the place of complementary therapies in an integrated model of refugee health care:...

The Place of Complementary Therapies inan Integrated Model of Refugee HealthCare: Counsellors’ and Refugee Clients’Perspectives

JUDY S INGER

University Centre for Rural Health, University of Sydney, Lismore, NSW [email protected]

JENNY ADAMS

Victorian Foundation for Survivors of Torture, Melbourne, Australia

MS received June 2010; revised MS received December 2010

This paper explores the place of complementary therapies in an integratedmodel of refugee health care at Foundation House, a leading torture and

trauma rehabilitation service in Melbourne, Australia. At Foundation Housecounselling and complementary therapies are practised collaboratively. Thepaper is based on two independent qualitative research projects: one project

examined refugee women’s experiences of complementary therapies and thesecond investigated counsellors’ reasons for referral to complementary therapies.The rationale for combining the two research projects in this paper is to provide

a comprehensive overview of this integrative model of health care that has notpreviously been documented. We formulate the areas of commonality in ourfindings under three ‘modes of action’: relationship, cultural familiarity and

somatic presentations. Our combined findings extend current notions of holisticrefugee health care to include culturally familiar health care practices in theform of complementary therapies. These therapies give primacy to caring for thecomplexity that is the ‘refugee body’: the amalgamation of physical pain with

the complex social, political and cultural factors that define the refugeeexperience.

Keywords: Complementary and Alternative Medicine (CAM), refugee, integrativehealthcare, torture survivor, traditional medicine

Introduction

The Victorian Foundation for Survivors of Torture, known as ‘FoundationHouse’, is a mental health service provider for refugees and asylum seekers inMelbourne, Australia. The organization was established in 1987 and two

Journal of Refugee Studies Vol. 24, No. 2 � The Author 2011. Published by Oxford University Press.All rights reserved. For Permissions, please email: [email protected]:10.1093/jrs/fer001 Advance Access publication 15 April 2011

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years later included a complementary therapies programme (CTP), in theform of naturopathy, Western herbal medicine, massage therapies, nutrition-al, dietary and lifestyle advice into its service delivery. Complementary thera-pies (CTs) is the commonly accepted umbrella term for the range of therapiesoffered by Foundation House. These therapies are delivered by qualifiednaturopaths and massage therapists who are salaried members of staff.

Complementary therapies (often referred to as complementary and alter-native medicine or CAM) include a diverse range of therapies that aredefined as:

[P]ractices and ideas which are outside the domain of conventional medicine in

several countries and defined by its users as preventing or treating illness, or

promoting health and well being. These practices complement mainstream medi-

cine by 1) contributing to a common whole, 2) satisfying a demand not met

by conventional practices, and 3) diversifying the conceptual framework of

medicine (Manheimer and Berman 2008).

Counselling and CTs are practised concurrently at Foundation House, withthe aim of providing a culturally relevant approach to health care. As weunderstand it, the inclusion of CTs as a core component of the service deliv-ery positioned Foundation House as the first Western-based torture traumaservice in the world to fully integrate non-biomedical health care practices.This approach heralded an innovative health care model. The CTP has con-tinued for over 20 years, and thus is a well established component of theagency’s overall service delivery. The role of the CTP in the organization’sdevelopment provides an important case study that extends existing multidis-ciplinary models of refugee health care practice and is the focus of the currentpaper.

This case study of the CTP at Foundation House is based on two quali-tative research projects. The projects have arisen from the authors’ clinicalwork as complementary therapy practitioners at Foundation House and theirlong-standing aspiration to document this integrative model of health care.The first author’s research explores the meanings and experience of CTsfor refugee women clients at Foundation House. The second author’sresearch investigates counsellors’ understandings of CTs and the meaningof referral to the CTP. The rationale for combining the two research projectsin this paper is to provide a comprehensive overview of this uncommonmodel of health care that has not previously been documented. By bringingtogether the perspectives of the counsellors who refer their clients to the CTPwith the clients’ experiences of CTs, the aim of the paper is to further developunderstandings about the place of CTs in a Western refugee health caresetting.

Before discussing the core findings from the research projects, the paperfirst describes the background context relevant to refugee health care andCTs as it relates to the topic under discussion. This examination is under-pinned by anthropological and sociological literature and focuses on the

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evolving interest in holistic approaches to refugee health care. A descriptionof the research site and discussion of research methods precede a detailedexamination of the CTP.

Refugee Health Care in Western Countries

The need to provide culturally relevant and holistic approaches within refugeehealth care settings has been substantiated by research from clinicians, soci-ologists and anthropologists (Bodeker et al. 2005a; Chung and Kagawa-Singer 1995; Grodin et al. 2008; Hiegel 1994; Hollifield et al. 2002; Jenkins2001; Julian 2004; Kneebone and Allotey 2003; Morris et al. 1993; Silove1999; Tribe 2007; Watters 2001; Westermeyer and Janca 1997).

What constitutes holistic health care in settings that provide services torefugees will depend on the cultural definitions within particular contexts.However, a number of authors agree on the need to move beyond singularbiomedical structures. In order for this view to progress further than‘multi-cultural rhetoric’ a paradigm shift in health care values is required(Julian 2004: 121). For instance, Julian describes how many Vietnamese refu-gees express feelings of depression as physical symptoms rather than as psy-chological concerns. ‘They therefore have different symptoms for the samedisease from Anglo-Australians [and] furthermore, given different symptoms,they seek different treatment: massage rather than counselling’ (2004: 102).The stigma and shame attached to mental ill health means that some peoplewill more readily seek help for the physical expression of their distress.

