Colombo, Sri Lanka Railroad Track. Photo Laurie L Charlés.

Colombo, Sri Lanka Railroad Track. Photo Laurie L Charlés.

*This post is an updated and modified version of an article by the same name, published in the July/August 2015 issue of Family Therapy Magazine. Used here with permission.

Last night was the final meeting of our Shoufi-Mafi: Global Mental Health [1], a student driven task group at my university. The group originated from a confluence of events, one of which was the curiosity of my student Yajaira, who relentlessly quizzed me after our Introduction to Family Therapy course on Thursday nights. “Dr. Laurie, How do you get to travel so much? Who contacts you? What do you do?”

Yajaira’s persistence and genuine curiosity inspired my own: What could I do to support this interest in global mental health? Was there interest in such a group? Using Yajaira’s initial questions as a starting point, the Shoufi-Mafi met for seven sessions this past Spring, doing every thing from viewing webinars on Mental Health Innovation Network, listening to family therapists working with refugees in our community, and discussing the role of gender in humanitarian situations across the globe. The meetings were informal, voluntary, and open to any graduate student. A highlight of our meetings was a Skype session with a Syrian psychologist, a colleague of mine who I met in a training I delivered last June. In that session, our Skype visitor, in the midst of the humanitarian crisis in her country, ended the meeting by wishing the students best of luck on their development as family therapists. Shoufi-mafi fell in love with her.

Humanitarian situations can occur in any place, but most often occur in a fragile, conflict-affected state, a low-resource setting of a middle- or low-income country. Fragile, conflict-affected states (FCS) are not labels I give to countries or the countries give to themselves; they are labels used by the international community, i.e., the IMF and the World Bank. Countries must meet specific criteria for these labels. While the differences between the countries are much more complex than the GDP or the number of internal armed conflicts, some things are remarkably parallel. In many of these countries, for example, health systems are severely compromised or exist only in theory but not in any operational format. A lack of human resources in mental health also means that family therapy, family psychology, or family counseling are unlikely to exist as professions. Yet, that is not to say that there is no relevance for family therapy—only that the people doing it are likely to be professionals in other disciplines. Some of my former trainees in projects completed outside the U.S. have included Buddhist priests, Arab Christian & Muslim psychiatrists, Tamil Christian and Hindu psychosocial workers, excombatants in Libya, secular Muslim psychologists in Kosova, and Central African nurses.

12 years ago my friend and colleague, Fred Piercy and I discussed in a piece in the Journal of Systemic Therapies our experiences as family therapists teaching in non-western countries.[2] Today I would modify that term to be more precise: I often find my work occurring in low and middle-income countries and fragile, conflict-affected states. The work I do in these places occurs precisely of each country's status within the international community. In 2014 I worked as a family therapist trainer: (1) in Libya, to teach family therapy to psychologists working with excombatants; (2) in Kosovo to teach an Introduction to Family Therapy course for a new family therapy graduate program in Prishtina; (3) and in Beirut, to deliver a training for the UN with Syrian psychologists and psychiatrists working in the context of the war in Syria. Each of these projects came about because of each country's state characteristics.

Mental health and psychosocial support (MHPSS) projects are delivered in low and middle-income countries, or during a humanitarian situation, in part because psychosocial needs are part of public health and well-being norms owed to every person as a result of international law (Cryer, Friman, Robinson, and Wilmshurst, 2007). The nation-state, in the eyes of international law, is responsible for the psychosocial well being of their citizenry, the families and communities that make up society. If this obligation is not met, international bodies (INGOs, UN, or other regional organizations) often become involved providing technical assistance. In terms of mental health and psychosocial support, the development of the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings “reflect an acknowledgement of the importance of psychological support by the humanitarian community and a commitment to meet the psychosocial needs” of populations (Jacobs, 2007).

Ramon Rojano (2004), in discussing community focused family therapy, advocated for “collaboration with community resources for professional support” (p. 59). Similarly, collaboration and capacity building of community resources has also been discussed in the global mental health literature as scaling up and task-shifting (Patel, 2012), and is seen as a critical method to enhance mental health and psychosocial support for human resource development in low resource settings (Charlés, 2014). The ability to conceptualize a human rights perspective—in concert with the complexity involved in taking a systems view—is critical to my work in LMICs and fragile, conflict-affected states. I become part of the system for a short time, but I also have to respect that I am always an outsider. This balance and robust respect of my double role is also something I think AFTA members can easily understand and relate to. We are known for being “expert” in terms of our brain trust in family therapy, yet we are also known for being critically thoughtful about the implications and limitations of our role. I also take my cue in this work from the work of people like Vikram Patel (2012): Outside subject matter experts can play a useful role by enhancing technical capacity and performing supervision, increasing both access and availability of psychosocial services among host country nationals already in the field.

