Integrating systemic and postsystemic approaches to social work practice with refugee families

THE WORLD IS EXPERIENCING rapid changes, from shifts in political allegiances to ethnic conflicts fracturing national identities. A worldwide increase in refugees is the result. A report from the United Nations high commissioner for refugees noted that there were 17 million refugees around the world in 1991 alone (Redmond, 1991). Between February and June of that year, nearly one million people were forced to seek refuge because of civil war and famine in Ethiopia and Somalia. More than 400,000 Liberians were internally and externally displaced, and the Persian Gulf War left thousands of refugees in Turkey, Iran, Syria, Jordan, Kuwait, and Saudi Arabia. Tens of thousands of Indochinese who failed to qualify as refugees were languishing in camps throughout Asia, with 62,000 Vietnamese boat people crowding camps in Hong Kong alone. This is four times as many in 1991 than in 1990. In 1992, a new surge of refugees fled from Haiti, and the breakup of the former Yugoslavia created the current war there and thousands of refugees. In 1993, the split of Czechoslovakia, although peaceful, left persons feeling displaced in their own country. In the past several years, Jews from the former Soviet Union have emigrated en masse to Israel, the United States, Canada, and elsewhere (Barankin, Konstantareas, & de Bosset, 1989; Flaherty, Kohn, Levav, & Birz, 1988). It can be said that the European Community and North America have become magnets to impoverished peoples of the east, south, and southeast parts of the globe. Yet as recession and unemployment have risen in the West, nations there have increasingly established caps on immigration. Although movement of refugees has slacked off in some parts of the world and some repatriation is occurring in Central America, Cambodia, and Vietnam, many parts of the world have witnessed an increase of refugees and a parallel crisis in meeting their needs (Redmond, 1991). The tragedy in Rwanda is the latest case in point.

This worldwide increase in refugees represents an important concern for social work practitioners as well as for policymakers and politicians. These refugees are at risk for mental health and family problems. In the United States, studies have found that the Southeast Asian refugees who poured into the country in the late 1970s and the 1980s often lived in inner-city poverty (Hoshino, Bamford, & DuBois, 1987); suffered psychiatric problems at a higher rate than the general population (Westermeyer, 1986); and had a higher incidence of marital and family problems, including family violence, than did the general population (Ben-Porath, 1987; Butcher, Egli, Shiota, & Ben-Porath, 1988). Similar physical and emotional problems and high levels of post-traumatic stress symptoms have been reported in refugee populations resettling in the United Kingdom (Moodley, 1990), Australia (Reid & Strong, 1987), and Canada (Barankin et al., 1989). Refugees suffer more problems than do other immigrants: hardship and torture in their own countries; lack of choice or planning in leaving; culture shock, racism, and language barriers upon arrival (Hoshino et al., 1987; Reid & Strong, 1987).

Thus, the need for interventive social work services has been documented worldwide. When a country offers sanctuary to displaced and persecuted people, that country has a responsibility to support and care for those people. In offering services, the receiving countries enable their new citizens to become productive and well functioning. As noted by Reid and Strong (1987), without early intervention the future is bleak for these individuals and future generations. Reid and Strong note that the literature on post-World War II European refugees showed psychiatric disturbances peaking after a decade in their new countries. Such disturbance is likely to affect the development and future functioning of their offspring (Ben-Porath, 1987; Reid & Strong, 1987). Appropriate clinical services need to be available as well as the necessary concrete services and social supports.

What kind of clinical services should be offered? Reid and Strong (1987) noted that psychotherapeutic work with refugees must involve their families as well as their legal, social, and economic situations. The refugees' cultural background and the effects of trauma need to be understood by the therapist. Others have observed that uncovering therapies are not as useful for this population as are problem-focused approaches (Butcher et al., 1988; Lappin & Scott, 1982). Aponte (1991) stressed the importance of training social workers and other therapists to work with the poor and oppressed groups in general. He noted that few therapeutic models address social ills together with emotional problems. Traditional, insight-oriented therapy is not the most useful therapeutic approach for these individuals and families in crisis.

A previous project tested the applicability of a family-systems approach to working with Southeast Asian refugees and found it useful (Cheung & Canda, 1992; Kelley, 1992). This article explores ways in which postsystemic approaches may be integrated with systemic approaches for work with a wider range of refugees.