Some scholars advocate that holistic health care for refugees requires theinclusion of medically pluralistic approaches in which the practices of trad-itional medicine and biomedicine coexist (Benedict et al. 2009; Julian 2004;Bodeker and Neumann 2011). Whittaker (2000: 49) explains that a pluralisticapproach is often a pragmatic choice for patients who are adept at blendingdifferent healing systems:

In theory the forms of knowledge of biomedicine and traditional healers seem

incommensurable, yet the differences are transcended everyday in practice as

people seek care and healing from various practitioners.

Many refugees are familiar with a medically pluralist approach in their homecountries, and they often seek out their own traditional healers in their newcountry (Sargent and Marcucci 1984).

Examples of effective medical pluralism have been documented within refu-gee camps, particularly in Asia. In their work on the Thai–Burma borderNeumann and Bodeker’s (2008) findings demonstrate that a large proportionof refugees prefer to use traditional medicines alongside Western medicalservices. Similarly, Hiegel (1994: 294), who worked for 17 years as a psych-iatrist in Southeast Asian refugee camps where he encouraged a pluralisticapproach incorporating both traditional medicine and biomedicine, concludes

The Place of Complementary Therapies in Refugee Health Care 353

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that ‘Western and indigenous care systems could exist side by side, supple-

menting and complementing one another’, thereby providing far more effica-

cious health care. In a migrant context Reed (2002) discusses the pragmatic

pluralism of British South Asian women in navigating a range of health care

practices and commodities in Leicester. In research exploring health pluralism

in relation to treatment for trauma in Sri Lanka, Tribe (2007) finds that it is

common for people to seek out biomedical and Ayurvedic medicine

concurrently.It is routinely agreed that addressing the complexity of refugee health issues

in Western countries requires diverse and flexible strategies (Hollifield

et al. 2002; Morrissey 1983; Porter and Haslam, 2005), and some literature

broadly supports the implementation of non-biomedical holistic approaches

(Hollifield et al. 2002; Silove 1999; Turner and Gorst-Unsworth 1990;

Watters 2001). However, in the international refugee rehabilitation context

an integrative or pluralistic approach that includes non-biomedical practices

alongside psychological and biomedical treatment is uncommon.

Complementary Therapies in Health Care Settings

The inclusion of CTs within a variety of clinical settings is a relatively recent

phenomenon of the past 10 to 15 years. Research examining this development

has predominantly concerned the perspective of biomedical practitioners, and

has focused on physical rather than mental health issues (Astin et al. 1998;

Botting and Cook 2000; Ernst et al. 1995; Jump et al. 1998; Schmidt et al.

2002). Current research about referrals to complementary therapists has pri-

marily examined the referral patterns of doctors and nurses; much of this has

been descriptive and based on questionnaire surveys (Berman et al. 1999;

Easthope et al. 2000; Fadlon et al. 2008; Pirotta 2000; Sohn and Loveland

Cook 2002; Thomas et al. 2003; van Haselen et al. 2004). Similarly, the

research investigating existing ‘integrative’ models of health care has focused

on settings that combine biomedical practitioners and complementary ther-

apists. This research reports on conflict due to differences in paradigms,

power and practices that challenge the very notion of integration (Adams

et al. 2009; Coulter et al. 2005; Hollenberg 2006; Patterson 1997; Shuval

et al. 2002; Soklaridis et al. 2009).There has been minimal research investigating the understandings and

attitudes, or the referral practices, of other health care providers, including

counsellors, to complementary therapists. Two surveys have questioned

psychologists (Bassman and Uellendahl 2003) and psychology students

(Wilson and White 2007) about their attitudes towards CTs. To our know-

ledge, Adams’ (2006) research is the only study to date that has investigated

the views and understandings of counsellors about CTs in an integrated clin-

ical setting.


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Refugee Health Care in Australia: Foundation House

Australia currently accepts 13,750 refugees annually from a wide range ofcountries, ethnic backgrounds and religious affiliations through its offshoreand onshore programmes combined. The cultural diversity of these peoplereflects both the national and international landscape of refugee politics andpolicies. Specific psycho-social health care for refugees in Australia has beenavailable since the late 1980s when centres providing support for survivors oftorture and trauma were established. Today there are eight independent tor-ture/trauma centres around Australia.

The primary function of Foundation House is to provide a mental healthservice for refugee survivors of torture and trauma, and so the majority of thedirect service staff are either social workers or psychologists and they areemployed in the specific role of ‘counsellor-advocates’ (referred to as ‘coun-sellors’ in this article). This model is important because it recognizes the needto provide the various advocacy services for both refugees and asylum seek-ers, alongside counselling (Aristotle 1990). Foundation House is funded bythe Australian Federal Government, the Victorian State Government, andalso by philanthropic sources. Both services and medicines are providedfree of charge to clients.

The two main components of direct service offered by Foundation Houseare counselling and CTs. In recent years a specialist mental health clinicstaffed by psychiatrists has been operating on-site. Counsellors and comple-mentary therapists also provide a group work programme. As previouslystated, CTs in the Foundation House setting include Western herbal medi-cine, massage therapies and dietary and nutritional treatment.

Clients are referred to Foundation House from various governmental de-partments and community sources including community health centres, hos-pitals, English language centres and public schools. Clients may self-refer andare often referred by family members already attending the agency.

Research Methods

The two research projects described in this article used qualitative methods toexplore the CTP at Foundation House. An essential feature of qualitativedata is that it is descriptive, capturing and communicating another’s experi-ence through telling their story in their own words (Patton 2002: 47). Bothresearch projects used qualitative methods in order to portray the voices ofthe clients receiving treatment at Foundation House and the referring coun-sellors. This method allowed an array of different views, experiences andbeliefs to be expressed whilst enabling a detailed picture of the CTP toemerge (Kvale 1996).

