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Assessment
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Assessment
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Assessment and Intervention with Kosovar Refugees:
Design and Management of a Therapeutic Team
Abstract
The Western Australian Department for Family and Children's Services (FCS) were invited to assist the lead agencies, the Department for Immigration and Multicultural Affairs (DIMA) and the Australian Defence Force, in providing services to the Kosovar refugees relocated to Australia in 1999. The department's involvement centred on needs assessment of the Kosovar and the provision of family and individual support and advocacy.
Family and Children's Services made an early decision to develop support infrastructure for staff prior to commencing work with the Kosovar. The management of staff was designed to reduce levels of tension related to the counsellors' work, build a strong and supportive team, reduce the possibility of worker burnout, and facilitate re-entry into the workplace upon completion of the Team's work.
This article reviews the assessment methodology and subsequent interventions undertaken with the Kosovar by FCS team members. It also examines the management strategies utilised to maintain the health and functionality of the Team so that they in turn could provide quality services to the refugees.
Assessment and Intervention with Kosovar Refugees:
Design and Management of a Therapeutic Team
Escalation of war the in Kosova in the late 1990's resulted in many ethnic Albanians (Kosovar) being made homeless. These events placed pressure on refugee camps in Albania and Macedonia and led the United Nations High Commission for Refugees to take the unprecedented step of relocating some of the refugees to other countries. Australia was one of these countries and accommodated 4,000 refugees in "Safe Havens" across the nation. Of these 4000, approximately 410 Kosovar were relocated to Leeuwin Barracks in Perth Western Australia. Leeuwin Barracks is located in the riverside suburb of East Fremantle and has exceptional infrastructure (i.e. swimming pool, canteen, coffee shop, hairdresser, shop, bus service, gym, squash courts, soccer fields, ovals, playground, internet access, school, medical centre etc) all of which was made available to the Kosovar during their stay.
For the purpose of clarity this paper will define the following terms. The term Kosovo is the western pronunciation for Kosova. The people of 'Kosovo' refer to their country as Kosova and henceforth this will be the term used in this paper. The people of Kosova refer to themselves as Kosovar and this will also be the term applied in this paper.
The refugees who arrived in Australia represented a unique cross-section of Kosova in terms of religion, beliefs, values, attitudes and experiences. According to many of the refugees they had experienced the practice referred to as 'ethnic cleansing'. Others stated that they had witnessed the murder, torture and rape of family, friends and community members and had watched the burning and destruction of their villages and communities. A number of the refugees revealed how they were denied both their cultural freedom and civil rights. They were forced to flee their homes, unable to teach their native language in schools, victimised and threatened, encouraged to relocate to foreign countries (via implied threats of what would happen if they did not) and in some cases were deliberately separated and isolated from family and friends.
All work undertaken by the Team was consistent with procedures outlined by the Australian Emergency Management Institute (1996) and community development, torture and trauma literature. Staff approached working with the Kosovar via an assessment of their needs and through the formation and development of working relationships.
A cross sectional needs analysis was conducted by FCS team members, to ascertain the Kosova people's requirements while living within the Leeuwin Barracks. The needs analysis was performed by dividing the Team into pairs that focussed on key groups of Kosovar people. The key groups were identified as being children under 6, young people aged 12 - 25, parents, single people and the elderly. The analysis was conducted via consultation and observation. The survey examined the areas of education, recreation, safety, health, and emotional/psychological wellbeing. The research also investigated what the Kosovar identified as being the crucial culturally appropriate knowledge required by the agencies prior to service provision (i.e. same gender service delivery, religious beliefs and expectations).
The data collected from the needs analysis, along with information gathered through consultation and research clearly delineated the gaps in services identified by the Kosovar. The refugees identified the need for a kindergarten and playgroup, activities for the men, opportunities to talk about concerns if and when the need arose, a special room for the young women so that they could talk in private, opportunities to undertake craft and art work, orientation to the city and advocacy and support when working with other service providers.
