozen I mentioned a few times and they were in other interviews as well, but I think it really emphasizes how this ambiguity impacts upon the ability to continue thinking both the young people, but also the professionals are involved, almost like a freeze on the thought because of the level of trauma. In some way, this example shows the depersonalization that can happen.

[00:15:07.510] Jo Carlowe: What is your advice then? I mean to both to professionals and also to carers around language. If you’re worried you’re going to get it wrong. Are you better off getting it wrong or holding your tongue?

[00:15:21.670] Dr. Hayley Rajpal: I think it’s about being honest at the start of a conversation and saying, this is the first time that we’ve met. I suppose, I would want to acknowledge that I might say things that might feel a bit clumsy or if I say anything that causes offense, if you were to let me know so that we can then think about other words that might feel more appropriate or that feel better suited. So I think if you can address it at the beginning, there might be some clumsiness or there might be something that has gone wrong. At least, you can then come to a position where that can be repaired and you can work through it rather than getting into a position where you feel too embarrassed or unsure so then you stop asking the questions or you don’t say the things that you want to say because, ultimately, then as I’ve been discussing, that, potentially, could restrict someone communicating what they want to or you being able to hear the things that are being said.

[00:16:10.420] Jo Carlowe: You touched earlier on the impact of difference and diversity. You also talked about racism and some of the media perceptions. When it comes to the provision of care for these children and young people, what issues arise then around difference in diversity?

[00:16:29.440] Dr. Hayley Rajpal: And that, again, was fascinating because it was kind of looked at in a variety of different ways within the clinic room, within the home environment, and also thought about in the context of society. So differences in expectations in foster placement, for example. Sometimes emulated a battle for territory. So there was a sense that, sometimes, it felt like foster carers had to maintain their ground within the home environment from invasion or war. So objects and space was fought over. The things being borrowed that shouldn’t really– the foster carers felt that shouldn’t be borrowed or they were then communal objects. But that kind of, I suppose, cultural understanding and boundaries were different. And also cultural ways were spoken of as being no good by the young people. So their way of communicating was saying, oh, this is no good in Afghanistan or wherever. This is how we do it, this is better. And foster carers were feeling a bit defended against that. So that was quite interesting.

And also how foster carers themselves were viewed by other people in society for offering a place in their home for unaccompanied minors. Some were welcomed and some were curious, others weren’t so. And so they weren’t invited to certain social events, for example, because of the young person that was living with them because they didn’t want that person to come along as well.

And other family members, older generations were talked of of finding it confusing or again, I think, there was a fear of getting things wrong but that couldn’t even be acknowledged or talked about. And again, with difference in diversity regarding ideas of risk and safeguarding. So terrorism and criminality were spoken about because, again, there’s a lot of risk assessing and safeguarding that is higher than Indigenous looked after children in some respects.

So there was a fear and anxiety around that of who do we have in our homes here and how do we have to change and adapt our family life for this young person to fit? But also how– the expectation of trying to encourage a young person to fit in with them and situation was quite difficult to navigate that kind of difference. There were those more religion and faith. I think around the time I did the study was Ramadan and there was so much confusion from the foster carers of what it meant that the young people that they were with, how they could support them. And there was a lot of night-time activity, obviously, at that time because of fasting. A lot of foster carers, maybe, we’re settling down for the night where the young people were up and wanting to cook and that didn’t fit in, again, with the routines and the dynamic.

I think, what was really beneficial was having this external space that the research provided, actually, because it encouraged them to be more reflective in terms of their internal capacity to think about some of this stuff and to share it with other people that were going through similar situations. So it was working through the conflicts, if you like, and the thoughts allowed them to be in touch with kind of feeling a bit more vulnerable and sensitive. It resulted in the demonstrations of the counts of love and emerging bonds by the end of the sessions together, which was quite a contrast from how it felt at the beginning of the research.

[00:19:25.450] Jo Carlowe: I mean, there’s an awful lot to navigate. Given all the challenges described, what advice do you have for care networks, including CAMH professionals?

[00:19:35.183] Dr. Hayley Rajpal: So I would say that needs to be detailed and specific training and supporting unaccompanied minors. Sometimes local authorities will say that they are under the umbrella, these young people, looked after children. And yes, they are looked after children, but they come with completely different complexities. Some similarities, but they do need to be looked at separate from that.

And I think it does a real disservice to the provisions that we then are providing if we don’t look at the separate things that they’re bringing in, they’re struggling with. And I think, one of the suggestions that the foster care has made was that, actually, young people who have been through the care system, unaccompanied minors, refugees, being a part of that training process would be really valuable and other foster carers who have fostered young people to share a lived experience. So questions could be answered directly. There was so much googling that went on and it didn’t– it wasn’t– it didn’t feel satisfactory to them. So that would be one thing, in particular.

And I think having a space which is safe, non-judgmental, kind of a bit like a supervision space, if you like, but separate from training and separate from supervision where, I think, professionals can be supported to think about their positions within society and political– the political context at the center of their work. And to recognize that discrimination and oppression is a likely reality when working with unaccompanied minors and refugees and for us to be able to talk about that, actually, and not feel ashamed or embarrassed or guilty. That is something that is interwoven within this work and if we can name it and think about it and talk about it, then we’re making a better headway, I think, with then making sure we get the support right as a team of professionals but also for individuals themselves.