Conducting research with refugee populations needs to take into accountcomplex cross-cultural factors, combined with the devastating consequencesof torture and trauma on individuals, families and communities (Ahearn


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2000; Gifford et al. 2007). The first author’s (Singer 2008) research withrefugee clients is contextualized within a framework that makes explicit theeffects of torture and trauma on the whole person and how these issues mustbe addressed at every stage of the research design and process.

In-depth interviewing was chosen as the most meaningful and effectivequalitative method to explore and describe refugee women’s experiences ofCTs. In the process of interviewing, stories often emerge which providedeeper meaning and help to facilitate insights (Powles 2004). In-depth inter-views are understood as a particularly appropriate methodology forhealth-related research amongst culturally and linguistically diverse groups(de Laine 1997; Rice-Liamputtong and Ezzy 2001; Sue et al. 1999). Whenvalues about health and illness differ from those of mainstream Westernsociety, an approach that seeks to explore the meanings people give to certainphenomena facilitates this process (Sue et al. 1999).

In-depth interviews with 12 current clients from Foundation House wereconducted during 2005. The participants came from a diverse range of coun-tries: Iran, Afghanistan, Serbia, Burma, Iraq, Yemen and Somalia. Interviewswere conducted by the first author two years after she left the organization.None of the clients interviewed were her former clients.

The practitioners (counsellors and complementary therapists) atFoundation House played a pivotal role in the recruitment process. Asthey had an in-depth understanding of the psychological and overall healthstatus of their clients, the practitioners selected the clients they deemed to beappropriate prospective participants. In this way, the practitioners acted as‘recruitment gatekeepers’ with the aim to minimize the prospective partici-pants’ sense of obligation to participate, and also to provide the necessaryscreening to ensure that only clients who were psychologically stable and metthe inclusion criteria were invited to participate. Selection of participantswas based on a purposeful sampling approach (Patton 2002: 230). As theunderlying principle of purposeful sampling is to intentionally select a smallernumber of ‘information rich cases’ for in-depth study, this provided anappropriate strategy for this project (Patton 2002: 230). At the specificrequest of participants, interviews were conducted either at women’s homesor at Foundation House and nine out of the 12 interviews were conductedwith an interpreter.

The in-depth interviews were guided by a theme list that covered five mainareas. The first two areas addressed background details and current life ex-periences in Australia. The next section explored the participant’s ‘homestory’ and the final two sections looked at experiences of CT atFoundation House. In order to generate a reflective atmosphere in the inter-views, the researcher intentionally began by asking the women: ‘In yourcountry, when you were sick, who did you go to for treatment and whatkinds of medicines did you take?’ The question was framed to prompt thewomen to describe their experiences spontaneously (Kopinak 1999). The firstauthor conducted and transcribed all of the interviews.


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In order to explore counsellors’ understandings and perceptions of CT, thesecond author conducted a focus group with 10 counsellors in 2006. Thesample of 10 counsellors for the focus group self selected from the totalpool of 12 eligible counsellors. Specifically, the focus group method waschosen as it is a useful method when the purpose of the research is to uncoverfactors that influence opinions or behaviours within a homogeneous group,such as an occupational group (Krueger and Casey 2000), and when the aimis to explore their in-depth knowledge, beliefs and attitudes (Carey 1994; Riceand Ezzy 1999). Questions for the focus group were formulated from theresearch objectives and explored themes such as counsellors’ experiences ofsharing clients with complementary therapists, their understandings of howCTs work, their reasons for referral to the CTP and their perceptions of therole of CTs in the agency. The inclusion criteria were that participants had aminimum of two years’ work experience at Foundation House and experiencein referring clients to the CTP. The second author conducted and transcribedthe focus group.

The in-depth interview and focus group methods are consistent with themethodology of grounded theory that was used in the analysis of data fromboth research projects. It is important to note that multiple approaches togrounded theory exist (Charmaz 2003; Glaser and Strauss 1967; Strauss andCorbin 1996) and there is an increasingly contentious scholarly debate on thevalidity of its different versions (Patton 2002). The authors predominantlydrew on the work of Strauss and Corbin (1996, 1998). In both projects acoding framework was developed and data was coded for dominant cate-gories and themes and analysed using thematic analysis (Gifford 1998;Patton 2002; Schwandt 2000).

The Complementary Therapies Programme at Foundation House

The Foundation House model of service delivery that combines the practicesof counselling and CT is unusual within the public health sector. Althoughmost torture and trauma services in Australia now include aspects of CT, thesize of the programmes and the level of integration vary significantly. AtFoundation House, the CTP is considered by counsellors and complementarytherapists alike to be a well integrated and valued component of direct ser-vice. We define integration, in the context of multidisciplinary models ofhealth care, following Boon et al. (2004: 50) as being determined by stake-holders having a common ‘philosophy and values that underlie [their]approach to patient care’.

The decision to integrate CT into the service delivery of the agency ratherthan introduce it as an ‘add-on’ or adjunctive treatment is seen by staff atFoundation House as a significant reason for the programme’s longevity.Integration brought legitimation for the CTP within the agency, making itsustainable and enabling the practitioners to develop practice skills and to


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build a solid body of knowledge and expertise. Summarized by ParisAristotle, Director of Foundation House:

[You] can’t appreciate the value and potential if it’s an add-on. It has to be

integral. If it’s not integral the full force of the other interventions can’t be

realized (Singer 2008).

At Foundation House the integrative model has enabled counselling and CTsto be practised concurrently and collaboratively. We argue that the successof the Foundation House model is based on several critical factors.Counsellors continually witness the beneficial effects of CTs on their clientsand thus keep referring new clients. Equally significant is the perceived para-digmatic congruence between CTs and counselling. The second author’s(2006) research, discussed below, demonstrates that at the practice level aswell as conceptually, it is apparent there is not the assertive power imbalancethat is problematized in much of the literature about CTs’ relationship tobiomedicine.

