It's like a really big pimple, where it's there but you don't want to point it out. You hope the other person doesn't point it out. — A 21-year-old interview participant offered this metaphor to describe his experience as a person of color on dating apps. The image is vivid, like something visible, uncomfortable, impossible [...]
Read MoreIn 2018, we (LLC and MP) met in person for the first time in the lobby outside a large conference room at the United Nations Office in Vienna. Although we had collaborated previously (Palit & Levin, 2016; Charlés & Samarasinghe, 2016), we had never met face-to-face. In Vienna, we were invited participants in a United Nations Office on Drugs and Crime (UNODC) technical consultation: “Elements of Family-based Treatments for Adolescents with Drug Use Disorders: Creating Societies Resilient to Drugs and Crime.” This consultation meeting included 25 experts across the fields of family therapy, staff from the UNODC PTRS unit, and the World Health Organization, and subject matter experts in substance use disorders and countering violent extremism. The meeting was convened for a memorable week in Vienna, with participants from over 13 countries. The goal of the meeting was “to identify key elements of effective approaches to the treatment of adolescents with drug use disorders and to provide guidance for the development of a UN training package on family therapy.” A key aspect of the “effective approaches” and “guidance” asked of us as a group of technical experts was that we had to consider FT adaptation and implementation in low and middle income countries. The challenge is clear; while research studies in many contexts illustrate how systemic family therapy practices are part of the evidence base, Busse et al. (2021) noted that:
…almost all these studies were conducted in high-income countries and almost all of them were conducted within a research context in university setting. As such, the findings might not be generalisable to studies conducted in LMICs …. Furthermore, adolescents with SUDs and their families in LMICs do not have or very little access to effective treatment such as family-based therapy. To address this accessibility gap as well as to increase quality and diversity of treatment options for adolescents with drug and other SUDs, the Treatnet Family (TF) was developed by the United Nations Office on Drugs and Crime (UNODC; 2020). (p. 2)
That package that was begun in 2018 in Vienna is now called Treatnet Family (see below for an example of some of the concepts addressed in the package). Treatnet Family has been a part of feasibility studies, has been implemented in many countries and regions, and involved hundreds of practitioners across the globe. The package is openly accessible at no cost, and as of this writing, has been translated into four languages, with more on the way. We need more multilateral efforts and collaborations like this one, and family therapy as an established field needs to hear much more and much more often about the ways practice must be adapted to meet country contexts across the globe.
A recent publication by Busse et al. (2021) described Treatnet Family (TF) as:
containing elements of evidence-based family therapy which has been developed specifically for adolescents with SUDs and their families in low resource settings. TF focuses on family interactions and uses elements of family therapy to interrupt ineffective communication within the family. It contains the key components of family therapy, such as:
TF has six sessions, with each session lasting between 90 and 120 minutes. Each session is to be attended by the adolescent with SUDs and his/her family members because the primary focus of the sessions is on the relationships among family members. The practitioner’s role is to interrupt problematic cycles, ineffective communication, and harmful behaviors family members currently use to meet their emotional and interpersonal needs. As change in family interaction can influence each family member’s behavior, family members are encouraged to be part of the solution.” (p. 2)
For more on Treatnet Family: https://www.unodc.org/documents/southeasterneurope/UNODC_Treatnet_Family_brochure_190320.pdf
The following are definitions for terms commonly used pertaining to becoming licensed in other states or practicing in other states. The definitions below represent how these terms are used in this article and may not represent how these terms are defined by others:
Portability: Portability or license portability is the general ability to take an individual’s qualifications for a license in one state and apply them for licensure in another state. The term “portability” is used to describe the various methods to allow a licensee in one state to be able to legally provide services to clients in other states, including through model laws, reciprocity, endorsement, or compacts.
Model Laws: Model laws, also referred to as model portability laws, are laws included as provisions within existing state licensure statutes that allow out-of-state licensees to obtain a license in a state in an expedited fashion without having to meet all of the requirements that an associate clinician applying for initial licensure would have to meet. Most MFT state licensure laws contact such model laws allowing an MFT licensed in another state to obtain licensure if they meet certain requirements or have been licensed for several years. Model laws are far more common than licensure compacts. Unlike compacts, the language in model laws can differ from state to state.
Endorsement: Endorsement generally describes laws that allow a state board to recognize or endorse a person’s license granted in another state, allowing that person to become licensed in the endorsing state. The terms “portability” and “endorsement” are commonly used interchangeably.