And going back to what I said about– the beginning about psychotherapy, it’s that kind of what’s in the unconscious, what can be brought more into our conscious thinking, so our biases and our internal racism. What is it that we’re sitting with and where does that come from? So if we can discuss that in a safe enough environment, if that can be created within our services, I think, that would be tremendous and I think that would be really, really helpful. And I think that again, just thinking about trauma, how that can become quite enlivened within relationships. So using supervision spaces to, maybe, take a sideways step to think about how that impacting and obstructing therapeutic engagements. So what is alive within that relationship and what might be trying to come away from as professionals to protect ourselves. And where can we go to think about that safety so that we can, again, be consciously aware of how that’s impacting upon.

[00:22:02.650] Jo Carlowe: So given what you’ve said, what’s your message, Hayley, to policy makers at both a local and national level?

[00:22:09.860] Dr. Hayley Rajpal: There needs to be a call for more consistency across services. Really, what service you get within the NHS, for example, is highly dependent upon where you are in the country and as a service, it’s massively underfunded. And so overstretched. People are working incredibly hard. It’s not in the state, at the moment, to be able to deliver a good enough service, I think, for these individuals.

I would say more consistency and funding which I don’t think is a new thing but, I think, also that within CAMHS services, maybe not all, but from some of the experiences I’ve had, they can often take a stance that unaccompanied minors. I think it’s CAMHS but also, I think, external services, I should say. There can be a stance that unaccompanied minors, refugees with mental health presentations and difficulties, these behaviours are proportionate or in accordance with what they’ve experienced and witness. And again, this is kind of dulling down that happens as if it’s a normalized thing because they’ve been through trauma or they’ve had to be uprooted and moved. So of course they’re going to be stressed and of course they’re going to be depressed. And so that kind of normalizing is really, I think, unhelpful and takes away from the individual experience again.

And I think the last two points, I suppose, is to just have in mind– there can be quite a hostile environment within the UK and there’s quite a challenge at times, I think, regarding assessments from the home office, some of the social care departments, and with others as well. Regarding credibility of ages, I think, of these young people as a real sticking point that comes up again and again and again. Some of the home office workers can be quite uninformed about the impact of trauma on memory and thinking. They can be treated as adults when they’re not. They’re children. And there’s a lot of scientific evidence out there now of what stress and trauma can do to a physical date and appearance of looking much more aged than you are. So again, as I said before within the care networks, really, the same thing of just being mindful, really, of the biases when writing these policies. Where are they coming from? Is it– not just looking at the numbers on a page but thinking about the individual experiences as much as they possibly can really.

[00:24:12.470] Jo Carlowe: The theme of Refugee Week 2022 is Healing. Defined as recovering from a painful experience or situation so that we can continue to live. How optimistic are you that healing is possible for children and young people who find themselves displaced?

[00:24:29.170] Dr. Hayley Rajpal:  And I’m aware I’ve talked about, probably, quite a lot of what feels like heavy material and possibly quite– not necessary negative but difficult stuff to possibly listen to it and to think about. But I think there is optimism and I think there is positivity out there. And I think we are individuals who experience things and we can experience the same situation and set of circumstances very differently depending upon multiple facets, really, of our cultural backgrounds, our family structures, our external support systems, what we’ve internalized and how our own internal worlds are shaped, for example.

So this means that we respond to events very differently. And this is still– it’s the same case for unaccompanied minors and refugees too. They haven’t had any adverse childhood experiences, for example. So the trauma that they might have experienced coming over to a different country, it might mean then that it’s not left an impact or had an impact in the same way as someone else who doesn’t have that foundation.

So I think we either have higher or lower resilience levels and I– we’re thinking here not just about displacement, but also loss and the other things that come along with that identities, roles, and responsibilities. So I think with the right response– the support, the right responses, being listened to, understood, healing is definitely possible. But it requires time. It requires well-funded and thoughtful provisions. And there are some out there that have been working incredibly hard recently and for many years.

[00:25:50.002] Jo Carlowe: Hayley, is there anything else in the pipeline for you that you’d like to tell us about?

[00:25:54.280] Dr. Hayley Rajpal: I hope to do a bit more presenting of these findings in other conferences maybe later in the year into next year. There’s just so much that I’ve worked really hard on it. It took a lot of time. So I don’t want to keep it to myself. I want to share it as widely as possible. And I’m hoping to have, at least, one journal article published in the Journal of Child Psychotherapy later in the year based, again, on foster carers predominantly within the study.

[00:26:17.505] Jo Carlowe: And finally, what is your takeaway message for those listening to our conversation?

[00:26:22.510] Dr. Hayley Rajpal: Well, I’d say, I think, it’s hard, sometimes, to think about and be allowed to have certain feelings in a caring role, if you like. And I think we need to consider the emotional processes involved as well as the possible unconscious processes that we’re having in our work and in our interactions. So I think to be encouraged to listen and not to hear what we anticipate and to not be afraid to be in touch with and challenge some of our own core beliefs and our biases and where these might come from.

Trying to spend some time thinking about that within ourselves and, maybe, how that’s contributing to our interactions and our thinking when working with these individuals would be a really good place to start and, hopefully, something that will be taken away by some of the listeners today.

[00:27:02.640] Jo Carlowe: Hayley, thank you so much. For more details on Dr. Hayley Rajpal, please visit the ACAMH website, www.acamh.org and Twitter @acamh. ACAMH is spelled, A-C-A-M-H. And don’t forget to follow us on your preferred streaming platform. Let us know if you enjoyed the podcast with a rating or review and do share with friends and colleagues.