(Unite 1

HANDBOOK OF WORKING WITH
CHILDREN, TRAUMA, AND RESILIENCE

United Kingdom Council for Psychotherapy Series
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HANDBOOK OF
WORKING WITH
CHILDREN, TRAUMA,
AND RESILIENCE
An Intercultural
Psychoanalytic View
Aida Alayarian
First published in 2015 by
Karnac Books Ltd
118 Finchley Road
London NW3 5HT
Copyright © 2015 by Aida Alayarian
The right of Aida Alayarian to be identified as the author of this work has been
asserted in accordance with §§ 77 and 78 of the Copyright Design and Patents
Act 1988.
All rights reserved. No part of this publication may be reproduced, stored in

a retrieval system, or transmitted, in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise, without the prior written
permission of the publisher.
British Library Cataloguing in Publication Data
A C.I.P. for this book is available from the British Library
ISBN-13: 978-1-78220-193-9
Typeset by V Publishing Solutions Pvt Ltd., Chennai, India
Printed in Great Britain
www.karnacbooks.com
CONTENTS
ACKNOWLEDGEMENTS vii
ABOUT THE AUTHOR ix
UKCP SERIES PREFACE xi

Alexandra Chalfont and Philippa Weitz
INTRODUCTION xiii
CHAPTER ONE
Overview 1
CHAPTER TWO
Traumatic experiences of children of refugees 7
CHAPTER THREE
Anxiety, depression, post-traumatic stress, and dissociation 19
CHAPTER FOUR
Rationale for development of new measures 59
v
vi CONTENTS
CHAPTER FIVE
Assessment 89
CHAPTER SIX
Resilience 99
CHAPTER SEVEN
Working with unaccompanied minors, trafficked children,
and child soldiers 119
CHAPTER EIGHT
Working with family 169
REFERENCES 185
INDEX 197
ACKNOWL EDGEMENTS
This book could not have been achieved without the advantageous
combination of inspiration from the people that I have been privileged
to work with during the last three decades. It goes without saying that
no work can be accomplished without the guidance of experts in the
field and again I feel privileged to have had some of the best to help
me to transfer my ideas into a product. I owe this satisfaction to many
of my good colleagues, friends, and family for their deep guidance,
understanding, and their patience for imparting the knowledge, when-
ever required, and forgiving me at times when I could not clearly con-
ceptualise my views. I would like to express my greatest gratitude to
the children and families who have helped me to work with them to
discover their resilience. I would also like to thank many of the won-
derful friends and colleagues who supported me throughout this work
for many years. I am grateful to Josephine Klein, Lennox Thomas, John
Denford, and Micol Ascoli for their continuous support and for their
wisdom, constant approval and encouragements. Special thanks goes
to Bede Stuat who helped me with his interesting questions and ideas
throughout the editing process for accuracy. I wish to thank David
Armstrong for his undivided support and interest that inspired me and
encouraged me to go my own way for the interest of the beneficiaries of
vii
viii ACKNOWLEDGEMENTS
the Refugee Therapy Centre. Last but not the least I want to thank my
friends who appreciated me for my work and motivated me, and finally
to Oliver Rathbone and Kate Pearce and everyone at Karnac Books, as
well as Pippa Weitz from the UKCP Book series who made this possible.
ABOUT THE AUTHOR
Aida Alayarian, BSc, MSc, DocSc, PhD, is a consultant clinical

psychologist, child psychotherapist since 1986, and adult psychoana-
lytic psychotherapist since 1998. She is the founder and current Clinical
Director and CEO of the Refugee Therapy Centre. She is a Fellow of
the Royal Society of Medicine and a Fellow of the British Psycholog-
ical Society, and sits on the executive board of the UKCP-CPJA. She
developed and is the programme leader of a four year professional
training and MA course as well as a doctorate in Intercultural Psycho-
analytic Psychotherapy. Aida’s work was awarded with the Women in
Public Life awards in 2009; the Centre of Social Justice Award in 2010
and in 2011 by the London Educational Partnership.
ix
UKCP SERIES PREFACE
Alexandra Chalfont
Chair, UKCP Book Editorial Board
Philippa Weitz
Commissioning Editor, UKCP Book Editorial Board
The UK Council for Psychotherapy (UKCP) holds the national register

