An experience beyond words: Trauma-informed ideas for Child services supporting Ukrainian Refugees
(This article was commissioned by the Journal of Child Psychology and Psychiatry)
The war in Ukraine is creating a humanitarian crisis in Europe not seen since World War II. As of the beginning of April 2022, more than 4.3 million people had fled Ukraine and are now refugees (UNCHR, 2022). By March 24th 2022, according to UNICEF, more than half of all children in Ukraine had been forced to leave their homes (UN News, 2022). It is estimated that hundreds of thousands of Ukrainian refugees, mostly women and children will be arriving in the UK seeking safety (The Guardian, 2022).
Following arrival to the UK, refugees often experience difficulties associated with isolation, loss, community and culture. These difficulties can be compounded by language and communication barriers and challenges with accessing health and social services. It is also well established that asylum seekers and refugees frequently experience racism and hostility in their new country (Hodes & Vostanis, 2019). A recent literature review found that children seeking asylum in Europe experience a range of mental health difficulties, including post-traumatic stress disorder (PTSD), depression, self-harm, and behaviour problems (Flood & Coyne, 2019).
These experiences mean that there are often significant barriers to refugees accessing health and mental health services. These barriers include; language, stigma and cultural beliefs about mental health, and health practitioners not having the skills to work effectively across cultures (Hughes, 2014).
The service I work in is a Paediatric Psychology service at University College London Hospital (UCLH). Whilst not a specialist refugee service, we are involved in supporting some refugees who are being treated in the hospital for a medical condition. In light of the war in Ukraine, we are reflecting on how we can build on our existing work and experience to provide effective support to Ukrainian refugees when they are referred to our service in the future. Drawing on trauma informed ideas, as well as some of the unique experiences of refugee communities, this article explores some key concepts that health professionals might hold in mind when offering support and interventions to Ukrainian refugees.
A safe place to stand
Most young refugees will have spent a considerable amount of time feeling unsafe. Many will have fled their homes without most of their possessions, experiencing great uncertainty and impending dread of what might be next. Some may have experienced, witnessed or heard about extreme violence, and their experience of people in authority might be one of understandable distrust. Therefore, one of the most important initial steps is to help children and young people feel safe and start the journey of developing trust. A foundational principle of trauma informed work is to help people feel safe in the present and in their bodies, rather than being thrown back into a perpetual experience of trauma that mostly exists in the past (Van de Kolk, 2014).
Therefore, it is important for safety to be held in mind from the first points of contact with a young person or family. In our team at UCLH we often start with a brief telephone conversation exploring the young person or family’s relationship to help (Reder and Fredman, 1994). One area that we can build with refugees is to ask questions about how to create a safe and comfortable initial assessment. For young children, it might be helpful to explain to a parent or carer that their child can bring a comforter, a teddy or toy to the session in order to help them feel safe and comfortable. For older children, asking who they want to bring to the session and whether they want time on their own or not might help a young person know that their needs will be placed at the centre.
These ideas connect to the notion of having a safe place to stand in order to be able to face something difficult (Ncube, 2006). This is arguably even more important when working with refugees who, although not in immediate danger, might still not feel safe emotionally, physically or legally with regard to their status in the UK. In her work as part of the Christmas Island Torture and Trauma Service, Poh Lin Lee (2013) describes creating safety in terms of providing an opportunity to experience comfort, relaxation, safety and acceptance in the company of someone who is fully present. She summarises this through the metaphor of creating islands of safety.
Similarly, Portnoy and Ward (2020) highlight that, “young people who have fled war can feel like they do not matter, so it is important to make sure they know that they do (p643)”. As such, during initial assessments it can be helpful to get to know a young person before talking about the problems and concerns that bring them to meet with the professional. Asking questions about their interests, skills and abilities and who is important to them provides young people with a relational experience and context where they are seen to matter and that they are more than the sum of their problems (Madsen, 2019).
Starting from a position of curiosity about what’s important to someone, also helps to further strengthen the safe place to stand that is needed before approaching areas of difficulty and creates the foundations of a trusting professional relationship. Creating and maintaining a sense of safety is something that requires ongoing attention, particularly if the intervention centres around trauma. In trauma informed therapies such as Eye Movement Desensitisation and Reprocessing (EMDR) and trauma focussed cognitive Behavioural Therapy (T-CBT) attending to safety is also a key consideration and worked on through techniques such as grounding, resourcing and through a collaborative therapeutic relationship.
Some questions to consider with regards to creating a safe place to stand:
- In what ways does the physical environment of your service help young people and families feel safe?
- What else could you do to create a safe setting?
- In what ways do your initial contacts with young people and families hold safety in mind from the outset?
- What else can you do to incorporate safety throughout the work?
Community and belonging
The refugee experience by its very nature is one of displacement and loss of community, culture and home. Therefore, arriving in a new country as a refugee will likely impact on an individual and family’s sense of belonging. This need to belong is third on Maslow’s hierarchy of needs with only physiological needs and safety/security being more fundamental (Maslow & Lewis, 1987). Indeed, numerous studies have identified community, family, and friends as important factors to consider when improving wellbeing and promoting children and young people’s adjustment to the host country (Nakeyar, Esses & Read, 2018).