Data was obtained, triangulated and synthesized from the following services: early education and recreation, counselling and support, and child protection (parenting information etc.). This allowed a holistic overview of all of the services and gaps in services offered or not offered to the Kosovar. The services identified by the refugees were then provided via consultation and involvement of community members. This approach is consistent with the process suggested by Papadopoulos (1999) and Sabbadini (1996). Papadopoulos emphasises the importance of a 'therapeutic presence' instead of imposing formal psychotherapy, and it is characterised by an avoidance of psychologising the evil nature of war atrocities and pathologising political dimensions. Mitchell and Everly (1997) highlight that this model of crisis intervention differs from formal psychotherapy in that it focuses on stabilization, normalisation, restoration of function and mobilization of resources.
Therapeutic presence also differs from formal psychotherapy in that it allows clients to form relationships with counsellors in everyday settings. Such a non-formal therapeutic setting facilitates the development of such relationships, which are built upon trust, rapport and communication methodologies (i.e. interpreter, non-verbal signs). Everyday availability also allowed the Kosovar to engage in therapy without having to arrange and then wait for a formal psychotherapeutic session. The Team's combined experience of previous involvement with evacuees illustrated a need for relationships to be developed between counsellor and clientele prior to therapeutic work being undertaken (Bayman, personal communication, 2000). The example of counsellors setting up in a room, in an evacuation Centre, designated for therapy and then not seeing any evacuees is a pattern this Team did not want to repeat.
According to Richman (1998) and van der Veer (1998) supporting refugees is not simply a question of 'treating their trauma' but must encompass cultural sensitivity. "This sensitivity only comes through collaboration, dialogue, developing trust, and working together to determine what is helpful" (Richman, 1998, pp. 184). Richman further advises that finding the elements that are supportive for a refugee community means developing these in conjunction with members of that community. It must also include addressing the practical needs of daily life, providing opportunities to talk about their experiences and problems, recreation, and encouraging self-advocacy.
The research results also illustrated that staff needed to overcome cultural and language differences identified by the Kosovar so that they could work effectively with the people. To assist in this process staff worked collaboratively with the other agencies to ensure that all clients obtained the service they required. This involved participating in regular morning briefings, at which critical information was disseminated, agency roles clarified, tasks and activities negotiated, and a fortnightly calendar of events endorsed. This forum provided information to the Kosovar Committee meetings attended by representatives from the Department of Immigration and Multicultural Affairs (DIMA), Defence and the Kosovar's own elected management council.
To further assist staff in their work with the refugees a literature and Internet review was undertaken focussing on Albanian history and culture. Numerous cultural consultants were also contacted to provide current information about lifestyle, cultural practices and ways of working (gender specific service provision). Cultural consultants also assisted staff by teaching basic Albanian phrases to assist in overcoming communication barriers. Later in the process, members of the Kosovar community residing on the Barracks conducted these Albanian lessons for staff. The Team also investigated a range of community development approaches and models of practice in working with survivors of torture and trauma. Demographic information of the people living on the Barracks was obtained from DIMA and Defence to assist in the Team's planning and work approach.
In general the FCS Team employed the broad principles of disaster recovery management and community development with sensitivity to cross cultural issues. The aim of community development is to empower a particular community or group of communities, the individuals within it, to address their needs. It involves a focus on issues such as access, equity and participation, and has particular relevance for marginalised groups and individuals within the wider community. (McGorry, 1995).
Other service providers in the Barracks and the Kosovar have acknowledged the success of the work undertaken by the FCS Team. For obvious reasons no pre and post measures could be taken to measure the efficacy of the Team's work. Therefore, the best indicator was the Kosovar's qualitative responses to the interventions undertaken by the Team. It should be noted that one of the Team's fundamental philosophies required that the Kosovar request the services they wanted. Subsequently, all of the services provided by FCS on Barracks had the support and encouragement of the refugees. The following examples of interventions are provided as measures of the Team's impact on the refugees.