The realities of today's practice call for a culturally sensitive model that is applicable to diverse groups of people. The model presented here argues for the usefulness of integrating postsystemic approaches (constructivist and narrative) into systemic ones. Although many postmodern theorists have turned from systems thinking, believing its ideas cannot be integrated into newer narrative models, such integration is possible because both models have concepts useful for work with refugees and underlying commonalities that can be isolated. The theories and their application to the refugee population are discussed separately, after which an integrated model is proposed.

FAMILY-SYSTEMS APPROACHES

Systemic therapies are especially useful with refugee populations because behavior is viewed in context, with the focus on problems arising from interaction between systems rather than on problems situated within a person. As noted by Lee (1982), migration disrupts individual and family life cycles, and restoring the unit to its previous functioning is desired. Many refugees suffer post-traumatic stress syndrome, and goal-oriented, concrete intervention is the treatment of choice (Lappin & Scott, 1982). Emphasizing short-term therapy for mobilizing strengths (Minuchin, 1974), interrupting negative interactive sequences (Haley, 1976), and taking into account familial and community factors (Aponte, 1991) are useful attributes of systemic thinking. However, a strict cybernetic view of behavior as regulated by a system of equally interacting parts has not been as useful and has failed to recognize the individual (Nichols, 1987) as well as the unequal power differential between and within systems (Cottone & Greenwell, 1992).

The several therapeutic approaches classified under the "family systems" heading share common theoretical bases, assumptions, and therefore can be integrated (Keeney & Ross, 1985; Papp, 1983). Family-systems theory explains human behavior as a logical part of family and community systems, consistent with the cultural beliefs of many refugees (Canda, 1989). Its emphasis on biopsychosocial factors parallels social work values and practice (Kelley & Jackson, 1987). Systems theory recognizes that various factors interact, but the focus of intervention is directed more toward interpersonal factors than intrapsychic factors, toward problem resolution rather than uncovering unconscious motivations. This problem-focused approach is less intrusive and is especially appropriate for refugees who suffer from post-traumatic stress syndrome.

An aspect of systemic approaches that is especially useful for working with refugees is their parsimonious design. Too much change, too fast, is stressful for persons who are already coping with rapid change. Maintaining stability while acclimating to change is important. Ideally, a change in one part of the system ripples out to other areas at a rate that allows members to adapt. With refugee families, it is generally useful to concentrate on concrete services and social support first, followed by psychological intervention aimed at supporting the resolution of immediate problems.

The integrated systemic model developed for the Southeast Asian Project noted above was instituted by the University of Iowa School of Social Work and funded by The Bureau of Refugee Programs, Iowa Department of Human Services. In that project, structural, strategic, life-cycle, and Milan systemic approaches were applied to a refugee population (Kelly, 1992). Contextual and life-cycle factors were noted during the assessment phase by means of genograms (Carter & McGoldrick, 1988; McGoldrick & Gerson, 1985) and eco-maps (Hartman & Laird, 1983). The genogram, which highlights family generational patterns, is especially useful in understanding families from other cultures by highlighting past and current relationship patterns. Eco-maps assess the family system's connections in the community, noting sources of strength and stress in the social network. Lee (1982) noted the importance of the family unit and community connections for Asian families. Eco-maps and genograms help therapists understand family structure, encourage cooperation, require fewer language skills, and view the family's current situation in context. For example, in the Southeast Asian Refugee Project, a genogram was drawn for a depressed single mother with several children. Her eldest son was out of control and in trouble with the law. The genogram served as a visual aid that helped circumvent the woman's minimal skills in English and highlighted the woman's extreme isolation (Kelley, 1992).

Useful therapeutic skills drawn from the strategic school (Haley, 1976), which were noted in the refugee project, include obtaining a clear and solvable problem definition from the client and minimal intervention aimed at interrupting the problem sequence. Lappin and Scott (1982) noted the importance of clear, concrete, goal-oriented therapy for Vietnamese refugees. Moreover, Lee (1982) stressed that culturally sensitive intervention with Asians avoids "talking" therapy and discussion of morbid thoughts but rather focuses on symptom relief. With the depressed client in our project mentioned above, the mother specified that she wanted us to "straighten out" her son, who was negatively affecting her other children's behavior and not showing respect for her.

