An Interview with Rainela Xhemollari, Family Therapist in the UK
The challenges of providing family therapy services during complex emergencies or humanitarian settings, such as those which may be found in a post conflict state, increase exponentially—in both quality and quantity—in ways that can be strikingly confounding, even for the most seasoned of family therapy practitioners. Post conflict states, also identified as fragility, conflict, and violence-affected states, are places in the world in a time of transition between war and peace. They are characterized by conditions that can be traced to, as the World Bank Group once put it, either a severe and long-lasting conflict, a short, intensive conflict, or the creation of “a newly sovereign state that has emerged through the violent break-up of a former sovereign entity” (as cited in Khalil, 2013).
From Charlés, L. L. (2015). Scaling up family therapy in fragile, conflict-affected states. Family Process, 54(3), 545-58. doi: 10.1111/famp.12107
“Humanitarian mental health projects are delivered within fragile, conflict-affected states in part because psychosocial needs are a part of public health and well-being that are seen as owed to every person as a result of international law (Cryer, Friman, Robinson, & Wilmshurst, 2007). Conditions in fragile, conflict-affected states often put citizens’ mental health and psychosocial support needs at risk. Yet, it is a challenge to identify relevant and appropriate needs in such settings, precisely because of the dynamic nature of their ongoing crises (Batniji, Van Ommeren, & Saraceno, 2005).”
Providing a public health service, such as systemic family therapy sessions (or a differently named version of it), in these places is as important as it is challenging. Not surprisingly, the conditions in fragility, conflict, and violence-affected states are the subject of robust research and analysis across disciplines. They are also increasingly the subject of training initiatives, requests, and plans in the field of systemic family therapy. Delivering family therapy services, like any public mental health initiative taking place anywhere on the globe, requires some clear essentials, two of which are: people (to do the work) and political will (to finance it). Yet, in fragile, conflict, and violence-affected states, such ‘clear essentials’ may quickly become unwieldy.
In addition to casualties—wars and violence destroy infrastructure and the institutions that sustain a society, such as the rule of law, health care, and the educational system. Violence also leads to long term physical, social, and psychological effects among survivors who have lost family members, those who no longer have the means to sustain their livelihoods, or who have experienced amputation, disfigurement, displacement, torture, abduction, sexual violence and disease (Phama, Vincka, & Weinstein, 2010, p. 98).
Negotiating the complexity of international incidents—such as war and conflict—that put families lives at risk across the globe require us to bring our best systemic hearts and brains to the table. How does one organize the provision and delivery of family systems focused mental health services in a humanitarian setting? What is an appropriate and realistic objective for delivering Mental Health and Psychosocial Support (MHPSS) in this context? How to meet those objectives given resource constraints and multiple challenges of delivering services within these settings? What is it like to do this work?
From “vulnerable populations” to “fragile, conflict-affected states”
About five years into my career, after I’d earned my doctorate in family therapy, I started working intensely with what we would call in the U.S. “vulnerable populations,” i.e., torture survivors and asylum seekers. Often, these asylum seekers and torture survivors were French speaking, and from West Africa. This was not really a coincidence. I had lived in West Africa as a Peace Corps volunteer shortly after earning my doctorate at Nova Southeastern University in 1999. By the mid-2000s, I was traveling as a family therapist to work in several countries in West Africa, training host country nationals and residents in the delivery of family-focused MHPSS services for vulnerable populations. Also not coincidentally, my doctoral research at NSU had been a qualitative analysis of large-scale crisis intervention—a hostage situation at a high school. Looking back, I can see now how that research experience has served to enhance my work in complex emergencies. Today, I continue to do work in fragile, conflict-affected states, with my most recent work contracts involving family therapy training in the Occupied Palestinian Territories and in Bishkek, Kyrgzstan. It was on one of my early trips as an international trainer that I first met Rainela, the family therapist in the UK whom I interviewed for this article.
A book with transcripts of interviews with war sexual abuse survivors, including their paintings and illustrations of trauma, mental health symptoms, suicidal ideation, and stories of their survival. Project photo provided by Rainela Xhemollari
Introducing Rainela Xhemollari, a Family Therapist in the UK
Rainela and I first met in the UK, in 2008, when she was a family therapy master’s student. Now qualified as a family therapist in the UK, Rainela had attended one of my presentations at the University of Bristol, given while I was on leave from an MHPSS project on another continent. Currently immersed in her doctoral research on how systemic family therapy makes sense in an Albanian context, Rainela contacted me a couple of years ago about an international training project she had begun in the Balkans. She graciously agreed to talk to me about it for Family Therapy magazine. We spoke several times about it, via WhatsApp and Zoom, and in subsequent email text conversations. The following interview has been condensed and edited by both of us.
Laurie: Can you tell us a little bit about your background, your work as a family therapist in the UK, and how this project started?
