Julia Bala, Ph.D, Johannes Rohlof, M.D., Adeline van Waning, M.D. Ph.D.

Introduction

In our clinical work with traumatised refugees and their families, we often find great differences in the reactions of individuals and even among the members of the same family who experienced the same extreme stressors. They utilise different methods of coping, and different resources to manage stressors from the past, present and the anticipated future. Refugees are often forced to cope with multiple stressors and sequential traumatisation. It is important for the therapists to study these coping strategies. First, we can learn from people who experienced extreme stressors what kind of coping mechanisms they use with a positive outcome. What did help them? We can then utilise this knowledge to broaden the coping strategies of those who have troubles with coping. We can also learn from our clients about the coping mechanisms that were less helpful, but can be regarded as a starting point to better coping. We can also learn from often more dysfunctional coping strategies like dissociation, alcohol abuse and in a way depression, that were probably at the certain time necessary coping attempts of individuals who had no better alternatives in that period. Lazarus (1966) was the first to make a connection between ways of coping with stress and cognitive, emotional and behavioural reactions, and to describe coping as a process. According to Lazarus and Folkman, ( 1984 ) this process includes ( SHEET 1) primary appraisal, where one evaluation of the situation as positive or negative, possibly harmful, threatening or challenging;. the secondary appraisal the evaluation of own capacities and resources to deal with the stressfull situation by either problem focused coping, emotional focused coping or by both.

Definitions

Coping involves several interrelated concepts, which need to be defined, differentiated and clarified in their possible relations. ( SHEET 2). We accepted the following definitions: Coping refers to the cognitive, emotional and behavioural strategies that one utilises to manage or reduce the stress and its effects (Toilettes, 1991). Coping is a process that includes the appraisal of the stress and of own possibilities to deal with it and the strategies to handle it. Defense mechanisms are intrapsychic mechanisms which alter or reduce the impact of the stressors. They are commonly viewed as subconscious or unconscious processes, automatically used as an answer to internal and external stressors. Protective factors are competencies and characteristics of the individual, family or community that buffer or modify the impact of the stressors. Protective factors facilitate competent adaptation and enhance the development of individuals and families. As long as stress and protective factors are in balance coping is manageable ( Losel and Bliesener, 1991). Resources are defined as reservoirs of support in the social field of the individual. They can be seen as a social division of protective factors, but include also institutional services and governmental policies. (Protective factors and resources are often used in the lierature as different terms with the similar conotation). Adjustment is commonly viewed as a short term outcome of the coping efforts. Adaptation refers to a long term process in which the individual acquires a long lasting feeling of being at ease with the new situation. Adaptation is the outcome of the joint process of coping efforts and utilisation of available protective factors /resources. Protective factors and coping processes could be seen as an inter-related system or a feedback loop. The more one utilises the available, adequate protective factors to counterbalance the stressors, the better one can cope with the life adversities. Each successful coping attempt strengthens the belief of the person in respect of internal locus of control. And furthermore, by re-establishing the positive self esteem the person is positioned for more successful coping in the future.

