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| Sebastian Ssempijja. Ph.D. Director of Sebastian Family Psychology Practice, cofounder of OCON Conference |
Our City of Nations
In the spring of 2015, I was fortunate enough to be included in a coming together of vested community members that took place after operating hours at Columbia-St. Mary’s Family Health Center clinic on the city's east side. The meeting was the first of its kind, and consisted of some of the major players serving the refugee and recent immigrants in the greater Milwaukee area. Also in attendance at the initial coming together were several other notable community members including representation from Mt. Mary’s graduate in counseling department and the Medical College of Wisconsin’s Global Health Pathway.
At the helm of this discussion were Dr. Sebastian Seempijja, clinical psychologist and director and owner of Sebastian Family Psychology Practice, and Dr. James Sanders, medical doctor who serves as Associate Professor of Family and Community Medicine at the Medical College of Wisconsin and who serves refugees and other at-risk groups through Columbia St. Mary’s Family Health Center.
Although the team included persons of relatively high social stature and significance, what became immediately evident was the need to operate without regard for status or professional proprietorship. Discourse took the form of shared inquiry that placed networking for the purpose of better service at a premium beyond all other ambitions. The spirit and tone of this first coming together set the stage for the collaboration that would proceed over the next several months in e-mail communications and committee meetings that would take place at offices and week-end rendezvous in the homes of
partners across the city.
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| James Sanders, MD Associate Professor at Medical College of Wisconsin, OCON Cofounder |
These efforts culminated in the first annual, Our City of Nations (OCON) conference that took place at the Medical College of Wisconsin of Wisconsin on December 3rd and 4th. This conference served as an inaugural coming together of medical providers, mental health professionals, social service providers, and educators with hopes of closing in the systemic gaps and oversights that make serving refugee groups and recent immigrants. I have compiled here some of the major themes from the conference, which are reminiscent of those investigated here on Community Feeling blog.
PUBLIC HEALTH vs. TREATMENT
One theme that was reiterated throughout the conference was an emphasis on public health as distinguished from treatment. This point was made clear through the contributions of two state-level administrators that took part in the conference. The OCON conference brought together Dr. Edward Ehlinger, the Minnesota Commissioner of Health, and Kevin Moore, Wisconsin Medicaid Director through the Wisconsin Department of Health Services.
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| Edward Ehlinger, MD Minnesota Commissioner of Health |
Dr. Ehliinger spoke from his perspective as Minnesota’s leading medical professional, tasked with protecting, maintaining, and promoting health needs for all Minnesotans. In his compelling keynote address, Dr. Ehlinger outlined the contextual nature of health and wellness, including greater consideration for the
impact that decisions that are made at governmental levels have upon the lives of all people. Access to good public transit, jobs, and educational opportunity were thereby included in a discourse that looked beyond the development of good medical facilities when it comes to the promotion of civilian health. Dr. Ehlinger emphasized the importance of promoting social equity as being a significant component of public health, liken to the promotion of healthy sanitation and environmental conditions.
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| Kevin Moore Wisconsin Medicare Director |
Kevin Moore provided perspectives from his role as Wisconsin’s Medicaid Director, with a focus largely on issues pertaining to fiscal responsibility and the management of limited resources. Mr. Moore referenced the soaring healthcare costs and the binds that these expenses place on payer systems, and how these needs are tapped by otherwise avoidable health conditions that disproportionately affect society’s marginalized populations.
Both of these dialogues were turned towards the unique living circumstances faced by refugees as they attempt to acclimate to life in the United States, as they face conditions of social displacement, poverty, and reliance upon foreign entities. Although access to medical treatment and services were undeniably a much needed resource to refugee populations, the living circumstances that many inherit (social isolation, underemployment, poor housing conditions in high crime communities, experiences with racism or stereotyping) have a broad and profound impact upon physiological along with the psychological experience of the refugee. This helps explain a phenomena that I myself have observed of refugee clients, namely that refugees are often pleased to receive medical resources for free in the United States which they can and do access, but that their health conditions none-the-less deteriorate after they relocate here - a fact that seems quite contrary to the idea that access to healthcare is of paramount and central significance to health outcomes.