At the organizational level perhaps the most distinctive factor is that thecomplementary therapists are salaried members of staff and therefore haveequal access to supervision, debriefing and team meetings as counsellors do.The CT team at Foundation House comprises two full-time and four part-time complementary therapists. In addition there is a small group of volun-teer practitioners who are supervised by the CT coordinator. Although theCT programme makes up only a small component of the direct servicedelivery (the ratio of counsellors to complementary therapists is abouttwenty to one), it is nonetheless highly regarded within the agency. Thesecond author’s (2006) research shows that counsellors and complementarytherapists value the opportunity to work collaboratively and both have clearunderstandings and respect for each others’ disciplinary role. Counsellorsdo not incorporate CTs into their counselling work, and complementarytherapists do not take up a counselling role.

Although demand for CTs by the referring counsellors has continued togrow, the organization has not matched this growth in demand by increasingthe number of CT practitioners proportionally to the increase in counsellors.We speculate that the reasons for this are based on the primary psychologicalfocus of the agency, coupled with the bureaucratically complex issues ofprocuring philanthropic and government funding for health care practicesconsidered outside the biomedical mainstream.

Complementary Therapies Referral Process

Within the overall structure of the organization there is a clear referral pro-cess for clients accessing the service. Based on the primarily psychosocialfunction of the agency, all clients are initially assessed and then allocated acounsellor who acts as a case manager. Significantly, clients’ access to CTs isonly possible on referral from a counsellor. In this way the counsellors have


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full control over which clients are referred. In effect, they are the gatekeepersto the CTP. The complementary therapists, however, determine which refer-rals they will take up, and they can reject referrals if they deem them to beinappropriate. The main reason for rejecting a referral is if a client is con-sidered to be too psychologically unstable at the time of referral. Referralsmay be postponed if the client is juggling multiple existing demands such asattending English classes and a variety of other appointments, or has symp-toms that have not been assessed medically. There are also logistical reasonsfor rejecting or postponing a referral, for instance, if the client is not able totravel to Foundation House. Clients also have some degree of influence inthis process. If they have prior knowledge about the programme (for exampleanother family member may already be accessing the CTP) and they wish tohave complementary therapy treatment, they can request to be referred bytheir counsellor.

The CT team provides ongoing education about CT for the counsellingstaff (Singer and Adams 2000). This happens in formal and informal con-texts. New counselling staff (and administration staff) receive a CT inductionsession that includes a detailed explanation of all aspects of the programme,including its philosophical stance, and information on how, when and why torefer clients. Combined group supervision with counsellors also provides aregular setting for complementary therapists and counsellors to develop andenhance their collaborative practice. The referral process provides anotherimportant avenue for complementary therapists to educate counsellorsabout the CTP.

A comprehensive CT referral system is critical to the effectiveness ofthe collaborative practice between complementary therapists and counsellors.All counsellors are eligible to refer clients; however, because the ratio ofcounsellors to complementary therapists is disproportionate, clear referralguidelines and management of the referral process are essential. As docu-mented in earlier work (Singer and Adams 2000, 2002), counsellors initiatethe referral process by completing a referral form and engaging in a‘pre-referral chat’. This conversation between counsellor and complementarytherapist aims to clarify the appropriateness of the referral and to thenassist the counsellors and complementary therapists to implement a combinedtreatment plan.

The flow chart on the following page (Figure 1) tracks the referral process.

Counsellors’ and Clients’ Understandings and Experience of

Complementary Therapies

In this section we report on our combined findings. Although the projectswere conducted independently, it became apparent during collegial discus-sions that the two projects shared common themes. It was the congruenceof our findings that provided the rationale for writing this joint paper. Wehave formulated the areas of commonality in our data under three ‘modes of


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Figure 1

Referral Process at Foundation House


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action’: relationship, cultural familiarity and somatic presentations. We in-corporate the voices of the counsellors and clients into the discussion.Pseudonyms are used to protect the identity of the participants.

In the integrative model at Foundation House, counsellors’ understandingsof how CTs work and their reasons for referral correlate with the clients’experiences of healing in the CT encounter. Of significance, are the ways inwhich these parallel experiences and beliefs intersect and inform understand-ings about the role of CTs at Foundation House, and in turn, the broaderrefugee health care context.

Relationship

For both the counsellors and clients the notion of ‘relationship’ was centralto the efficacy of CTs. Counsellors described the relationship between com-plementary therapists and their clients as fundamental to how CTs work.Aspects of the relationship, namely the formation of trust and intimacy,were seen to promote recovery and to potentially become transferable toother relationships. The establishment of trust was emphasized as being keyto the efficacy of CTs. Counsellors refer clients based on the perception thatengaging in a safe relationship facilitates the healing process. Significantly,counsellors at Foundation House do not see the importance of trust in rela-tionship as exclusively their domain; the trust that clients form with theircomplementary therapists was cited as an important reason for referral.

When I make a referral it’s also about facilitating a relationship with someone

else where trust would be created . . . for all the referrals that I’ve made, the trust

that they have established with the complementary therapist is so valuable and

important . . .when you look at how much they have benefited from either mas-

sage or herbal medicine it’s as much or more through the trust that they have

established in the relationship (Counsellor: Lola).

I want to emphasize that the treatment I received and the behaviour and the

loving care that I received from Kate [complementary therapist] is affecting me

directly and putting a positive effect on my health, she just gives me the strength

to trust again (Client: Sita).