Assessment

In our work we try to assess which coping mechanisms the refugees use, which strategies are more or less functional in the given situation. We try to discover with each client, what are the coping strategies one mostly uses to modify stressful situation or lower the level of distress. We ask them what did they found helpful, what not. We try to broaden the alternatives where they are few and repetitive, and not any longer functional. We have been searching for questionnaires, for instruments to achieve a more thorough and investigation on the coping mechanisms, with the possibility of comparision. We found with other colleges, the COPE questionnaire (Carver, Scheiyer & Weintraub, 1989) useful. It differentiates 13 conceptually distinctive dimensions of coping and refers to the ways they are correlated. This questionnaire makes it possible to do a Trait examination ( personality style to handle stress), as well as a State ( situation reactions) examination and thus to understand better the coping ways of our clients. With an adapted questionnaire (Wim Kleijn et al, 1996) we can get a better insight into the preferred coping style, and about the coping reactions. What we do miss is a scale in which the coping process is more clarified. Reichert ‘s and Perrez (1991) scale attempts to do that by scoring the feelings about the situation, the assessment of the situation, the goals, and the action. Questionnaires may be still far from offering an sophisticated assessment of coping as a process, therefore we try to discover more about it within the treatment process. We do it in a way that enables the direct connection between coping process assessment and interventions directed at the broadening of coping alternatives. We search for the cognitive, behavioural and emotional attempts to manage the stressfull situation or reduce its consequences. We try to understand the primary and secondary appraisal; the meanings attached to the stressors and the beliefs about one’s abilities to deal with them. We try to understand how one interprets what has happened. What did one do and why did one behave that way? What does one think about what one did? How does one evaluates his/ her own coping efforts.. We try to find out which coping attempts were helpful before the traumatic events and what is helpful now? What can be done in the future. With the help of questionnaires and/or detailed interview we try to understand better both the coping reactions and coping process. (SHEET 3) We are assessing also the protective factors , the individual, family, community or cultural resources that are perceived by the refugees or the refugee families as available and potentially helpful. ( SHEET 4 ) What are the resources one perceives as possibly available and useful? Which beliefs of the individual or the family influence the coping efforts and how? Does one have a stable emotional relation, a network from where one may receive support? Which sort of social support does one need? From whom may one receive it? Which family or cultural rituals may facilitate the mourning process? As we map the available coping strategies and protective factors ( SHEET 5 )and learn about the coping processes, we search together with our clients for the ways of coping that may ensure a somewhat better outcome.

Family coping

Coping can be seen as an individual, family or collective process.Family coping could be viewed as a co-ordinate problem solving behaviour of the whole system but it could also involve efforts by individual family members which fit together as a synthetic whole” ( McCubin & Patterson 199? ). The appraisal and the meaning of a traumatic event or ongoing stressors can be shared by the family members as well as the chosen strategies to manage or reduce them. But the coping efforts of the individual members may be different and affect the other family members in various ways . The active coping strategies utilised by a husband, may reinforce the passive strategies of the wife. Or, the whole family may jointly try to search for a problem solving strategy or management of their tension through joint activities. Within the family, the assessment may include: discovering if there is a co-ordinated coping effort within the family? How do the various coping efforts of family members affect each other? Which family/individual beliefs influence the coping efforts and how? What are the preferred coping strategies? What are the available resources? Are the coping strategies of parents facilitating or constraining the coping efforts of children? Coping processes in the family are shaped by modelling, rules, rituals and traditions. The father comments on some details from the traumatic event told by the child : That was terrible. But we would not think any more about that. We’ ll forget it. Would they? Beside the transgenerational transmission of the traumatisation, the acquired coping strategies are also transmitted from parents to children. It is not only the traumatic past and attached meanings and feelings that run through the families from one generation to another, but also the beliefs, the coping strategies, told or modelled by the parents to their children.

Cultural aspects

So far there is relatively little attention given to the influence of culture on psychopathology, and there are hardly any studies on the influence of culture on coping with trauma. We did however see specific coping mechanisms in refugees form different cultural backgrounds. This enabled us to make some comparisons of Western and other cultures in this respect. It is important to stay conscious of the attitudes within our culture in regard to psychological problems and their solution. In the Netherlands there is generally more emphasis on individualism, reason, communication through language, integration of self, personal responsibility, more or less open expression of the emotions or making unconscious conscious. In other cultures, which differ from each other a lot, there is often more emphasis on the group, the extended family, the tribe, the social network. Family loyalty bonds , non verbal communication are seen as more relevant, with tendencies in some cultures of keeping emotions inside. How is the cultural context influencing the appraisal and management of stressors or their consequences? What does it mean to be without an extended family in another culture where it does not seem so important. How to replace this valuable social support? Pride, shame and receptivity are important within certain cultures. Would one, coming from a culture where pride is so relevant have difficulties with accepting help? Would a belief in the influence of supernatural forces be a coping attempt, would it facilitate or hinder other coping attempts? Cultural diversity certainly has an influence on coping strategies and can mark the available resources and the patterns of their utilisation. . The most important cultural aspect of coping is to give a meaning to extremely stressfull experiences. For instance, it seems that people who were tortured because of their political involvement cope better then people who were tortured because they belong to an ethnical group. Each group, has its own explanatory frame, its narrative in which meaning is assigned to the events. These processes where collective interpretation and meaning are assigned to the events are influencing the process op coping and its outcome in an important way..