The fact that our current approach to medical care focuses largely on treatment of refugee groups, but does little to address larger public health conditions, is one reason that increasing expenses does not always relate back to improved quality of care. These considerations raise some compelling challenge areas, namely how are medical providers to impact upon these type of need areas? According to Dr. Ehlinger along with Mr. Moore, the answer to this question lies in the community. Through greater collaboration between organizations serving refugee groups and providers of medical and related services a nexus of community agents may succeed in the provision of services, where larger more costly entities would be at a loss. This could be done through nesting health services more seamlessly throughout the community, and by the promotion of service models that go beyond the treatment or management of existing conditions, to the promotion of knowledge and resources that enhance healthy living through the promotion of healthy lifestyle, self-care, and more meaningful social integration of refugee groups into their communities.
CULTURAL COMPETENCE vs. CULTURAL HUMILITY
Another focus of much of the conference was on the area of culture. The education and training many of us received in our respective professions included a considerable emphasis upon the issue of cultural competence. This is a a term that can be defined in different ways, but has to do with the ability to understand, appreciate, and interact with persons from different cultures and/or believe system other than one’s own, based on various factors (Seligman's Medical Dictionary, 2011). The variance and lack of specificity of definitions pertaining to cultural competence can be problematic. In particular, service providers may come to the premise that certain factors must be taken into consideration when serving refugee and immigrant group that would not normally be considerations when serving other populations.
The idea of cultural competence relates back to a philosophy of specialization, which suggests that professionals operate ethically when they limit their scope of practice to areas that they have received specialized training in. When demographic groups such as different cultures are approached from this standpoint, the assumption is that only professionals with special training regarding the culture group are equipped to serve these populations. A further assumption might include the idea that an individual who knows about a particular culture and has special training, will be a preferable match for a given individual group.
Over the course of the conference, cultural competence was explored and considered as being an important component of treatment of refugee groups that extends beyond related concerns such as offering appropriate interpretation services. For instance, when if comes to cultural competence and interpretation services, the cultural background and gender of the interpreter is an important variable that providers should be attentive of as it may influence considerably what information the refugee client or patient is willing to share.
Although knowledge and familiarity about a patient or client’s culture remains clearly consistent with best practice, rigid upholding of this expectation at a systemic level could serve as yet another barrier to the provision of services to already underserved populations. Additionally, the idea that simply having a surplus of “information” and “knowledge” about the cultural background of a given refugee group necessarily equips providers with the provider with the necessary components to ethically treat the client is also problematic. Providers need to recall that understanding about the individual’s cultural background does not permit the professional to make assumptions about treatment or care without appropriate involvement from the client.
This brings us to the concept of cultural humility. Cultural humility has been defined as the “ability to maintain an interpersonal stance that is other-oriented (or open to the other) in relation to aspects of cultural identity that are most important to the [person]” (Hook, 2013). Cultural humility takes the concept of cultural competence one step further, by embracing the idea that it is the client’s experience of culture that remains of central significance when it comes to culturally informed treatment and care. By inviting the client to share their cultural understandings of conditions or treatment related needs, providers can efficiently and effectively navigate cultural confounds that would otherwise remain overlooked through the treatment process. Cultural humility is essentially an attitudinal shift in the “expert professional” motif towards client/patient empowerment, placing the service professional in the “learner role” and affirming the client/patient’s central agency in the treatment process.
On Friday during our large group format following Dr. Ehlinger and Kevin Moore’s presentations, participants were provided an opportunity to hear from Dr. Fred Coleman, noted psychiatrist and
“healer” serving Hmong refugees at Madison’s Kajsiab House. Kajsiab House is a unique resource that offers the Hmong community a cultural center for community and healing, combining cultural practices with psychiatric and behavioral treatment. Dr. Coleman serves a clinical role at Kajsiab House, where he operates through the principal of cultural competence through cultural humility. Hmong refugees like other refugee groups face a disproportionate amount of mental health concerns, including depression, Post Traumatic Stress Disorder, and psychosis. However, equipped with a deep appreciation and understanding for Hmong culture and reverence for the choice and agency of the individual, Dr. Coleman has cultivated the capacity to serve the needs of Hmong community members who would otherwise not be open to treatment services. This has required him to remain ever attentive to the unique needs of the individual as expressed through a cultural lens.