As a component of the therapeutic relationship, the establishment of trust isproposed as being central to recovery (goals) for refugee survivors of tortureand trauma (VFST 1998). Post-traumatic stress theory describes how affectedindividuals experience a pervasive loss of trust in others, creating emotionalisolation despite whatever social networks or intimate relationships theperson may have (Marcias et al. 2000). Significantly, Grodin et al. (2008:802) argue that ‘recovery must take place in the context of new relationshipsin order to reform this bond with the world’.

I think Anna [complementary therapist] is an angel, and it was that her hands

were healing because it was coming from her heart, it wasn’t just doing some

techniques, there were her feelings, she had this human touch, wanting to help


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me and sort of like she wished that I’m well and I felt very relaxed and she

would talk to me gently, she understood me, it was that connection. Mostpeople’s problems stem from not being happy and not getting enough love.

And think that’s what you get here, it’s what you really need (Client: Rosa).

Like Rosa, the women’s experiences of the therapeutic relationship with theircomplementary therapists confirmed the counsellors’ views of the significanceof relationship in healing trauma. In this context, the relationship is one of‘deep care’. Used literally, this term conveys a particular kind of therapeuticrelationship that includes qualities of trust, safety and for many, the experi-ence of feeling loved.

In the CT therapeutic relationship, primacy is given to engaging with theeveryday lived experience of the body and this may also include literal ‘touch’in the form of massage treatment:

There is compassion and you feel you are loved . . . there is a feeling that another

person, somebody cares whether I’m better or not . . . it brings the value of the

treatment a lot higher than if it was just a physical massage (Client: Raza).

I feel that she is doing this work with all her heart, it is coming from her heart.

She is not just doing a job to get paid, she is doing it genuinely because she

cares. She feels with me, our feeling together get engaged with one another. Sheis like an angel that touches me . . . I feel that there is someone who really loves

me (Client: Amar).

Consistently the women explained the efficacy of their CT treatment as beingbased in their experience of feeling deep care from their practitioner. Deepcare was intrinsic to the actual physicality of the CT treatment. In the contextof their overwhelming loss, the women’s readiness to make meaningful con-nections and to expose their bodies to their complementary therapists is, weargue, even more remarkable.

Belonging: Cultural Familiarity

Counsellors cited ‘cultural familiarity’ as another part of their assessment forreferral to CT, as well as a reason for the existence of the CTP within theagency. As a mode of action it was seen to create a link to a client’s past byoffering medicines or therapies that are familiar, trusted and congruent withmany refugee clients’ beliefs about healing. Herbal medicine was namedin particular as being part of clients’ histories, connecting them to theirpre-traumatic past through memories of family and ‘home’.

I can’t think of a client who I’ve referred who has not had experience of herbal

therapies or doesn’t have some story about the gathering of herbs in the hills

whether by parents or grandparents (Counsellor: Peter).

The CTP at Foundation House does not set out to replicate the traditionalhealing practices of the clients who attend the service. Rather, the intention isto create the opportunity for refugees to connect with and access health care


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practices that make sense and are meaningful. Most of the women inter-

viewed strongly connected both to their own traditional medicines, and to

the experience of CT at Foundation House. Many had extensive knowledge

about traditional medicines and had been educated in the craft by mothers,

aunts and grandmothers and knew the herbs and foods to take to treat a

variety of illnesses.

There is a particular flower and they make a tea out of it. It releases the tension

and it is used for nerves and calming. And the oil of mint, which is called

‘atta’ . . . this is used for stomach problems. And the rosewater, or ‘atta of

roses’ is very good for the heart (Client: Raza).

The stories told by the women of their experiences of herbal medicine at

Foundation House connected their past with the present and possibly estab-

lished hope for the future. Particularly for refugees, re-establishing connec-

tions is pivotal in order to begin the process of healing. For many of the

women interviewed, the role of CT at Foundation House was a way of

reconstituting these aspects of their identity as they grappled with the new

life in Australia.

I’d like to tell you about the situation in Afghanistan with my own kids. I’d

like to express my own experience of how I treated my own children . . . I

keep taking my children to herbal therapy. For example, when they get the

diarrhoea I actually treated it by myself, if they got the chest problems or

some cold or flu, I just treated my children by myself and they got better

(Client: Frasa).

The counsellors’ sensitivity to the challenges of working cross-culturally also

informed their referral to CT both via recognition of the limitations of coun-

selling and by an awareness of the potential for clients to accept CT as a

legitimate and comprehensible form of therapy.

For symptoms like anxiety and lack of sleep a lot of the clients that I see have

used it [complementary therapies] . . . it is something that is not threatening to

them . . . it is not like referral to a psychiatrist or doctor, they are a lot more

open to CT because they have either tried it before or it is something that is

quite acceptable in their culture (Counsellor: Lola).

Although counsellors describe ‘cultural familiarity’ as a reason for referring

clients to CT, the reality is that it is not necessarily the system of massage or

herbal medicine that is familiar. Clients come from hugely diverse back-

grounds and hold a wide range of cultural beliefs about health, illness and

effective treatment. Refugee clients’ past exposure to any form of medicine,

whether biomedicine or traditional medicine,1 depends on multiple factors

including geographic, social, political, economic, religious, educational, cul-

tural and individual differences (Bodeker et al. 2005b; Julian 2004; Kleinman

1980; VFST 2001).