Therapy and care

Traumatised refugees have to deal with uprooting, migration and marginalisation., often coupled with the problem of long procedure to get admitted ton a Western country. As a result of the pressure of all these stressors we often see among our clients the ” shattered assumptions” ( SHEET 6), a disturbance of the basic assumption that most of the people have: as described by Janoff- Bullman as: . – the world functions on a reasonably understandable orderly and meaningful way. – as regards to self image: you are valuable, you have a place in the world – disasters will not happen to me. It is obvious that in severe cases of traumatisation, these assumptions are severely shattered. Uprooting often reinforces further the doubt in those beliefs. These shattered assumptions may undermine the functional coping efforts. The ability to manage these shattered assumptions increases when the therapist and the client try to construct a personal narrative. Traumatised refugees, as other victims of extreme stressors, are trying to give an interpretation to the events by answering to some questions, like: ” What happened”? “Why did it happen” “Why did I reacted as I did?” “Why have I reacted as I have, since”. What if something like this happens again? These questions, according to Figley, (1989) are some of the crutial questions, at which families also try to find answers.. By answering these questions they construct a narrative, an explanatory frame, that helps organising their experiences. This process of constructing the narrative can be seen as coping by reframing, reinterpreting or as a new reappraisal of the events. The therapist may help by emphasising the successful coping attempts or by reframing ely those perceived as inappropriate in a certain way. The therapist may help reframing the passive coping as a need for rest, necessary in order to take charge, or as an important self protective act at a given time. He/she may facilitate the process of searching for available resources and new coping strategies that may be more functional in a given situation. The therapist may reinforce the existing protective factors by supporting the re-establishment of positive self esteem, by assigning small achievable goals for the client, and help with symptom control as a way to re-establish internal locus of control. When the differential use of the thirteen strategies of coping, from the adapted Cope questionnaire is further clarified in semi structured interviews, the therapist may facilitate the choice and the development of one or another aspect of coping; venting emotions for example or he/she may assist in finding adequate forms of social support. Active coping, even though considered as more functional, is not always possible, not even always appropriate to the given situation. In some situations, talking to people, building up a network is much more helpful. Some need first to get control over the overwhelming emotion.. The therapist works as an auxiliary ego, changes dysfunctional coping and defence mechanisms to realistic options,which are less harmful. When coping is utilised without variation, the therapist can help with searching for alternatives. “The more extensive the repertoire of coping methods, the more effective is the coping itself.” (Rutter, 1987) Besides of these personally adapted therapeutic interventions, there are descriptions in literature of more general therapy programs to enhance coping. Goldfried uses in his therapy program several forms of behaviour techniques focused on: problem solving, relaxation, cognitive restructuring, communication training skills. People who cope with the effects of severe traumatisation can be helped with the use of different techniques of different nature. The therapist can utilize his/ her own experience in the treatement situation, his/her own countertransference feelings to help the refugees.The therapist who feels his/her own anxiety, powerlessness and ambivalence working with traumatised refugees can be confronted with ambivalent and opposite feelings he/ she needs to cope with. Next to signaling about clients feelings this is an important learning process for him/her about own reactions. With this learning process, the therapist can be better attuned continuing facilitating the clients search to find their own, most helpful personal style of coping.

Literature: on demand