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| Fred Coleman, MD Psychiatrist at Kajsiab House |
The first major challenge that faces so many professionals when serving marginalized groups from greatly different backgrounds, is simply to make ourselves and services useful and relevant to those in need of them. Dr. Colman spoke to an audience including educators, social service workers, and related professionals on strategies for us to better engage our patients, clients, and students through embracing culture pluralism as a median for human connection and understanding that can bridge the divides that so often stand between us and our ability to serve others.
Speaking deeply from his own experience, Dr. Coleman outlined the transactional nature of “helping” and “healing”. It is our artful use of self, the sincerity of the provider, and the commitment to overcoming cultural and societal barriers in the interest of the other that determine our capacity to help, in our professional tasks to educate, empathize, and heal.
Of all the statements made over the course of the conference, it was a statement made by Dr. Coleman that I will carry with me most clearly. Speaking in general terms to an assembly of trained professionals and experts in various fields, it was the concept of “hope” that Dr. Coleman chose to highlight above all others. “Hope”, Dr. Coleman asserted, “is a biological necessity. As individuals, we can live without many things…. but we can’t live without hope. Even if the hope we live by, is someone else’s.”
SOCIAL INFORMANTS of ILLNESS vs. PATHOLOGY MODEL
Like other marginalized groups, refugees face a preponderance of physical, psychological, and behavioral concerns, that place them at greater need for medical, social, and psychiatric/psychological resources. These concern areas invariably lead them to well intended medical and behavioral health professionals whose training equips professionals with adequately identifying pathological physiological or psychological processes that are amenable to medical intervention and/or treatment. In this way, providers may efficiently address medical and behavioral concerns through managing disturbances at the level of the bio and psychogenic factors implicated in the malady.
However, what happens when the source of the condition is outside of the individual? What happens in cases when past and present sociological factors including sociopolitical realties and circumstances serve a causal role in setting off symptoms? More often than not, these appear to be relevant considerations when looking at our “medically complex” clients/patients who have experienced sociopolitical displacement.
Friday’s breakout session with Marianne Joyce, from Heartland Alliance’s Marjorie Kolver Center, and Dr. Tarif Bakdash, from Children’s Hospital of Wisconsin, provided some compelling insight into the various social informants of physical and psychological dysfunction, as well as perspectives on unique implications this has for treatment.
Speaking from her experience with the Majorie Solver Center, Marianne Joyce offered perspectives on the three tiered process of sociopolitical displacement. Ms. Joyce delineated the thee stage process that accompanies every refugee experience, that includes exposure to social threat requiring relocation, the disruption and risks associated with the flight into refuge, and the stressors and social adversities that are confronted as refugees need to adjust to a new reality post migration. Although representing distinctive aspects of the refugees journey, each stage of this transition invariably shapes and influences how the next stage will come to be experienced. Furthermore, each stage offers the refugee a different set of stressors that challenge and affect the individual on psychological as well as physiological levels. The final stage of acclimation to life in the host country thereby remains a highly individual experience, which may be more accurately construed as a multigenerational process. The fact that refugees may experience medical or mental health related services or attention along the way by no means guarantees these resources will be put to benefit or prevent medical or psychiatric malady down the road. This is because the factors that influence physical and emotional health and wellness are ongoing and serve to offer their full impact over the course of time.