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Even clients who have previously used traditional medicines will not always

be familiar with CTs as they are practised at Foundation House. There areparadigmatic and technical dissimilarities as well as obvious contextual dif-

ferences. However CTs broadly share some common elements with systems oftraditional medicine and in an attempt to explain ‘cultural familiarity’, we

outline those common features.One area of commonality is found in the epistemology and ontology of

the body in CTs and many models of traditional health care (O’Connor

2000). For example, synonymous with many traditional models, comple-

mentary therapies ‘insist on an understanding of disease as something thatinvolves a systemic dislocation of the whole person, not just of the body’

(Foss 2002 in Robson 2003: 2). The body is not viewed in isolation, whetherin disease or health. Complementary therapy models pay attention to under-

lying causes of illness and see health as a state of harmony or balance,both within the individual and in relation to his/her environment

(O’Connor 2000).As well as common principles, a number of complementary therapy prac-

tices have common features with traditional modes of health care. Herbal

medicine, massage and dietary therapies are practised across many cultures

(Macintyre 2003). These modalities that address problems at the level of theirphysical manifestation, valuing a language of the body, may be more con-

sistent with client beliefs about appropriate treatment than a psychologicalapproach which assumes a psychological aetiology and attempts to address

the same problems through the verbal medium of counselling (Hiegel 1994).For this reason, counsellors’ own critique of the psychological model as a

Western construct that has the potential to inappropriately psychologize refu-gee distress leads them to consider alternative approaches (Derges and

Henderson 2003; Summerfield 1999).

Somatic Presentations

Counsellors understand CTs to work on and through the body because they

engage with client’s physical symptom expression and provide a model whichfosters integration of the physical body and the psychological. Amar, an Iraqi

woman, shares this understanding:

Sometimes I go [into the complementary therapies appointment] in a very de-

pressed mood. I go out after the massage hopeful again, optimistic again . . . she

does two things at the same time, she treats me emotionally while she is treating

me physically. Like she is treating me physically, but it is also emotionally.

Somatic symptoms such as headaches and body pain are commonly cited

on referral forms as the ‘reason for referral’ to CT. As a mode of action,counsellors referred to the ability of CT to address the physical expression of

emotional or psychological distress. Similarly, the clients described


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a significant decrease in physical pain, often improved sleep patterns and en-

ergy levels, fewer headaches and an improved experience of wellbeing.

After the first treatment I felt so much better I feel so relaxed, I feel that the

pain has diminished, but also I feel that I could fall asleep and sometimes I do

and she really has golden hands and it really is quite a dramatic improvement

(Client: Vesna).

The inclusion of the CTP within the agency is seen as an acknowledgement

that trauma can have an ongoing impact on a person’s physical as well as

psychosocial wellbeing. Moreover, several counsellors suggested that CTs

provide a more direct route to addressing clients’ somatic presentations

than counselling. Some counsellors alluded to a perception that somatic pres-

entations were not always amenable to psychotherapy, especially when phys-

ical symptoms were predominant. Counsellors stated that they try to attend

to clients’ physical symptoms in the context of counselling, but the view was

expressed that counselling alone was sometimes inadequate to address

somatic symptoms:

I saw someone last week, she’s got sore feet and sore legs because she had to

stand for about two weeks in a concrete compound . . . she’s had everything

checked out, there’s not actually anything physically identifiable . . . the emotion

associated with that experience is very distressing, and the physical sensation,

like she can literally feel the coldness of the concrete beneath her feet, they’re

inseparable. And addressing that at a physical level just seems a much more

direct way to get at that . . . she’s seen innumerable GPs who say there’s nothing

wrong with her . . . [this] I think of as an obvious referral when you’ve really got

that complete enmeshing of the physical and the psychological (Counsellor:

Roger).

Faduma, a young Somali woman, was referred for CT specifically because

she suffers with severe headaches and body pain which are exacerbated by

intrusive thoughts. Faduma’s entire family were murdered, and the grief for

her only remaining sister who is stuck in a refugee camp in Kenya and con-

tinually refused a humanitarian visa, is unbearable. Yet, through the gentle

interaction with her complementary therapist, who used herbs and massage

which were familiar to Faduma and connected her to positive memories of

her mother, she found a meaningful way to attend to her own violated body,

and in turn, bring some comfort to her deep wounds:

I get nervous when thinking too much [about her sister stuck in a refugee

camp], I always have neck, shoulder burning. When they give the massage, I

feel better, I really feel good (Faduma).

The inclusion of CT in the agency was seen by counsellors to provide recog-

nition for ‘the body’ within a predominantly psychosocial model of service

delivery. As they aligned complementary therapists’ sphere of competence


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with ‘the body’, referral to CT can be seen as an attempt to specificallyincorporate physical treatment for their clients.

The non-discursive methods of complementary therapy treatment, withtheir emphasis on massage, diet and herbal medicines, are grounded in andthrough the body. Although some forms of Western psychotherapy will usethe body as the site of therapeutic engagement, this occurs discursively in apsychodynamic exploration of bodily sensation and bodily memory (Young2002). The significance of CT in this context is that is it provides a practicaland efficacious approach to caring for the physicality of symptoms withoutmedicalizing or psychologizing the person’s experience. In the CT encounterthe space is created that allows the body to be attended to and validated inways that are quite distinct from both counselling and biomedicine.

Extending Concepts in Refugee Health Care: Attending to the ‘Refugee Body’

As described by clients and counsellors, CT capacity to provide health carewhich effectively treats physical symptoms should not be underestimated.However, we suggest that in an integrated model of care, complementarytherapy treatment has the potential to move beyond ‘symptom reduction’to provide a deeper level of care for refugee survivors of torture andtrauma. In this section we again employ the voices of counsellors and clients,as well as theories of embodiment in our exploration of what it means to‘attend to the refugee body’.

It is routinely understood that in a refugee health care context the experi-ence of ill health cannot readily be reduced to a named pathology or diseasestate (Benedict et al. 2009). Distress is multidimensional and moves beyondthe bounded notion of self to a complex interaction with the social and thepolitical. Extrapolating Scheper-Hughes and Lock’s (1998) seminal work onthe ‘three bodies’ into a refugee health context, some academics havedeveloped the notion of the ‘refugee body’: the amalgamation of physicalpain with the complex social, political and cultural factors that define therefugee experience (Coker 2004; Gronseth 2001). We employ the concept ofthe refugee body to articulate an embodied understanding of the complexityof the refugee experience as signifying the interaction between the individualbody—the lived experience of pain; the social body—a symbolic repre-sentation of extensive social trauma; and the body politic—reflecting thebroader socio-political upheaval of war and violence (Scheper-Hughes andLock 1998).