Rainela: I’m Rainela Xhemollari and I’m an Albanian-born family therapist, trained in the United Kingdom. I have practiced family therapy exclusively in the UK until last year. Early in 2021, I received a request from a Kosova non-governmental organization (NGO) for some ideas on how to use Score-15 (SCORE-15 Index of Family and Change; Carr & Stratton, 2017) for a family interventions project. The family interventions that the NGO wanted to put in place were part of a wider study that they were doing with the support of an NGO from Denmark, and with the funding provided by the British Embassy in Kosova. Their target group was women who have suffered sexual violence during the 1997-1998 conflict. They were looking to address the transgenerational trauma that’s left in families of the victims in question.
As you read through this article, you will notice difference spellings of “Kosovo” and “Kosova.” In comparison, this past summer, the United Nations accepted the change of the public/international name of Turkey to Türkiye. Kyiv, until recently, was known as Kiev as this was the name given by the occupier. In this case, Kosovo was not only the name given by the occupier, but also spelled according to their linguistics. US, UN, and international acknowledgement of the name is Republic of Kosovo, but ethnic Albanians feel strongly that the correct way to say it is “Kosova.”
Laurie: How did you become engaged as the trainer for the project?
Rainela: The reason why they contacted me is because I had translated Score-15 from English to Albanian, as part of a wider project of the to translate this psychometric measure in many languages—European languages but also including languages outside Europe. So, they wanted some ideas on that. However, what emerged in our conversations that followed is that I was the best placed person to deliver the actual training for the family interventions. After multiple conversations, we ended up devising a program that would be the equivalent of what in Europe is the first year of systemic training, including supervision. Training was delivered in Pristina and other cities in Kosova and was held from May 2021 until the end of January 2022. The supervision continued until July 2022.
Laurie: You worked with several partners and organizations to devise the program and collaborate on its implementation.
Rainela: My collaboration with the Dutch Family Therapy Association meant that I went through a process of accreditation with them where I had to display everything that I was doing, answer their questions, and provide evidence of how the course was meeting accreditation criteria, which it did eventually meet. The Dutch Family Therapy Association is a member of the European Family Therapy Association de facto, so this meant that the course had a European accreditation.
The accreditation gave my words and my requests for supervision to the management of the NGO and those who were funding the study a different sort of context. And it’s really important for this to be read in as realistic a way as possible.
This is the life we live. We need evidence. We need documentation. It’s not part of goodwill, developing trainings. You know, developing systemic provision in a country is not about “goodwill.”
And let’s not forget that at the heart of all this lies the fact that Kosova is an entity that depends on others to fund this kind of initiative. As such, a training has to be credible to the donors. And for this, I worked a lot with my doctoral research supervisor, Dr. Robert van Hennik, a Dutch family therapist, to look into the degree or the quality of the training and whether it would meet criteria for accreditation from a European Institute.
From Charlés, L. L. (2015). Scaling up family therapy in fragile, conflict-affected states. Family Process, 54(3), 545-58. doi: 10.1111/famp.12107
“Professionals who work as international subject matter experts in these projects must bring and use their expertise in ways that are credible and useful to the people they are focused on helping (Roberts, 2010). However, they must also bring an enhanced capacity to contextualize suffering of the clients, supervisees, or trainees they work with (Madsen, 2014), and they must do this in relation with the broader political and economic factors in the country (Batniji, Van Ommeren, & Saraceno, 2005; Zarowsky, 2004).”
Project photo provided by Rainela Xhemollari
Laurie: What did it look like when you were there in the ‘day to day’ of the training?
Rainela: Devising the training meant that I took ideas from the needs of the of the population, according to the NGO that had worked with them for 20 years. The needs of these families were related to problems that predominantly mothers were bringing; mothers who had been victims of sexual violence. Also, my knowledge as a trainer, of what consists of a systemic training. What are the basic ideas, the main schools of systemic theory, and practice? Another problem that they brought forth was parenting issues and the parental role of the mother, who was, in their words, “carrying the trauma.” And then, my own ideas as a systemic therapist.
I believe strongly in not being organized by the program; not being organized by diagnosis. The professionals I was about to train were mainly psychologists, but also medical doctors, as well, as social workers. It’s a group of roughly 13 to 15 people and they had been working in this NGO and they had received numerous trainings with regards to trauma, domestic family violence, and other problems that were pertinent to their target population, but always from an individual perspective. Just as their work was individually focused, their clinical understanding was very much problem-organized or oriented. And a point where we got a little bit stuck with each other was that I went there to deliver the training, and they were looking for a manual. This was how previous trainings had been organized. I belong to, I believe, the majority of family therapists, who don’t believe in the manual, per se. There are ways to organize one’s work. That’s undeniable. But not in a manualized approach, necessarily.