In the second half of this breakout session, Dr. Tarif Bakdash provided a compelling portrait of the
devastating circumstances that necessitate mass evacuation, and the dire and desperate circumstances that befall refugees in transit. Dr. Bakdash is a Neurologist at Children’s Hospital of Wisconsin where he specializes in youth with movement and tic disorders. However, his participation in the OCON conference was less related to his expertise as a neurologist, and more from the standpoint of his personal and professional experience outside of the hospital and through the philanthropic work that he does serving refugees of his native country of Syria in his numerous trips overseas to serve the thousands of Syrian refugees residing in refugee camps throughout Eastern Europe.
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| Tarif Bakdash, MD Neurologist at Children's Hospital of Wisconsin |
Syria is a nation of around 23 million and has seen the exodus of over four million of its population to neighboring regions since 2011. This mass displacement was prompted by a four year civil war that has left much of this the once industrialized nation a decimated waste land no longer fit to inhabit. As much of Syria seeks out safety from the perpetual warfare, they are faced with a bitter irony. Syria, once lauded as a nation of goodwill for its harboring of refugees from nearby nations, now faces an ambivalent reception from global community. As Western nations struggle internally with the decision to accept Syrian refugees, Syrian refugees are forced to endure degrees of social hostility in refugee camps.
The socio-political context leading up this forced migration represents and all too familiar trajectory when involving the governance of oppressive regimes. In 2011, organized protests that were directed against Syria’s president, Bashar al-Assad, were met with brute force in a severe crack-down that has prompted the nation to tail spin into an all out civil war.
Tactics employed by the Syrian government to deal with broad social dissension and upset have seemingly known no limit. In his presentation at the conference, Dr. Bakdash shared unforgettable images of the human carnage that have become a daily reality for Syrians. In one image in particular, Syrian military had executed several young children, who’s small bodies were rendered unrecognizable in the hail of gun fire that mowed them down where they were left in plan view to send a message to the rest of the community members. As with the ongoing bloodshed occurring in Iraq, much of the violence has been organized around sectarian lines, has amassed sizable casualties, and has impacted broadly upon the nation's social order and infrastructure. Another image shared by Dr. Bakdash included hundreds to thousands of Syrians, filing out of a decimated city, looking bewildered as they pass between the ruble of demolished buildings in refuge with literally no personal belongings in tow.
Current estimates suggest that up to 220,000 have died due to the ongoing warfare. There is no clear end in sight for persisting conflict, nor hope for future return for the growing number of refugees. These are the circumstances that have driven hundreds of thousands of Syrians to seek out a meager and uncertain existence in the numerous refugee camps in Lebanon, Iraq, Jordan, and Turkey.
Over recent years, Dr. Backdash has been involved in organizing humanitarian aid in the form of medical care and other support to Syrian refugees residing in refugee camps throughout the area. This has afforded him the opportunity to experience first hand, the conditions of the refugee camps that serve as temporary home for Syrian victims of warfare as they anxiously await an uncertain future.
Dr. Bakdash described these circumstances which, more often than not, constitute their own public health crises. Refugee camps are overcrowded and lacking in modern day resources that refugees previously took for granted. Housing consists of innumerable tents constructed in makeshift fashion which are in close proximity to one another set up in columns and rows in plots of land that were previously uninhabitable. Bathrooms are shared and resources for bathing and self care are scarce and limited. Frequently, inhabitants are forced to endure open sewage systems that sit in close proximity to food trucks and tents that are set up to serve food. Children are left without ample play space and schools are nonexistent. The medical care that is provided meets only the most basic needs and is manned by a rotating international cast of medical providers made up largely by foreign doctors. Everywhere there is scarcity, distrust, and hostility. The humanitarian aid that is offered, is required to conform to the regional codes and biases of the host country or risk international incident.
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| Syrian refugee camps lacking proper sanitation |
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| Syrian refugee camps over crowded |
to the region, Dr. Bakdash has assembled teams of well-meaning “do-gooders” who have joined in his adventures as ambassadors to human good and betterment. He has found in his efforts, that virtually any manner of support and assistance can be put to good use.