Faduma’s experience articulates this concept:

If you have problem like with your finger, you fix it. But I feel pain about my

family. When I call my sister I don’t sleep for two weeks because she tells me a

lot of things, bad things ‘we don’t have food, we don’t have clothes, we don’t

have safe place’. Because they live in a refugee camp and at night time guards

come and they rape her, take what she has. When she tells me lots of things and


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I can’t do nothing, I feel very sad, I feel tired and headache and nervous . . . I

always have neck and shoulder burning.

Theories of embodiment suggest that the ‘body’ provides the subjective ex-perience of existence; life is experienced ‘in and through the body’ (Busby1996: 135). In this understanding the body is the site for experiencing physicalsensations as well as something that can perceive itself. Perceiving the body as

both subject and object breaks down divisions between mind and body(Csordas 1994). Jackson (1994) suggests that pain confounds mind–bodydualism because it is simultaneously experienced as emotion and sensation;

both subject and object. When pain is seen as something physical or of thebody, there is a tendency to conceptualize it ‘in terms of a physical objectinside oneself’ (Jackson 1994: 207). Here the origin of pain is conflated with

the experience of it. Similarly when pain, including mental torment or suf-fering, is relieved by an ostensibly ‘physical’ therapy such as massage, itprovides an opportunity for insight into the nature of pain and mind–body

interconnectedness. Faduma explains:

I feel very tired and body ache and much nervous and even sometimes I don’t

even want to get up from the bed because I feel bad. My kids come and say

‘mummy, mummy do this one do that’, and I can’t get up from the bed, my

body feels tired . . . I’m very happy to see Lucy [complementary therapist], she is

changing my world. She gives the [herbal] medicine and they work, she gives the

massage and I sleep well. I’m more patient with my kids now.

Central to the CT consultation, the focus was not so much to eliminatethe symptoms or ‘cure the trauma’, but to offer Faduma a space in whichshe could allow her refugee body to express the complexity of her circum-

stances. Implicit in this space is the understanding that the body tells a story;it often holds the unspeakable. Like Faduma, the women interviewed hadphysical symptoms that were deeply entwined with painful memories of

past trauma and torture, of severed connections with loved ones or wereentrenched in the turmoil of upheaval and dislocation. To try and separatethe physical from the emotional or social context would therefore be

meaningless.With this understanding, counsellors acknowledged that they refer clients

to CT not only for their potential to relieve chronic symptoms but for theresulting change in the way clients understand their symptoms. This is con-

sistent with their own goals of psycho-education. In referring to CT forsomatic symptoms the counsellor is acting as a conduit (Nandy et al.2001). They do not discontinue their psychotherapeutic contact when theyrefer, but will initiate this kind of referral where they perceive limited benefits

of a verbal approach which psychologizes somatization (Kleinman andBecker 1998). Counsellors perceived CT to provide clients with an oppor-tunity for insight through an experience of temporary respite from chronic

symptoms: a therapeutic interruption. Through such an experience a client


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may integrate an understanding of mind–body connectedness. The example of

massage therapy was used to illustrate how clients may experience a state of

relaxation, in direct contrast to their usual state of chronic tension and anx-

iety, and how this may produce embodied learning by reframing their under-

standing of, or relationship to, their symptoms and their experience of self.

The benefits have the potential to persist beyond the actual therapy session

(Csordas 2002).

Through the massage for instance the likelihood of that person being able to

experience some level of relaxation or giving them some space . . . it’s not only

the headache that might be alleviated, but the person may learn a whole lot of

other things. Or if someone has a lot of difficulty sleeping and they learn how to

feel a state of calmness in their body it won’t only help them with sleeping, but

will help them during the day whenever they get distressed (Counsellor: Lola).

Excruciating physical symptoms were directly related to the torture inflicted

on Amar whilst imprisoned in Iraq. The brutality of her experiences left her

with severe physical debility and pain; it was a constant reminder of what she

had endured:

They dragged me on the asphalt and skin came off [my knee] . . . they scraped

my knees with broken glass . . . they broke my bones and my body . . . you can

say emotionally, I was dead.

Amar’s body was the repository for the physical and emotional abuse of the

torture she endured. The physical pain became a living nightmare directly

connecting her with the lived experience of torture. In radical contrast the

experience of massage ‘made me feel that I am alive’.In this communication of care, Amar’s tortured body was given respite, an

‘angelic touch’. She felt safe to let her body be seen and to express the

physicality of her pain:

I had been hung from my right arm and Anna said there are three spots that

she can feel, I feel that she is very knowledgeable. When she is massaging these

spots, when my eyes are closed, I feel her going into each spot one by one. She

is aware of how I feel in these particular spots.

When asked how it was for her to receive massage after enduring such phys-

ical brutality, Amar responded by saying:

Anna shows me affection; she shows me that she cares . . . the effect she [Anna]

has on me is like an angel that touches me.

Countering the devastating effects of torture and trauma, Amar’s narrative of

her CT encounter describes her experience of respite and renewal for her

refugee body. In this encounter there was a shared understanding between

Amar and her complementary therapist that recognized that the body itself

requires particular care. The potential for massage to provide clients with an


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experience of being nurtured and cared for was also described by counsellorsin terms of it being an ‘antidote’ to torture experiences and an importantreason for referral to the CTP.