The needs analysis illustrated a requirement for a kindergarten and playgroup for the children aged from 4 - 6 years. Conversations with the Kosovar indicated that such a facility would be well patronised as it would provide activities for preschool children and allow the mothers to meet and talk. Subsequently, the FCS team planned, developed, set up and ran this service. The success of this process is illuminated below via a case study.
Case Study
The children who attended the kindergarten programme were initially reticent, fearful and unsure about the toys, craft materials and teachers. When the children did play they engaged in aggressive games that mimicked the actions soldiers and incidents they had seen. Similarly, their mothers sat silently along the wall of the kindergarten watching the children and offered no interaction with other refugees or teachers. The parents appeared unsure of their role and requirements at the Kindergarten and were fearful of leaving their children with the teaching staff.
After 3 to 4 weeks this picture had altered dramatically largely due to the relationship building activities undertaken by the kindergarten staff. All of the children were happy to play with the toys and craft material. This play was constructive, interactive and non-violent. The mothers joined in and played with the children and assisted staff. They were more than happy for their children to be left alone with teaching staff. The women also talked freely to one another in this setting and many friendships and support networks were developed. The mothers used the setting to ask the teachers and the Clinical Psychologist working in the kindergarten, advice on parenting and managing their children's difficult behaviours. Over time parents became comfortable enough with the staff so that they were happy for the children to go on outings by themselves, off the barracks, with the teachers. This result is a considerable achievement given that the parents were initially wary of letting their children out of their sight and suspicious of Australian service providers in general.
Over time the Kindergarten became so popular that young children (< 4 years), teenagers and fathers would drop in for a visit to say hello and watch their children or siblings play and sing. The Kindergarten students would run to the school or wait in the car park early in the morning for their teachers to arrive. Some of the mothers enjoyed attending the Kindergarten as much as their children as it was their only exposure to English lessons due to the large number of children in their family or extended family. The rudimentary English taught at the Kindy proved a great success with both children and mothers using newly developed verbal skills outside of the kindergarten.
Many of the parents (including fathers) volunteered their time to help on occasion in the Kindy. One young mother, who had been a kindergarten teacher in Kosova, became a regular assistant teacher. She was invaluable and assisted FCS staff with culturally appropriate curriculum and translations. She also appeared to use the opportunity to teach in the kindergarten as a therapeutic healing experience. She would often share her experiences with staff and discuss her life prior to coming to Australia.
The Kindergarten proved to be one of the FCS team's greatest successes. The relationships it helped establish, the education it provided, the support networks it facilitated, the information and informal counselling it provided, as well as a safe friendly environment with caring staff all contributed to the programme being one of the most widely used by the Kosovar. It was also recognised by other service providers on the Barracks as the most successful ongoing programme provided to the refugees.
Another finding from the needs analysis was a request by the Kosovar men for some meaningful activities for them to do during the day. One member of the Kosovar community worked as a fisherman and he suggested fishing excursions, which was easy to organise as Leeuwin Barracks is 50 meters from the Swan River and close to the beach. Prior to the first expedition an Officer from the Department of Fisheries gave some background on fishing limits, types of fish (poisonous versus non-poisonous), bait and techniques. The first trip saw 12 men enjoy catching large amounts of fish. These were then taken back to the Barracks for the community. The next trip saw much more interest with a busload of men enjoying another successful outing. On the bus on the way home to the Barracks the men started singing traditional Kosovar songs and soon the whole bus was laughing and singing. Many of the men started talking with Staff of their experiences prior to coming to Australia. One of the old men told a colleague that this was the first occasion in nearly six months that he had heard his people sing! Other men reported that the fishing excursions were the most enjoyable events that they could recall in years. The fishing excursions subsequently became a popular event for the men and many of them took the initiative and fished the river whenever they had the opportunity.