Children eagerly await the kind and friendly interactions of any well intended individual who might have time to engage them and provide some manner or respite from the daily trials and tribulations of camp life. Beyond medicine, refugees yearn for a listening ear and the genuine empathy of others who have remained unaffected by the collective despondence that has festered in the face of
shared misery. The presence of a global audience in any form offers a uniquely validating impact, as refugees slowly habituate to a new reality that has been unalterably constructed through the shifting lines of power and allegiances that have come to define the encompassing social order over recent years. Dr. Bakdash made his plea to participants of the conference, urging students and practitioners in the fields of medicine, counseling, and psychology to consider joining him in future visits to the area where the need remains great.
shared misery. The presence of a global audience in any form offers a uniquely validating impact, as refugees slowly habituate to a new reality that has been unalterably constructed through the shifting lines of power and allegiances that have come to define the encompassing social order over recent years. Dr. Bakdash made his plea to participants of the conference, urging students and practitioners in the fields of medicine, counseling, and psychology to consider joining him in future visits to the area where the need remains great.
That refugees suffer physiological and psychological consequences from exposure to profound social disorder and the circumstances of refugee life is supported by both research and practice. However, the nature and extent of the impact varies greatly from individual to individual. Factors such as age and health status of the individual at the time of relocation, the extent and severity of exposure to threat and wartime trauma, coping techniques, and access to and quality of medical and other resources throughout the transition period are variables that impact upon individual outcomes.
However, refugee health is also impacted by factors that refugees face when they are finally received in their host countries. The social climate of the host country, availability to meaningful work experience, educational opportunity, diversity, and access to cultural and spiritual resources are examples of community factors that could play significantly into an individual’s capacity to successfully integrate into communities that will become their new home.
In the end, medical and mental health providers are tasked with the job of addressing physical and psychological ramifications of war exposure, bitter transitions, and the factors of social hardships endured in their new communities. In particular, the disillusionment and discouragement that slowly sets in as refugees come to terms with the permanency of their circumstances post-displacement, may be taken into consideration in relation to the medical complexity that vexes treatment providers attempts to address a confounding array of symptoms and maladies that frequently persist and worsen over time.
DEMOCRATIZATION vs. PROFESSIONALISM
Finally, perhaps the most compelling theme that emerged over the course of the conference pertained to the roles of of Democratization vs. Professionalism relative to addressing the needs of refugee groups.
Refugees come to rely on the coordinated efforts of numerous professions, with each profession serving a unique and un-replicated role in the life of the refugee. Like interlocking pieces of a jigsaw puzzle, a complete appreciation for the multifaceted needs of refugee communities can only be sufficiently understood by looking at “the big picture” and through consideration of how each service area relates to all other areas.
At it’s inception, the conference was an effort to overcome the professional boundaries for a higher purpose - to support the needs of refugee groups and recent immigrants acclimating to life in the United States and relying on a milieu of services and resources to address broad sweeping need areas. A basic principle of the conference was that all participants could learn from one another, regardless of level of education or manner of work.
To achieve a democratic atmosphere of mutual contribution, OCON planners paired professionals from different fields together for the purpose of extrapolating upon different aspects of refugee life and the continuum of care and services for refugee and immigrant groups. Interpreters, social service professionals, and resource providers partnered with psychologists, medical doctors, and program directors in critical examination of all aspects of the refugee/immigrant experience. Through a process of inclusive reflection and sharing, participants were able to expand their awareness of aspects of the refugee/immigrant experience that otherwise lied beyond the limited frame of reference that participants held at the onset of the conference.
Over the course of the conference, the theme of democratization was also extended to include a premium placed on greater consideration of the need for client/patient empowerment. Although the benefits of client/patient empowerment are not specific to working with refugee populations, the need to align services with the desires and private priorities of the individual are particularly important with refugees and others who may have experienced systemic maltreatment which has in turn shaped their capacity to fully trust the intentions of perceived “authorities” who hold a manner of power over the individual. Through active involvement of refugee/immigrants in the treatment processes and with regards to decision making pertaining to services that are provided, refugee/immigrants experience a shift in their relative sense of agency and significance.