Clients who experience distressing symptoms such as chronic headaches,sometimes fear they have a serious illness and are not necessarily reassured bymedical investigations that fail to detect a pathological basis. When an experi-ence of relaxation, mediated by CT, is juxtaposed against a state of chronictension and pain, the sufferer has the opportunity to reinterpret his or her bodilyexperiences (Jackson 1994; Becker 1994). Not only is the pain relieved but thefear of some structural or physical abnormality is also alleviated.

I thought I had physical problems in my body. But after I did everything [all themedical tests] and they told me I have nothing, I have no problem in my body.

Maybe the sadness attacks my stomach . . . sometimes when I think about pastproblems, I feel headache, I feel stomach pain . . . the stomach talks . . . but when

I relax, I try to forget everything. I say this is my fate. I take the herbal medi-cine and I feel better (Client: Mary).

CT treatment started out by implicitly legitimizing the physicality of Mary’ssymptoms, acknowledging her lived bodily experiences. In this way attentionto the body is not passive, but rather encourages exploration of Mary’s sub-jective experiences. For Mary and the other women interviewed, the experi-ence of bodily pain, both literal in-the-body and symbolic, is understood inthis context as an embodied expression of life-pain:

When we were in Turkey my father passed away and then when we cameto Australia my sister passed away and I know I shouldn’t allow myself to

get so upset, but because I don’t have anybody here, no family, it is reallyhard and it has affected me . . . I was really, really in pain. It was caused by a

few things, but mainly the stresses we had in Iran, the revolutionary guardsattacked our house and took my father and my brother away and that was

really stressful . . .Anna [complementary therapist] works very hard, because mymuscles are very hard and tense, she works very hard to loosen them up and

that helps the pain . . .when the pain lessens then the feeling is emotionallybetter too. So here when I go to the massage, . . . it’s a feeling like I want to

fly, my body is so much lighter, I feel I’m taking off. That is how I feel (Raza).

Like Raza, the women described their experiences of ill health in languagethat was evocative of their life circumstances: the physical symptoms symbo-lizing the complexity and trauma inherent in their experiences.

For Lani, an elderly Afghani woman, the irrevocable separation from mostof her family members is a constant cause of profound distress and heartache.Equally compelling, her excruciating physical pain, originating from a horseriding accident many years ago in Afghanistan is now exacerbated by herpainful life circumstances:

As soon as I am tense and worried, the pain in the shoulder becomes stron-

ger . . . it’s just that I’ll picture all my children and grandchildren and I’ll miss


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them and that puts too much pressure on me and I can feel the level of the pain

rising.

Although apparently causally unconnected, Lani’s body pain and ‘refugee

pain’ had become inseparable. The physical pain symbolized her life pain;

the body representing social dislocation. The massage became a meaningful

treatment which attended to Lani’s body-life pain:

I was always in pain . . . I was always taking a lot of conventional medicine,

sometimes eight Panamax a day and that was not doing anything, nothing

seemed to be helping. But when I came home [from the massage treatment]

the old pain was a lie. It didn’t even exist, I was feeling so comfortable . . . I still

remember the experience of that first day that I received massage. From the

time I came to Australia, I remember that was the happiest day I had ever had.

I was extremely happy because I had no pain in my back and some herbal

tea was given to me as well. I just boiled that and I had a cup of nice and warm

tea before going to bed and that night I slept through the night very

comfortably.

Both clients and counsellors described CT as working directly with the body.

Counsellors saw referral to CT as an opportunity for clients to reframe their

perception of self and symptoms. The potential for clients to see themselves

or their symptoms differently, even if only temporarily, is an important

reason for referral to CT. This understanding of therapeutic efficacy is con-

sistent with the notion that CT can work via ‘changing lived-body experience’

and thereby ‘creating new meaning’ (Barry 2006: 2646).

Conclusion

The original rationale for the inclusion of the CTP at Foundation House was

to ensure a holistic approach to service provision. CTs are seen to broaden

the therapeutic choice for clients through access to therapies which are per-

ceived to have a strong resonance with the beliefs and practices of the cul-

turally diverse client group.At Foundation House, holistic service provision is seen as a ‘complemen-

tary duality’ where the relationship of parts to the whole is emphasized,

rather than a unified holism where everything is considered part of a single

unit (Scheper-Hughes and Lock 1987: 12). Counsellors’ recognition of the

role differentiation, specialization, and the capacity of complementary ther-

apists to add a ‘bodily dimension’ to their work with clients suggests that

they believe holism can be achieved by combining the congruent modalities of

counselling and CT. For many refugees, physical symptoms are better under-

stood as a combination of complex factors that require a holistic approach.

Clients’ narratives highlight the value they ascribe to receiving CT as an

important part of their healing; counsellors echo this view.


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A growing number of scholars are recommending the utilization ofnon-biomedical approaches in services that provide health care for refugees(Grodin et al. 2008; Hollifield et al. 2002; Bodeker and Neumann 2011;Watters 2001). In the Australian context and internationally, some servicesare utilizing a range of different CTs. However, there is limited evidence inthe literature that these services have included CT in the integrative mannerthat has been employed at Foundation House.

The research projects described in this paper are the first to document amodel of integrative care that combines counselling and CT in a torture andtrauma rehabilitation agency. Despite their small scale, our findings indicatethe relevance of including non-biomedical therapies, in the form of comple-mentary therapies, in services providing health care for refugees in Westerncountries. Furthermore, we argue that the success of any CTP is dependenton two critical factors: first, full integration of these therapies within theagency’s service delivery, and second, the agency’s commitment to on-goingfunding for the CTP.

Acknowledgements

The authors acknowledge the helpful comments made on this paper byAssociate Professor James Bennett-Levy of the Northern Rivers UniversityDepartment of Rural Health.

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