The Milan systemic school (Boscolo, Cecchin, Hoffman, & Penn, 1987) emphasized meaning as well as intervention based on a systemic hypothesis. The hypothesis is aimed at viewing a system that makes sense in context as a solution to a problem. The Milan school's emphasis on understanding the meaning that clients attach to events is an important aspect of therapy that has been underemphasized by other schools. It leads into the newer postsystemic therapies. This emphasis is especially important in understanding people from different cultures. Circular questioning, a technique elaborated by the Milan theorists to help elicit meanings, laid the foundation for the narrative approaches. Family members are asked to comment on differences and degrees of closeness in their relationships; additional questions are asked in response to their discussion. This technique helps the therapist understand the situation from the family's perspective rather than try to fit behavior and events into a preconceived framework. Through these culturally sensitive discussions, family members begin to see other ways to understand a situation, which creates momentum for growth.

With the project client noted above, circular questioning was minimal because of language difficulties. Systemic hypotheses, however, proved useful in developing a treatment plan. It was hypothesized that the son's acting-out behavior and noncompliance maintained helper involvement in the family, which decreased the mother's loneliness. It also reinforced the cultural norm for the male to be in charge of the family, but ran counter to the cultural norm for the parent to be charge of the offspring. It was further hypothesized that the family hierarchy was reversed by the children's learning the language before their mother did; they thus accumulated power in the family.

The emphasis on hierarchies in the structural approach, originally developed by Minuchin (1974), may not be useful across all cultures, but it was found to be helpful in the Southeast Asian Project. Lappin and Scott (1982) and Lee (1982) noted the importance of hierarchy in Asian families, which is consistent with our experience. Refugee family hierarchies are often reversed as a result of the children learning the new language and culture faster than do their parents. The childrens' new ways of acting and relating are not consistent with their parents' views or cultural values. Parents feel a loss of control with and respect from their offspring and need help in regaining control in the family. With the project family client, the main intervention consisted of restructuring family boundaries. The eldest son was asked to assert his authority with the younger children by enforcing his mother's rules and by being her helper. This plan gave the mother an ally and recognized the son'S authority by having him become second in command. It also eased his transition from child to adult.

Aponte (1991) presents an ecostructural approach--a modification of Minuchin's work. This approach was developed for work with poor and minority populations in general and is especially relevant for work with refugees. Aponte stresses that this therapy must deal with the immediacy and concreteness of the problems, the family's structural organization, the values of the family and its community, the family's community resources, and the links between the family and the community. In using structural approaches, the practitioner should not assume one right structure or hierarchy for all families, but rather should understand the family's view regarding how families should be organized.

Some common elements of systems approaches found useful in the Southeast Asian Project include the following: short-term intervention; focus on presenting problems as defined by the client; assessment rather than diagnosis, with no assumption of pathology (although in cases of extreme mental disorders, referrals may be made for medical treatment as a supplement to therapy); search for and emphasis on strengths; viewing behavior in context; and deemphasis on causality. The systemic concepts of equifinality and equipotentiality--that same beginnings can have different endings and that same endings can have different beginnings--are important ideas for persons beginning a new life in a new place. The systemic approaches noted here are also consistent with the newer postsystemic approaches.

POSTSYSTEMIC THERAPIES

The postsystemic theories addressed here fall under the general heading of constructivism. Whereas systemic theory is based upon cybernetic theory, constructivist theory is built upon second-order cybernetics, in which reality is believed to be constructed in the mind of the client and in interaction with others, including the therapist. Clients' perceptions of events and their meanings are expressed through narratives (stories). With postsystemic approaches, change occurs through client-therapist "coauthoring" of stories through their dialogue. As with the systemic schools, related postsystemic approaches share some common assumptions and can be integrated. In this article, the works of Hoffman (1990), Anderson and Goolishian (1988), Tomm (1987), de Shazer (1991), and White and Epston (1990) are used to develop a practice model.

In ethnic-sensitive practice, it is especially important to understand reality as it is constructed by the client. The narrative approach of White and Epston (1990) and the solution-focused approach of de Shazer (1991) are useful in dealing with persons who have been victimized or have suffered trauma. Borden (1992) discussed the usefulness of the "narrative perspective in psychosocial intervention following adverse life events" (p. 135), which is pertinent to refugees suffering from post-traumatic stress syndrome. He discussed how stories help organize experience and interpret events and how one's sense of "coherence and continuity may be taxed beyond adaptive capacities" (p. 135) following extreme adversity. He advocated a brief psychotherapy model for the treatment of post-traumatic stress syndrome disorders and other stress-related disorders to help clients regain previous levels of psychosocial functioning. In his brief therapy, a narrative approach is combined with other problem-solving efforts, educational strategies, and provision of resources. Clients are encouraged to tell their stories and then make sense of them by looking at other life events, perceptions of self and others, and inner resources. A central task is the incorporation of the adverse event into the ongoing life story by which the client understands the past, experiences the present, and anticipates the future. The therapist helps the client develop a progressive narrative, characterized by movement toward goals rather than a regressive narrative characterized by movement away from goals.