Holding this in mind is important when considering interventions for young refugees. Alongside individual interventions for trauma, physical health and emotional wellbeing, it is important to consider ways of promoting community and belonging as a treatment in its own right. This can include interventions to help with integration at school, and bringing communities together. There are also trauma-informed approaches such as the Tree of Life and Team of Life, whereby developing a resourceful community is held at the centre of the intervention. Such approaches have been used effectively with young refugees (Hughes, 2013).
In this way, community is seen as a “protective winter coat”, that strengthens refugees’ sense of belonging and identity, which can be a powerful intervention during times of transition (Tjin A Djie, 2003). At UCLH, we try to promote belonging through bringing together groups of young people who have a shared experience. Most often this involves young people that connect through having a similar medical condition. In addition, colleagues have recently started a ‘Rainbow Group’ creating a community of young people who identify as LGBTQ+ and also have a health condition. During the pandemic, we also ran some online peer support events for young people (Glazer, Daniilidi and Valentino, 2021). In this way, creating a community and sense of belonging can be a powerful antidote to feelings of isolation and loss. It is important for our service to consider how we can build on this work with young refugees where a sense of community and belonging is crucial for health and wellbeing.
Some questions to consider with regards to supporting community and belonging:
- In what ways does your service already bring young people and families together in ways that create a sense of belonging?
- How might you help refugees join these communities to build a sense of belonging in a new country?
- What else can you do to create a sense of belonging?
- How can you support refugees to build a sense of belonging within their own communities?
It is likely that many referrals for refugees to CAMHS services will be for PTSD and/or the psychological effects of trauma. Trauma reactions might also be an aspect of referrals to paediatrics and other health and social services. Common trauma reactions in children and young people include; nightmares, flashbacks, avoidance of reminders, difficulties with concentration, hypervigilance, physical complaints such as stomach aches and headaches. Younger children might temporarily regress developmentally and lose the ability to feed or toilet independently. Although NICE recommends trauma focussed CBT or EMDR for PTSD, in practice there are a range of considerations, perspectives and beliefs when it comes to addressing trauma in refugee populations.
Children and young people who have suffered significant war related trauma might be making sense of these experiences in ways that complicate, maintain or impact on their current sense of self or their view of others and the world. For instance, it is not uncommon for young children to internalise suffering and feel that they are to blame for bad things that have occurred. Older children might be struggling with how trauma has shattered assumptions of safety and certainty that are placed around life (Janoff-Bullman, 1992). Therefore, meaning-making is central to the experience of living with the effects of trauma and most trauma informed approaches address meaning in some way. For instance, drawing on narrative therapy, Hughes (2013) describes the need to identify stories of resilience and strength in refugees alongside those of vulnerability. This is seen to ensure people are less likely to be re-traumatised or put back into a position of victim (White 2004). In EMDR, processing traumatic memories is always carried out alongside working towards preferred meanings. One particular thoughtful and effective EMDR approach to processing traumatic memories with children is through the use of storytelling (Logie et al., 2020). Here, children and young people who have experienced trauma can help create a story of their experience that makes sense and places their preferred identities and meanings at the centre.
Most refugees have experienced a sense of powerlessness, not having a voice and feeling unimportant. Therefore, attending to a child or young person’s unique trauma story is important for them to feel that their experience is valid, can be thought about, and that they matter. This work is always done holding safety in mind as a condition of the work and within the context of a trusting therapeutic relationship.
“Trauma is an experience beyond words” (Meichenbaum, 2012).
In writing this article, it is possible to describe in words some of the traumatic experiences that children and young people who have fled the war in Ukraine are likely to have experienced. However, the quote “trauma is an experience beyond words” encapsulates how the experience of living through terror, suffering and trauma is one which cannot be fully understood through narrative alone. Neurobiologically, during trauma our emotional and sensory systems are heightened whilst our thinking brain and language centres are more shut down (Brewin et al., 2010). So, it stands to reason that describing a trauma experience in language is likely to be restricted. In accordance with this, Bessel Van der Kolk (2014) famously described how “the body keeps the score”, meaning that the body holds on to the memories in physiological states.
Therefore, in working with young refugees who might have experienced unimaginable horrors, it can be helpful to incorporate some non-language-based approaches into the work to aid communication and understanding. For children and young people this can take the form of using creative tools such as sand tray or arts and crafts. There are also some excellent free tools for creative expression that can be found online such as www.onlinesandtray.com. With an understanding that trauma is encoded and held in body-state memories, approaches that focus on developing an attuned relationship with the body such as yoga and drama therapy also have been found to be effective (Van de Kolk, 2014).
Some questions to consider with regards to addressing trauma:
- How can you support children and young people to help make sense of their experiences?
- Beyond the use of words, what tools can you use to help with communication, to identify meanings and develop new understandings?
- How can you help children and young people to hold their preferred identity at the centre of any trauma-informed intervention?
As a result of the war in Ukraine, services will soon start to receive referrals for Ukrainian refugees. This article has highlighted some concepts and themes to consider when working with children and young people who have experienced trauma. As such, a focus on how a service might offer a safe place to stand for refugees is a useful starting point as it is only when a person feels safe enough that challenges can be explored. Alongside, it is important to consider ways to promote engagement and to build the protective winter coat of belonging and community. In addressing trauma, considering creative methods to help a young person make sense of their experiences, whilst holding their preferred identity at the centre.