Other measures of success in terms of the Team's relationship building and interventions with the Kosovar are illustrated by the invitations the Team received to attend community functions, such as weddings and birthdays. Despite the fact that the refugees have returned to their homeland some time ago, members of the team still communicate via the internet (email) and telephone with the people they worked with and are up to date with their progress in Kosova.
To achieve the outcomes described above it is evident that the quality and experience of the staff running the programmes has a lot to do with their success. Perhaps the single most important part of managing a therapeutic Team in such an environment is the selection of such personnel. The aim of selection was to develop a broad based multidisciplinary Team of professionals from diverse cultural and professional backgrounds. Volunteers were called for from FCS staff who had experiences in disaster management, working with victims of torture and trauma, early education, cross cultural and language expertise, high level counselling skills and good self care strategies. The Team Leader then counseled volunteers and informed them about the nature of the intended work, the likely intensity, time commitment and potential personal cost. Those who still wanted to volunteer for the project were forwarded to the senior management group making the final team selection.
Twelve team members were selected from this pool by senior management based on their knowledge and experience in dealing with disaster recovery management, working with refugees, working with people suffering from trauma and torture, community development/psychology, working in culturally diverse communities, ability to work under pressure with little direct supervision and their availability to be released from normal duties. Several staff were selected for their language skills and experience in interpreting and translation services.
Membership of the team subsequently included senior clinical psychologists, senior social workers, senior education officers, children's services officers, community development officers, cross cultural and administrative support specialists. Having selected the appropriate staff the next step was to ensure that they had information to prepare them for the arrival of the Kosovar. A number of training workshops, facilitated by the senior author, were held with team members so that staff could undertake refresher programmes. These refresher courses allowed for the revision of the counselling skills and techniques (i.e. working with interpreters, working with cultural consultants, debriefing methods, communication techniques) most likely drawn upon in work with refugees. These workshops also promoted the development of sound working relationships and allowed the project's rationale for intervention to be clearly understood.
In addition to the above mentioned workshops, information was provided on Kosova, the war and the people themselves. The Team also attended a number of lengthy briefings provided by DIMA, Defence, members of the Albanian Community and the Association for Services to Torture and Trauma Survivors (Asetts). The training workshops and briefings were invaluable in developing work strategies, discussing staff support infrastructure and management and staff expectations. Team members noted that these initial sessions allowed them to get to know each other, develop an idea of the skills and knowledge held by Team members, and gain a rudimentary understanding of the Kosovar.
As part of the management strategy devised by the Team Leader to support the therapeutic staff, debriefings were provided on a daily and weekly basis. Three briefings were conducted each day. These three daily briefing meetings were essential as they encouraged peer support and communication through the sharing of information about daily experiences and events. They also provided a forum for the planning of future activities and projects.
The first meeting consisted of reviewing issues from the previous day and allocating work to be undertaken. The second briefing occurred over lunch away from the Barracks. This meeting was considered extremely important by both staff and management as it facilitated a break from the therapeutic environment and Kosovars. This briefing allowed staff to relax and interact freely, which otherwise would have been difficult in the work environment. The lunch briefing also was important in that it allowed the discussion, resolution and the identification of potential work barriers. Additionally, the meeting provided an opportunity for staff working in other areas (e.g., early education and adult programmes) to meet and share information.
The final meeting of the day was perhaps the most important. It was used to summarise the work the Team completed during the day. Issues were identified and plans for dealing with them discussed. Team consensus was required on the mode of implementation. For example, a proposed activity for teenage girls away from the Barracks was discussed by the whole Team and the possible problems and outcomes identified. It was a requirement that each proposal be the direct result of a request by the Kosovar and that it not impede any ongoing or previously planned activities. All of the material discussed during the day, and in particular issues discussed at this briefing, were recorded on a log and entered into the computer data base to provide a reference tool for staff. This information facilitated the tracking of issues, monitored problem resolution and gathered qualitative indicators of the Teams progress.