Laurie: This is both a historical and ongoing contemporary debate in the field about the art and the science of the systemic therapy process; when it’s being implemented as a clinician or a trainer. Some people see the art of it as a challenge and some people the science as the challenge. How did you, as a trainer, when you’re with these new folks trying to learn and who are accustomed to a certain way of learning—how did you deal with that?
Rainela: The first exercise was to split them into groups. I asked for one group to identify the systems that they belong to, to just identify through a conversation while the other group was listening. And as the other group was listening, they were writing down a list of all the systems where they belonged. They had to ask themselves: How do we know that I’m a part of a system? What are the criteria to be part of the system? How have they been announced to us? How are they known? You know, if you’re part of the neighborhood, how was that defined? But kind of looking at it a bit, into how are these things shaped in said or unsaid ways? I think the first day was somewhat fascinating for them, seeing through the systemic lens, but all of this was happening in their language, Albanian. Back home, a vast majority of training is delivered in English, or other languages, but mainly in English.
Laurie: My most recent trainings across the globe have involved simultaneous translation. In many cases, I have an interpreter who is very, very good. And even if I had a number of trainees who speak English in the training, we’re working in a third language that the trainees have in common, Arabic or Russian, for example. And, you know, in any training in any language, there’s always translation issues, and transliteration and interpretation issues. But in multilingual trainings, I’m often confronted with establishing trust with trainees without relying on language to do it. I want to ask you more about language. First, in what language did you do the training? What languages do you speak?
Rainela: I delivered the training exclusively in Albanian and the Powerpoint slides were in Albanian, but, of course, I didn’t have any academic material in Albanian, so, I used English. I speak Albanian, Greek, English, Italian, and Spanish.
Laurie: Was it easier for you, knowing Albanian?
Rainela: It was and it wasn’t. I’m Albanian born and I was educated from year two to five of my life in Albanian. Then I moved to Greece. All my education, up to earning my BSc in Social Work, was in the Greek language. I then moved to the UK, and all my education, predominantly family therapy education, has been in English. So, there was a lot of work with myself beforehand in terms of what I was doing in PowerPoint. I talked to many colleagues from psychology and other disciplines, Albanians, trying to find ways to get around terminology. I also advised participants to give me ideas on whether words were making sense to them; words I had chosen as the right translation of systemic terminology. Understandably, the standards on an operational level were not at the highest; we didn’t have a Course Book (Handbook) in Albanian before starting the course, for example, or we didn’t have a framework of service delivery as family therapy is unknown in those territories. The latter is an important obstacle for sustainability of learning in terms of international training.
Laurie: You raise another important point—how much of the field of family therapy is narrated in English. I just came back from Kyrgyzstan, where I was doing a training with folks who are from Kyrgyzstan, Uzbekistan, Tajikistan, and Kazakhstan; their common language is Russian. My co-trainer and I did the training in English, which was interpreted in Russian through the use of simultaneous interpretation by two UN interpreters. The training materials and documents had already been translated into Russian—a minimum requirement in a project like this—and the Russian version of the Powerpoint was up on the big screen, which was great. But what I have found in many family therapy trainings across the globe is that a number of trainees catch the family therapy “bug” and want to learn more after the training. They want to immerse in the ideas. But where’s the body of literature we can share with them in the language they use with clients? One set of PowerPoint slides is great, but not enough.
Rainela: In my case, looking back on the training, there was also a huge power dynamic shift in the group itself, because not everybody among the 15 participants had the same command of English. Although these trainings were delivered in English, and theoretically they understand English, not everybody has the same command of the language. So, whatever new ideas I was describing, I would always connect it through a roleplay to what it looks like in action . . .
I made sure to have examples of Albanian language and the systemic ideas, but from our own folklore, our songs, our poetry; the systemic existence in Albanian context. And that was a good connection. It brought a lot of emotional conversations as they were bringing the experiences of the survivors of that atrocity. But also, I must say, I was 17 when the conflict happened. I was very young. It wasn’t easy, emotionally, I must say. But it also brought us close as a training group. It also increased my understanding of the importance of such training to be delivered in the local language.
Laurie: You’re an insider, as an Albanian or person speaking Albanian, at the very least, even if you’re new to the group and new to Pristina. But you are an outsider, too, because of where you work and live and your systemic personhood that you are bringing to the table. How did you negotiate all these identities, professionally, and personally, and having experienced the atrocity on the telly when you were 17? There are probably not a lot of 17 year olds around the globe were aware of what was happening in Kosovo in the way that you were.