Reciprocity: Licensure reciprocity is when a state honors and recognizes licensees from certain other states through mutual agreements in other states. However, in the healthcare field, these agreements, which must be approved by officials in each state, are not found in most states pertaining to mental health licensure as states are reluctant to grant reciprocity.
I (LLC) interviewed Alexandra “Xan” Weber, International Institute for New England’s (IINE) Senior Vice President for Advancement. IINE was founded in 1918, and is a non-profit social service organization that serves refugees and immigrants through resettlement, education, livelihood/career advancement and support for the journey toward citizenship. Responsible for resource development, advocacy, and strategic initiatives, Xan oversees the organization’s fundraising, institutional partnerships, advocacy initiatives, and strategic planning. She began her career at IINE in 2008 as IINE’s Director of Community Services, managing the Boston site’s refugee resettlement program, various victim services projects, and behavioral health services. IINE is an affiliate of the United States Committee for Refugees and Immigrants, and one of the nine national networks contracted with the U.S. Department of State to resettle Afghan evacuees. In 12 weeks, IINE resettled over 450 Afghan evacuees throughout New England.
Laurie: What are the most important things that clinicians need to know about this group?
Xan: In my presentations to the community, I often list everything that refugees usually go through—statelessness and forced migration, violence, war. This population faced an additional challenge—evacuation, an additional trauma. At IINE, we’re not used to receiving evacuated populations who have had no time to prepare and process their resettlement. Afghan evacuees did not prepare for resettlement and I think that that in itself has created another layer of suffering. We are meeting many Afghans who do not have a sense of refugee identity. Evacuees made a life or death decision to evacuate—a lot to process in just a short amount of time. And we’ve heard the actual evacuation itself was horrible and traumatic. People rushing the airports and tarmacs and getting trampled, getting pulled over barbed wire fencing to reach an airplane, some people making it onboard and others not and families separated.
Afghan evacuees were air evac’ed from Afghanistan to a third country, and this step added to the complexity of their resettlement process. From overseas bases, evacuees were flown to Dulles Airport in Virginia and then dispersed to military bases in the U.S. A shuffling between U.S. bases in multiple countries is not the typical refugee experience, and when they arrived at U.S. bases, most lacked processing documentation. Lack of documentation impacted evacuees’ sense of security—they did not enter the country with traditional refugee documentation, work authorization, etc. The U.S. government didn’t really know who they were and they had to go through months of processing on U.S. bases to generate critical documents. On the U.S. military bases, families struggled. Even if they had shelter, heat, and food that they could eat, for some there was so much dust in the air, their children had asthma attacks.
Laurie: Can you say a bit more about the term used for the evacuees? “Humanitarian parole”?
Xan: Most Afghan evacuees were offered Humanitarian Parole by the U.S., and they entered as parolees. Humanitarian Parole is a rare authorization—it’s an opportunity offered to people ineligible for admission to the U.S. to enter temporarily due to a compelling emergency. This designation is outside of refugee processing, and it doesn’t confer the same benefits. Afghans who have humanitarian parole have been authorized to stay in the U.S. for two years, and within that time, they have to adjust their legal status or they will become unlawfully present. Afghan evacuee status presents, therefore, an additional significant concern—without a broad status adjustment of the 100,000 Afghans who are here now, every single one of them will need an attorney to adjust their legal status in the U.S. The adjustment process is extraordinarily time consuming and expensive.
Laurie: How would you say your organization looks at mental health and psychosocial support needs of the families you serve, in particular the Afghan families?
Xan: I think it’s our mission to consider clients’ health, mental health, and well-being. The logistical support offered by resettlement is not enough. Refugees by definition have been through persecution, for many physical and emotional violence, and upon resettlement need time to adjust. Ideally, IINE would have clinically-trained case workers who could enhance client health, even providing practical and logistical support alone. We don’t have many clinically-trained case workers on staff, but we are lucky because we work with amazing community health center partners, and over the summer we moved offices in Lowell and are now co-located with the Lowell Community Health Center. In considering our move, we asked ourselves, what’s the most important support that our clients need that we don’t provide? We don’t provide healthcare [at IINE]. In combining skill sets with partners, we can achieve holistic support.
Laurie: What have you seen that’s on the minds of these families? What’s the thing that they’re telling you or telling your caseworkers?
Xan: I’ve worked with a few Afghan families myself, and our staff have shared lots of different stories about their experiences resettling Afghan evacuees. Honestly, I think our staff, on the whole, are very challenged by many of the Afghan families that they’ve met. The evacuees’ expectations are so high, and many seem so dissatisfied with what we can offer through the resettlement program. The U.S. resettlement program is one-size-fits all: every refugee receives the same services and support, right down to the the number of forks, spoons, and knives per family…it’s very, very proscribed.