As an adjunct to the daily briefing meetings an onsite formal debrief was also conducted on a weekly basis. The formal debriefs were conducted by a Senior Clinical Psychologist from FCS, who was located off site. The debrief process involved providing information on appropriate self-care, self monitoring and signs of vicarious trauma in an adaptation of the Vicarious Traumatisation Model used by Saakvitne, Pearlman and Staff (1996). The nature of the debriefs was relaxed, flexible and sensitive to the Team's issues and concerns and often involved an interweaving of personal and procedural issues (Mitchell and Everly, 1997). While initially reticent about the formal debriefs staff appeared to enjoy the process over time and became more forthcoming with their feelings and ideas. Staff members, who for some reason could not attend the debrief meeting, actively sought individual meetings with the debrief leader.
Another management strategy incorporated by the Team Leader was the encouragement of peer support strategies. Team members were encouraged to work in pairs so that they could provide ongoing support for each other and assist when communication with the refugees was difficult. Each of the paired workers was allocated a portfolio (e.g., early education, behavioural management, and youth activities) and it was up to them to ensure that the goals were met. The co-workers were given a great deal of encouragement and flexibility so that problems encountered in their portfolios could be solved creatively and expeditiously.
Working co-operatively assisted many of the paired workers to develop sound working relationships with the Kosovars and this was reflected by the success they achieved. Pairing workers gave them the opportunity to debrief with one another informally as the day and their work progressed. Pairing workers meant that peer support was ongoing. Testimony to the success of this management strategy was that all Team members reported feeling supported and validated by their colleagues due to this process.
Perhaps the major contributing factor to the success of the Team working with the Kosovar was the formation of a functional group of people who related well, respected each others abilities, dealt with concerns as they arose, supported and cared for one another, encouraged one another and had the ability to laugh at themselves. The development of a strong team was essential and one of the active management strategies employed to facilitate such a team was encouraging an egalitarian management process. All staff had portfolio management responsibility for their own work area. They had relative autonomy to use whatever measures enabled them to meet the Teams outcomes and goals. These plans were discussed with the rest of the Team prior to implementation. This resulted in the staff feeling that they had a degree of ownership over the work they were doing and resulted in them striving to meet the outcomes they made for themselves.
When reflecting on the Team management it was apparent that the majority of the business decisions were made via the entire Team's consensus. The Team Leader's role was to ensure these plans were put into action and to negotiate resolution should the Team reach an impasse. The Team Leader's major function was to translate the Team's goals to the other lead and support agencies in the Barracks so that the Team's position was clear and transparent.
FCS also provided the Team ongoing administrative support, which allowed staff to concentrate on their work with the Kosovar. This support proved to be highly valuable as the administrative officer concerned was highly competent and managed all the administration work generated by the 12 team members. This officer's role was highly valued by the other Team members because freedom from the administrative work allowed the counsellors more time with the Kosovar people.
The final management strategy to support staff centred on the reintegration of Team members back to their previous work roles. One technique used in staff reintegration was that Staff went from fulltime to part-time work at the barracks 6 weeks prior to the end of the Team's work with the Kosovar (i.e. 6 weeks upon notification of the Kosovar's repatriation date). Staff resumed normal duties in the remainder of their full-time hours. Upon the completion of the Team's work with the Kosovar (i.e. after the Kosovar were repatriated) a final full day formal debrief was held. This debrief was used to look at the Team's achievements. The first part of the morning was spent finalising and reviewing the day journal so that each member, their managers and the departmental library had a copy. This was a valuable exercise as it allowed the Team to revisit the highs and lows of their work. The morning was also used to complete a journal article that has since been published locally. In the afternoon a formal therapeutic debrief was held for all Team members. This debrief allowed staff a final opportunity to discuss Kosovar related issues, share re-integration experiences and coping strategies, and thank colleagues for their support. This was followed by an operational debrief which was attended by the Team, their line managers, senior management and members of FCS Executive. The operational debrief allowed management the opportunity to see the depth and breadth of the work undertaken by the team as well as the team's commitment to the project.