In a similar vein, Wynne, Shields, and Sirkin (1992) discussed illness as narrative in family theory and therapy. The experience of illness quickly becomes part of a transactional, relational narrative. The illness creates role disruption, whereby family caretakers and later professional caretakers become involved, creating a transactional narrative in which reality is co-constructed (White & Epston, 1990). Wynne et al. (1992) stress the importance of externalizing the illness to perceive it as "afflicting the self" (p. 12), not constituting the self. A problem perceived as outside oneself becomes more manageable.

Dolan (1991), in her work with survivors of sexual abuse, helped clients define themselves as something other than "survivors." Events that occurred in the past are not solvable. Dolan states that having clients continually retelling their stories without a corrective experience revictimizes them. She encourages clients to recognize the past but to keep their stories more future-oriented.

Just as it is not useful for clients to develop their identities solely by reference to their illness (diabetic, schizophrenic, alcoholic) or by their past victimization, developing an identity on the basis of adverse political, cultural, or societal events is not helpful either. If people perceive themselves as "refugees" rather than as persons who have survived a refugee experience, their personal narrative becomes problem-saturated, leading to a "stuck" position that may be reinforced by other helpers.

White and Epston (1990) developed a narrative approach that is useful in applying the principles discussed above. They view therapy as having two stages: the deconstruction stage, in which the dominant, problem-saturated stories are deconstructed, and the reconstruction stage, in which alternative stories based on other truths are developed. The truth of the dominant story is not challenged, but other "realities" from which the client may draw are added to the repertoire of experiences remembered. The corrective experience is built into storytelling by careful listening and questioning. People "story" their lives; that is, they arrange their life events into sequences to develop a coherent view of self and to ascribe meaning to their experience. Because it is impossible for a narrative to encompass every life experience, the narrative structuring is a selective process. People prune certain experiences that do not fit into the dominant story line and remember events that support it. Sometimes experiences are even imagined to fill in the gaps.

Experience that falls outside the dominant story is called subjugated knowledge. Many presenting problems fall within the dominant story. To help clients deconstruct the story, White and Epston (1990) carefully listen to understand it, establish a time frame to create a history, externalize the problem to separate the client from it, and map the problem's influence in the client's life. Through careful listening for "unique outcomes" or differences in parts of the stories--similar to what de Shazer (1991) calls "exceptions"--White and Epston (1990) help the client resurrect subjugated knowledge. This self-knowledge helps clients "restory" their lives by developing other true stories, thus allowing them alternative ways to view their lives, which helps clients see options and allows them the power of choice. In these constructivist views, the unpleasant realities of violence, poverty, or other adverse experiences are not dismissed as constructs of the mind; instead, the meanings and power given to these events are challenged. Through expanding self-knowledge, clients empower themselves to fight the effects of the trauma and develop their strengths.

In a case example from the Southeast Asian Project, a severely depressed single man from Cambodia had suffered loss of family and status and was lonely. He was not able to focus on a presenting problem but wanted to talk about his losses and resulting depression. Although the systemic approach helped this client cope with his life, if narrative approaches were known then, his depression may have been reduced further. Using such an approach, the practitioner would have focused on listening for and mobilizing the strengths the man had shown in surviving the trauma as well as on listening to the man's stories of success before he was a refugee.

AN INTEGRATED PRACTICE MODEL

As problems with systemic theory emerged, some practitioners and theorists looked to other approaches. Cottone and Greenwell (1992) suggest that it is time to rework and refine systemic concepts, rather than discard all of the ideas, even those that have proven useful. It is important to isolate and underscore the many commonalities between the systemic and postsystemic schools and to integrate their concepts. The integrated model presented here contains useful aspects of systemic therapies and emphasizes meaning and understanding through the use of narrative approaches. Although this model may be useful for many practice situations, it was developed specifically for work with refugees. However, the model is theoretical and has not been field tested with this population.