While the content of what I deliver as a family therapy trainer in a country is often similar, my method of delivery changes considerably from place to place. Like client families, trainee groups are really unique in their dynamics and those unique dynamics are also totally dependent on context. And as in therapy, I can plan ahead for how the training might proceed, but when I arrive in Tripoli and am on the ground with 42 Arabic speaking family therapy trainees in post conflict Libya, I have to negotiate what I planned to deliver with the unplanned dynamics of the training group I have just met and the presenting context in which they are living and working.

While family therapists may have skills that enhance the capacity to contextualize the suffering of the clients, supervisees, or trainees we work with, in global mental health one must be able to do this in relation to the broader political and economic factors in the country (Batniji, Van Ommeren, & Saraceno, 2005; Zarowsky, 2004). And it is here where U.S. based family therapists need “scaling up.” Preparing family therapy trainees in the U.S. to work effectively as systemic family therapy clinicians in humanitarian relief contexts requires a shift from the nationalist focus of traditional family therapy training toward one that is a critically global lens (Platt & Laszloffy 2010).

In training groups, I am still very conscientious about my social location (my intersectionality and identities such as gender, nationality, education and economic status, race and ethnicity, religion, ability) but tend to be much more focused on how intersectionality is performed and discussed (or not) within the training group. That is because while my background may be interesting to the group for a variety of reasons, what I find is that usually I am irrelevant because I am an outsider. What becomes more important, as in a family session, is to observe how individuals interact and perform their intersecting roles with each other, and to build on the capacity of what I see and hear. My qualitative research skills of participant observation and attention to nuances of dialogue and personal expression are critical in this regard.

One afternoon as I was nearing the end of my stay in Tripoli, I was alone with some of my female Libyan trainees in a room used during the Muslim call to prayer. The room was also used as a break room, complete with TV for news. The afternoon of the day before I was slated to leave the country, I was astonished when some of the women expressed their affection toward me in a physical way, touching me and playfully taking pictures with me as we hugged and held each other. I knew they liked me and felt close to me, but none of them had been so expressive to me during the training.

This expressiveness between us would not be acceptable in front of the training group, which consisted half of men; indeed there was no sign of such physical affection in public. Yet at the same time, I very clearly felt affection from the men as well, who did not touch me, and in fact hesitated to come near me at all! Still, albeit using a larger radius of personal space, the male trainees and I posed for photos together often, which, unlike the women, we only did in public and never in private. I never had any private moments with the male trainees as I did with the women; this would have been totally unacceptable, due to the strict social mores in the culture. What was so moving was to feel the strong affection both ways, in the absence of and the presence of physical contact. This taught me a lot of things—one of which was a better understanding of Libyan families and the power of ties to family, clan, and tribe.

Many families and communities in the midst of a humanitarian context or living in a LMIC do not necessarily rely on things taken for granted in a stable, high income country—potable water, electricity, and internet service are a few of these things, but there are more. In fact, their situations are often even less reliable because they may also be evading bombs, snipers or landmines, fleeing sexual violence, or witnessing atrocities in the same space and time.

Even in moments of crisis in the U.S., U.S. citizens have an incredibly reliable safety net. Although potable water or electricity may not be conveniently at your doorstep after a storm, it will never be too far away—even if it does not always feel that way. I cringe when I remember the moment a friend of mine—a sensitive person, committed to social justice—told me, heartbroken it seemed, how hard it was for her to boil water for three days when she lost electricity after a tropical storm in her city. After living comfortably, without electricity in Togo, it was hard for me to appreciate her view. Today, after working in so many low-resource settings, I am even less tolerant. In this way, having time in the field (where you experience first hand what it is like for the people you are wanting to help), and on the ground in a low resource setting can be such useful preparation[3]. You learn what it is you need (potable drinking water); you learn what you can live without (it doesn’t have to come out of a tap in your home).

In low resource settings or FCS, such conditions may continue for years at a time—and in quite worse circumstances. Yet, as my Syrian colleague shared with the Shoufi-Mafi group, psychosocial needs and family therapy work continue. Work goes on, in spite of the absence of electricity or water, in spite of ongoing violence. Ironically, this lack of traditional resources is the nexus of innovation in many areas of psychosocial health. This is one of the interesting findings of a recent study a Sri Lanka colleague and I completed; innovation is born when resources are few.

It is one of the great rewards of my professional life that I am being paid to do work that in fact, I would do for free, any time, any place. (And did do for free in the beginning, many times). But it is not work meant for everybody, just like being a family therapist is not for everybody. The work is painful at times, in ways that often surprise me and often disturb my sleep. It is also mostly silent work. I often use writing as a method of inquiry, yet I can rarely write about my international experiences. While not everything needs to be written about or said to be understood, I feel very strongly that the things I have seen in this work require bearing witness, and not only by me. I am also committed to sustaining this work in the field in which I identify myself. It is a reason I support and will continue to support our Shoufi-Mafi task group.