Rainela: I was 17 when the war erupted in Kosova. I was in Athens. Greece is a country historically affiliated with Serbia. What the Greek media were saying at the time was very much against the Albanians. So, I experienced that war very painfully, as you would experience someone you know, speaking about your suffering relative, your suffering mother or sister or brother or father. That’s how I experienced it. And I am not ashamed to say that when I entered the country to do the training, I entered the country with tears. I entered the country with tears because there was an eruption of joy that they were free. When I heard the stories in the training, I actually shed many more tears. At the end of day two, some tears were in front of the participants; something that you wouldn’t imagine doing, you know, in the West. You would hold it. But no—I couldn’t hold it. And I left those first two days of training, crying all the way on my trip back to my city in Albania. You can also imagine my emotional investment, wanting to do the training the best way possible. I didn’t want to just check a box; go there and give them some techniques. Give them some questions to ask the family and get on with it. I wanted it to be, and my fellow colleagues and trainers wanted as well, for it to be the best. There was a huge, emotional investment which I had then to work on in my own supervision, so it doesn’t cloud, doesn’t become hindering, but instead becomes a motivational factor.
From Charlés, L. L. (2015). Scaling up family therapy in fragile, conflict-affected states. Family Process, 54(3), 545-58. doi: 10.1111/famp.12107
“As an investment in host country nationals, who are typically the beneficiaries of such projects, technical training in family therapy and mental health and psychosocial support can contribute to a population’s psychosocial well-being. The increased production of mental health services is seen to benefit the overall economic potential of the country (Andrimihaja, Cinyabuguman, & Devarajan, 2011) and a country’s stability and security. A useful role for outside subject matter experts in such projects is to enhance technical capacity and perform supervision, which increases both access and availability of psycho-social services among host country nationals already in the field (Patel, Chowdhary, Rahman, & Verdeli, 2011).”
Rainela Xhemollari, at the training described in this article. Photo provided by Rainela Xhemollari
Laurie: One final question: What is the systemic skill, or idea, that you found most helpful in your effort to do the work on this project? Is there something specific you can name?
Rainela: I think it is very much the difficulty, as well as the benefits and the experience of sitting with a curiosity. Now, in the space for things to unfold, for the multi perspective/multiple perspectives to be brought in; you need to maintain your curiosity. The risk of “I know” was very high, that is the culture—they wanted me to have the answers, because that is what trainers do. But that is not the systemic approach. There’s curiosity! The belief that family therapists have that curiosity is not uncertainty; curiosity can be safe; curiosity is a process; curiosity is a resource.
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Laurie L Charlés, PhD, is a licensed marriage and family therapist and an AAMFT Professional Member holding the Clinical Fellow and Approved Supervisor designations. Over the past dozen years, she has delivered family systems training and supervision support in humanitarian contexts in multiple countries, including in Syria, Libya, and Lebanon; in the Central African Republic, DRC, Burundi and Cameroun, and in Guinea, West Africa during the EVD2014 outbreak response. Her most recent consultations have been as an international trainer for the United Nations Office in Vienna, working to deliver the UNODC Treatnet Family package to practitioners in Central, South, and Southeast Asia, and as a consultant to create a grassroots toolkit for practitioners engaged in Transitional Justice and Reconciliation Initiatives in Sri Lanka. She has twice been a Fulbright scholar: in 2017-2018 as a Fulbright Global Scholar Program Fellow in Kosovo and Sri Lanka, and in 2010 as a U.S. Fulbright Scholar in Sri Lanka. She holds a PhD in Family Therapy from Nova Southeastern University and an MA in International Relations from the Fletcher School of Law and Diplomacy. She is author/editor of seven books, most recently International Family Therapy: A Guide for Multilateral Systemic Practice in Mental Health and Psychosocial Support (2021, Routledge).
REFERENCES
Andrimihaja, N., Cinyabuguman, M., & Devarajan, S. (2011). Avoiding the fragility trap in Africa. Policy research working paper 5884. New York: The World Bank, Africa Region.
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.
Carr, A. and Stratton, P. (2017). The Score Family Assessment Questionnaire: A decade of progress. Family Process, 56, 285-301. https://doi.org/10.1111/famp.12280
Charlés L. L. (2015). Scaling up family therapy in fragile, conflict-affected states. Family Process, 54(3), 545-58. doi: 10.1111/famp.12107
Cryer, R., Friman, H., Robinson, D., & Wilmshurst, E. (2007). An introduction to international criminal law and procedure. New York: Cambridge University Press.
Khalil A. A. (2013). Contracting out health services in fragile states: Challenges and lessons learned. Webmed Central Public Health, 4(1), WMC003875 doi: 10.9754/journal.wmc.2013.003875
Madsen, W. (2014). Taking it to the streets: Family therapy and family-centered services. Family Process, 53, 380-400.
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.
Phama, P. N., Vincka, P., & Weinstein, H. M. (2010). Human rights, transitional justice, public health and social reconstruction. Social Science and Medicine, 70, 98-105.
Roberts, J. (2010). Teaching and learning with therapists who work with street children and their families. Family Process, 9(3), 385–404.
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.
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