In this integrated model, common features of both schools include the contextual view of behavior, stressing how interpersonal and societal forces help shape problems; brief intervention, focusing on the immediate problem as defined by the client; mobilization of strengths; and attention to the client's interpretation of events and meaning as well as the events themselves. During the assessment phase, more emphasis is placed on social history than on psychological tests and mental-status exams. Both have been questioned for their lack of cultural relevance (Westermeyer, 1986). Similarly, standard intake forms often are not cross-culturally sensitive. The standard social history used by social workers, however, is easily adapted to work with refugees because it is similar to the narrative approach, wherein clients are asked to tell their story and define the problem as they see it. As with most social work interviews, careful listening and questioning are important. The circular questioning techniques of Boscolo et al. (1987) are especially appropriate when working with families and eliciting ideas and meanings from family members.

The solution-focused approach (de Shazer, 1991) asks clients to look at how things would be without the problem and then assesses when that is happening already. The problem is defined as something occurring in the here-and-now that can be changed in the future, thus allowing the focus to be shifted from the problem to the solution. The problem is externalized to separate it from the client and to make it more manageable. Then scaling questions, such as "how often" or "how bad," and relational questions, such as "who is bothered the most" and "what affects whom," are asked. Listening carefully for "exceptions" (de Shazer, 1991) and "unique outcomes" (White & Epston, 1990) is consistent with the systemic concept of searching for strengths (Minuchin, 1974; Boscolo et al., 1987). Clients might be asked, for example, how they are able to fight depression some of the time or how they control their children well in certain situations.

This search for strengths can help the social worker and the client assess past losses in a different way. Refugees may have been of higher social and professional status before their move. Instead of viewing this only as a loss, they can be encouraged to carry their pride with them and talk about their past achievements. Similarly, they can preserve the love they have for those left behind and cherish the memories of those persons. Also, telling stories about past achievements and relationships can reveal sources of strength by offering clues that may be used in problem solving and that offer hope for the future. Another value of storytelling for migrating peoples is that it helps maintain a sense of the culture left behind and to pass that sense on to the next generation. This feeling of continuity can be healing in itself. Thus, the model described here recognizes that clients carry the solutions to problems within themselves and is sensitive to clients' beliefs and values.

Storytelling can uncover sources of strength, but obstacles to storytelling may occur. An obvious problem is that refugees usually do not have a high level of skill in their new country's language; thus their stories may lose some meaning through oral translation. One way to overcome this problem is to ask clients to write their story in their own language at home. The translator can then take time to write out the message, carefully assessing meanings. As a result, discussions in sessions are easier for translators to explain. Genograms and eco-maps are useful in this regard, too. These visual tools require less language skill, are easier for translators to explain, and help social workers understand and "see" the client system from the client's viewpoint. The genogram also helps define who is in the family. Standard intake forms in the United States tend to view family more narrowly than it is viewed in other cultures. For example, in Asian cultures, the term cousin may refer to a close friend or relative and family may include members of the community who are not related by blood.

After clients have defined their immediate problem, narrated their stories, and visually shown their extended family and community through genograms and eco-maps, they can assess where they want to go and how they want to get there. Strengths can be drawn upon, subjugated knowledge about self can be brought out, and alternative stories can be developed. If clients see options, they may also see ways to attain their goals. Therapists may offer an occasional suggestion, modify the structure, interrupt a sequence, or help access community resources, but clients mobilize their strengths to solve clearly defined problems.

Short-term clinical interventions that help clients solve immediate problems are useful because clients regain their previous level of psychological functioning. As problem sequences are discussed, the stories are repunctuated to help clients focus on their strengths rather than their weaknesses. Solutions come into better focus. Small changes can ripple out at a rate to which the client can adapt. These interventions should be combined with clients' indigenous support structures and the helpers in their respective communities. The social worker is in and out quickly, allowing the natural support systems to continue the efforts.

SUMMARY

A worldwide increase in refugees has meant many more persons at risk for mental health and family problems. As refugees from many cultures seek assistance from general service providers, clinical social work approaches that are culturally sensitive but do not require in-depth understanding of a particular culture are needed. The culturally sensitive model presented here was developed for application to refugee families.

Some constructivists believe that systems concepts should be discarded and that these newer views cannot work in conjunction with systemic concepts (see Cottone and Greenwell [1992] for further discussion of this point). In this article, however, an attempt was made to demonstrate how these concepts can be integrated. In addition, the point is made that a combination of these two approaches can benefit a wider range of refugees than can either approach by itself. Last, the commonalities of the two approaches are underscored and an integrated model is presented.

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Patricia Kelley is Professor, School of Social Work, University of Iowa, Iowa City, Iowa. This article was adapted from a paper presented at the American Association for Marriage and Family Therapy 50th Anniversary Conference, October 17, 1992, Miami Beach, Florida.

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