I would like to see more emerging family therapists routinely well-prepared to do global mental health work, in ways that are consistent with international standards yet with the integrity of thought and vision that for me, is so much a part of what AFTA is all about. Although I sometimes feel that in the U.S. family therapists are not focused enough on global matters in a critical way, I also feel that possibilities to change are very ripe. AFTA is part of that ripe future in my view. We are familiar with how to negotiate the global aspects of family context in a critical, informed way, and for AFTA members, this type of work I describe here is work that is understood, and part of the organization's history. For me, this work has been transformational. It has changed me; it has changed my life. It is also of course adventurous work, in exotic and beautiful places, and alongside wonderfully inspiring and creative host country nationals. Those things are just icing on the cake. But getting from there to here, from "What’sNew?” to “Now What?”, requires a commitment. It requires a commitment to the future of family therapy beyond what is comfortable and learn instead what it means for others on the globe who are curious and invested in doing this work, on their own terms, in their own countries, in languages other than English. It is these future professionals who will innovate ideas we cherish and use daily, who will translate our best books and articles into a languages many of us likely won’t understand, and who will create new forms of family therapy we may not easily recognize at first glance. (One of my Libyan trainees once talked about the need for a tribal family therapy model, to deal with the conflict in her country). Systemic change—in a family, in a community, in a country—does not always come out the way we think it should or how we want it to. It does not always fit our politics; it does not always feel familiar. Yet, in AFTA, we are engaged in the world, whether it is a familiar world or a strange one, because we are committed to the progressive future of family therapy. For me, that is best part of being a member of this organization. It is also the best part of the work I do: an investment in a future I look forward to.

[1] Transliterated from Arabic word meaning What’s New? Or What’s Up?

[2] p. 27 “In this paper, we have taken our cultural knowledge and biases—both tacit and known—to contexts outside the United States. There, we have had to challenge ourselves to develop new resources, reshape old ones, and think on our feet in new ways. The experiences we have had overseas have only made us better at what we do at home.

[3] Immersion courses or cultural plunges, such as that described by McDowell, Goessling and Melendez (2012), Platt (2012), and Solorzano, Castaneda-Sound, Biever & Bobele (2014) are two ways family therapy trainers have addressed these training gaps.

References

Batniji, R., Van Ommeren, M., & Saraceno, B. (2005). Mental and social health in disasters: Relating qualitative social science research and the Sphere standard. Social Science and Medicine 62, 1853–1864.

Charlés, L. L. (2014). Scaling Up Family Therapy in Fragile, Conflict-Affected States. Family Process. doi: 10.1111/famp.12107

Charlés, L. (January/February, 2005). Living and working in West Africa: A family therapist in the Peace Corps. Family Therapy Magazine. American Association for Marriage and Family Therapy: Alexandria, VA.

Charlés, L. & Piercy, F. P. (2003). Reflections on Teaching Family Therapy in Several Non-Western Countries. Journal of Systemic Therapies, 22(4), 15-28.

Cryer, Friman, Robinson, and Wilmshurst, 2007 An introduction to international criminal law and procedure. New York: Cambridge University Press.

Jacobs, G. A. (2007). The development and maturation of humanitarian psychology. American psychologist, 9, 32.

Kakuma, R., Minas, H., Ginneken, N., Dal Poz, M. R., Desiraju, K., Morris, J. (2011). Human resources for mental health care: current situation and strategies for action. Lancet, 378, 1654–1663.

McDowell, T., Goessling, K. and Melendez, T. (2012), Transformative Learning through International Immersion: Building Multicultural Competence in Family Therapy and Counseling. Journal of Marital and Family Therapy, 38: 365–379. doi: 10.1111/j.1752-0606.2010.00209.x

Patel, V. (2012). Global mental health: from science to action. Harv Rev Psychiatry, 2012; 20(1):6-12

Patel, V., Chowdhary, N., Rahman, A., & Verdeli, H. (2011). Improving access to psychological treatments: Lessons from developing countries. Behavior Research and Therapy, 49, 523–528

Platt, J. J (2012). A Mexico City-based immersion education program: training mental health clinicians for practice with Latino communities, JMFT, 38(2):352-64. doi: 10.1111/j.1752-0606.2010.00208

Platt, J. J., & Laszloffy, T. A. (2010). Critical patriotism: Confronting nationalism in marriage and family therapy training. A paper presented at the annual conference of the International Family Therapy Association, Buenos Aires, Argentina.

Rojano, R. (2004), The Practice of Community Family Therapy. Family Process, 43: 59–77. doi: 10.1111/j.1545-5300.2004.04301006.x

Solorzano, Castaneda-Sound, Biever & Bobele (2014). Developing cultural understanding through immersion experiences for mental health professionals. Unpublished manuscript.

Zarowsky, C. (2004). Writing trauma: Emotion, ethnography, and the politics of suffering among Somali returnees in Ethiopia. Culture, Medicine and Psychiatry, 28(2), 189–209.