At IINE, we’ve been doing this a long time—we try to assess each family’s needs and we give as much individualized support as we can. Because of an incredible outpouring of support from community members and funders, the Afghan evacuee population is receiving about five times the amount of funding and resources than any other resettling refugee population. But many evacuees are upset because they expect to resettle into a middle-class American life, and the U.S. refugee program doesn’t provide resources to begin life in the U.S. at that economic level. Most families we have met are completely focused on their children, and they are here for their children. They’re also really focused on working; they want to get a job. They want to know where their paperwork is. They want to know where the grocery store is. They want to know how to get work authorization. They want to know where things are, they want to do things. They want a bank account, they want to finally move into the driver’s seat in their life after having a huge, disruptive time of feeling out of control.
After the evacuation experience, it hard to know how so many function so well. Most are simultaneously experiencing deep grief, because most of their family is still in Afghanistan.
Laurie: Have you noticed things that have worked that have been helpful to reduce the worry for the families you work with, or that caseworkers work with?
Xan: I think when evacuees get their questions answered, that’s the most helpful, moving away from complete uncertainty about everything and toward control. Even if it’s just receiving a food card to go and buy their own groceries. These are practical things that I think have helped people start making their decisions, and feeling more in control.
Laurie: You mention the deep grief for families, who are separated from each other, with many still in Afghanistan. Can you say more about what is happening regarding reuniting families?
Xan: Most evacuees left most of their family in Afghanistan when they were evacuated. We refer evacuees to our attorneys to explore legal reunification options. But we haven’t had success in helping Afghan families in country to get out. An IINE case worker is an Afghan refugee whose family resettled in Canada, and she and her husband were admitted to the U.S. Her entire family fled Afghanistan through Pakistan, and just barely escaped. They recently joined her sister in Canada. The CTV W5 Channel broadcasting station did an entire video series on her—with graphic footage of the Afghan evacuation. Watching it, I realized it is hard to put into context what people endured. People had to decide who in their family was going to try to evacuate and who would be left behind.
But those who fled have not left their connections behind. Many Afghans are motivated to resettle and work because they want to be able to send money home, to those now struggling in an Afghanistan on the verge of famine. I was just talking to someone who worked in Afghanistan for years, and he said all of the money wire channels are still open, and people can still send money through Western Union to family in Afghanistan. At the end of the day, what you learn as a resettlement provider is that those offered a chance to resettle in a new country and rebuild their lives are not just here for themselves. They try desperately to share even the most basic, modest support they are given with others still in hell.
I (LLC) interviewed Alexandra “Xan” Weber, International Institute for New England’s (IINE) Senior Vice President for Advancement. IINE was founded in 1918, and is a non-profit social service organization that serves refugees and immigrants through resettlement, education, livelihood/career advancement and support for the journey toward citizenship. Responsible for resource development, advocacy, and strategic initiatives, Xan oversees the organization’s fundraising, institutional partnerships, advocacy initiatives, and strategic planning. She began her career at IINE in 2008 as IINE’s Director of Community Services, managing the Boston site’s refugee resettlement program, various victim services projects, and behavioral health services. IINE is an affiliate of the United States Committee for Refugees and Immigrants, and one of the nine national networks contracted with the U.S. Department of State to resettle Afghan evacuees. In 12 weeks, IINE resettled over 450 Afghan evacuees throughout New England.
Laurie: What are the most important things that clinicians need to know about this group?
Xan: In my presentations to the community, I often list everything that refugees usually go through—statelessness and forced migration, violence, war. This population faced an additional challenge—evacuation, an additional trauma. At IINE, we’re not used to receiving evacuated populations who have had no time to prepare and process their resettlement. Afghan evacuees did not prepare for resettlement and I think that that in itself has created another layer of suffering. We are meeting many Afghans who do not have a sense of refugee identity. Evacuees made a life or death decision to evacuate—a lot to process in just a short amount of time. And we’ve heard the actual evacuation itself was horrible and traumatic. People rushing the airports and tarmacs and getting trampled, getting pulled over barbed wire fencing to reach an airplane, some people making it onboard and others not and families separated.
Afghan evacuees were air evac’ed from Afghanistan to a third country, and this step added to the complexity of their resettlement process. From overseas bases, evacuees were flown to Dulles Airport in Virginia and then dispersed to military bases in the U.S. A shuffling between U.S. bases in multiple countries is not the typical refugee experience, and when they arrived at U.S. bases, most lacked processing documentation. Lack of documentation impacted evacuees’ sense of