One of the issues that confronted some team members was that colleagues in their work units might not understand their work with the Kosovar. This in fact proved to the case for some staff with a number of their colleagues unhappy about picking up extra workloads. Others did not understand the nature of the work the team member had been involved with or had been provided with the wrong information. These problems may have been avoided if work colleagues in the service delivery units had regular reports on the outcomes of the team's work. This information should have been more regularly conveyed to management so that all tiers were aware of the team's ongoing activities. It is interesting to note that those team members who did maintain open communication with work colleagues did not confront these problems upon reintegration. It is recommended that in future work of this nature that staff are assisted in maintaining clear links with their work units through a weekly Team communication bulletin that provides information on the progress of their work.
To ensure that their work was both validated and communicated to staff; senior management were invited to attend the final part of the debrief to hear the Team members talk about their work and their successes. All of these managers were impressed and shocked by both the quality and quantity of the work undertaken by the Team. Managers invited Team members to talk about their experiences in a formal setting when they returned to the work units. Finally the departmental Director General issued a statement to the entire department applauding the Team and the way in which they had conducted themselves.
Recovery management at Leeuwin Barracks was best conceived as being conducted on an interim basis. It was acknowledged that victim recovery might take considerable time due to the nature of psychological damage sustained by the refugees. Sadly some may never recover from the trauma of their experiences.
Family and Children's Services role at Leeuwin Barracks has been both a unique and profound experience for those staff involved. Working with the refugees was complex, difficult and required highly creative strategies. Activities undertaken by the Team was mindful of community recovery and development models in particular, cross cultural models and issues of cultural sensitivity, client empowerment, and the need to create a supportive and safe environment were a continuing focus.
The approach favoured by the Team was activity based and consisted of programmes that promoted psychological and physical resilience. These activities focused on recognising existing and developing new skills. The approach was deliberately competency based as opposed to analysing deficits within the community. In many respects the Team benefited from not engaging in the work of formal trauma therapy. Subsequently Team members were free to encounter the Kosovar people as a 'therapeutic presence' rather than as clients to whom they were providing therapy. Qualitative data and anecdotal information clearly illustrate the value of the intervention model employed by the Team. The Lead Agencies in the operation, other state organisations, and most importantly the Kosovar have acknowledged this work themselves.
In terms of managing therapy staff, who worked long and stressful hours, perhaps the greatest success was the formation of a strong and healthy multidisciplinary Team. All of the Team members have successfully reintegrated into their substantive positions and none reported any long-term stress related symptoms that related to their work with the refugees. All Team members have stated that the Team management methodology, their colleagues and the supportive networks developed around the team were the major reasons they were able to remain both healthy physically and mentally while working with the refugees. Once back in their substantive positions a number of Team members have reflected that they were 'homesick' for their close supportive relationships with colleagues and that they were missing their active management role.
Staff members who were involved in the Family and Children's Services response to the Kosovar crisis still meet socially to provide ongoing support and are involved in a number of joint project which reflect their expertise gained at Leeuwin Barracks.
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McGorry, P 1995. Working with Survivors of Torture and Trauma: the Victorian Foundation for Survivors of Torture in Perspective. Australian and New Zealand Journal of Psychiatry. 29, 463-472.
Mitchell, J.T. & Everly, G.S. 1997. Critical Incident Stress Debriefing: CISD. An Operations Manual for the Prevention of Traumatic Stress Among Emergency Services and Disaster Workers. 2nd Edn Revised, Elliott City, Chevron Publishing.
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Saakvitne, K. & Pearlman, L.A. 1996. Transforming the Pain: a Workbook on Vicarious Tramatization. New York, W.W. Norton and Company.
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