When we enter into professional roles, we assume a certain degree of state sanctified power, which we may not always be cognizant of and which we may take for granted. It is for this reason that it is particularly important that we as service providers take time to examine ourselves and our relationship to power systems, and actively include our clients and patients in ways that promote a sharing of this power. When appropriate, professionals may need to clarify the role that they are serving, including limits of the professional’s scope of authority and power, and the significant role played by the refugee/immigrant in their role as patient/client.
By viewing the refugee/immigrant as being active decision makers who have their own established views and preferences and who tend to know themselves best, service providers will be better equipped to enlist the individual’s healthy involvement in treatment and the provision of services. As the client/patient assumes an active and directive role relative to services that are being provided in their interest, a dynamic is established that confers a new status upon the individual who’s active access of available resources serves as an inaugurating step towards citizenship.
This in turn brings into full view, the significance of “democratization” as an underlying theme of the conference and as related to the experience of the refugee and recent immigrant. Refugee status is conferred upon groups that have experienced living conditions that have necessitated relocation in the face of imminent threat and danger. Immigrants, on the other hand, willingly seek out a new life in a different nation, where circumstances of life will offer a better or preferred future. In both cases, individuals are prompted to take drastic measures in hopes that they will find a better living experience in a foreign place. Under hostile living conditions where human rights have been systematically defied, basic freedoms restricted, and where the threat of persecution of annihilation are imminent, relocation becomes a biological imperative.
However, such transitions also bring a multitude of other adversities which can contribute to further disillusionment and feelings of subjectivity. The loss of culture, family, and basic identity in a new and unfamiliar land shape the refugee/immigrant’s experience in ways they could not have anticipated and for which there is no preparation. Stripped of material comforts and status, the refugee/immigrant finds themselves struggling to find a foothold in communities that may be ambivalent at best to their arrival.
It is in the face of these circumstances that service providers in the United States first come into contact with the refugee/immigrant. Although free from the immediate threats of danger that prompted relocation, the refugee/immigrant is by no means free from social hardship. The process of acculturation and social integration constitutes a multigenerational experience which may not be completed until decades after a family establishes legal citizenship. In the meantime, the refugee/immigrant’s experience is one of uncertainty and marginalization, as they remain on the cusp of a social order that has permitted and tolerated their basic presence but which appears to carry on its functions independent from and indifferent to the needs and experience of the refugee/immigrant. It is not until the refugee/immigrant finds a consequential place within a new social structure that the hopes of a new life really start to take form.
The OCON conference thereby offered all participants greater perspective into the role each of us play in supporting the gradual and necessary process of social integration that serves as the final transition for the refugee/immigrant. Through better understanding the mechanisms of social inclusion that set the foundation for renewed personhood, we are provided invaluable insight into ways we as providers can facilitate surer acclimation to life in America. The outcomes of a healthy and complete acclimation to a new social experience may ultimately be reflected in the physiological and psychological experience of the refugee/immigrant. Only within a truly pluralistic and tolerant social order will this transition be complete, as attitudes and biases of the host nation serve as a final barrier to overcome in a complete and meaningful transition, in which the status of refugee/immigrant dissolves permanently into status of citizen. From this standpoint medical outcomes and social status have a powerful and profound relationship, with the hopes and health of the refugee and immigrant held under the sway of our social order.
CONCLUSION
The first OCON conference offered a framework where these issues can be explored and considered. Through this coming together, we are better suited to establish a continuum of care, that can more efficiently accomplish a goal of supporting the needs of the refugees and immigrants amongst us.
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| Blog author Ben Rader, Psy.D w/ son Solomon |
References
Hook, J.N. (2013). Cultural Humility: Measuring openness to culturally diverse clients. Journal of Counseling Psychology.
Segen's Medical Dictionary. (2011). Retrieved January 2 2016 from http://medical-dictionary.thefreedictionary.com/cultural+competence
Segen's Medical Dictionary. (2011). Retrieved January 2 2016 from http://medical-dictionary.thefreedictionary.com/cultural+competence
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