of psychotherapists, psychotherapists qualified to work with chil-
dren and young people, and psychotherapeutic counsellors; listing
those practitioner members who meet exacting standards and training
requirements.
As part of its commitment to the protection of the public, UKCP
works to improve access to psychological therapies, to support and dis-
seminate research, and to improve standards, and also deals with com-
plaints against organisational as well as individual members.
Founded in the 1980s, UKCP produces publications and runs meet-
ings and conferences to inform and consult on issues of concern to prac-
titioners and to support continuing professional development.
Within this context, the UKCP book series was conceived to provide
a resource for practitioners, with research, theory, and practice issues
of the psychotherapy profession at the heart of its aims. As we develop
the series, we aim to publish more books addressing issues of interest to
allied professionals and the public, alongside more specialist themes.
We are both extremely proud to be associated with this series, work-
ing with the UKCP Book Editorial Board to provide publications that
reflect the aims of the UKCP and the interests of its members.
xi
INTRODUCTION
When I want to understand what is happening today or try to decide what

will happen tomorrow, I look back.
—Omar Khayam (1099)
Torture is a strategic means of limiting, controlling, and repressing the

basic human rights of individuals and communities that are often sur-
reptitious and denied by the authorities. Torture of children includes
deliberate infliction of pain and suffering in order to obtain informa-
tion, though it is not limited to it. Both adults and children are punished
for offences, real or imaginary, intimidated and coerced on the grounds
of their social class, ethnicity or political affiliation; indeed they are
discriminated based on their race or their parents’ political activities.
Despite conventions and declarations in many countries, children are
deprived of their childhood by harrowing experiences. A wide range of
practices exist in many countries throughout the world which subject
children to torture and the premature loss of childhood, and other vari-
ous forms of cruelty on unsubstantiated grounds. Torture, deprivation
of basic human rights, and ongoing adversities in childhood critically
xiii
xiv INTRODUCTION
affect children’s psychological developments that vary depending on

the child’s coping strategies, and cultural and social circumstances.
The aim of this book is to look at the impact of torture on children’s
psychological development and the effect it has on their growth into an
adult personality. I will discuss this through the lens of psychoanaly-
sis, thus, looking at some of the causes and effects. I hope to develop
a much needed agenda for future lines of research on the relationship
between children and young people’s exposure to torture and other
human rights violations, and the impact of these on the development of
psychopathology and, indeed, the impacts on society as a whole.
Working with children of refugees and their families, and with unac-
companied minors, though it is rewarding, is not without emotional
challenges for professionals. Examining the effects of trauma on the
family, the psychological impacts of trauma, and working with parents
or carers of children who have endured trauma, necessitates a spe-
cific intercultural way of working with differences. The discourse in
this book is guided by an interest in prioritising care for the children of
refugees, particularly in cases where the parents or carers themselves
have endured horrific experiences. Some of the behaviour presented by
children who have experienced torture or other forms of human rights
violations can be challenging. As professionals we need to find ways to
identify these in order to provide effective intervention. Working with
children often involves working with parents or carers, which requires
a particular understanding to help support the child in the best way.
Difficulties in understanding barriers to education and opportunity for
children of refugees and unaccompanied minors are an important con-
straining factor that needs consideration. Understanding the position of
children of refugees or unaccompanied minors requires knowledge of
the barriers these children often face in gaining a quality education and
obtaining other forms of social service care provided to others. Having
some background information on children of refugees and unaccompa-
nied minors is important. Prior to arrival in a country of resettlement,
unaccompanied minors or children of refugees are exposed to a range
of experiences that may be extremely traumatic, impacting not only
their psychological health, but also their physical health. Children’s
resilience that is too often overlooked by professionals in all sectors will
be discussed. The resilience approach to working interculturally with
children of refugees and unaccompanied minors is a means for provid-
ing effective psychological support to those we seek to serve.
INTRODUCTION xv
All the cases and vignettes I will present here are of work I have
carried out at the Refugee Therapy Centre (RTC). It is therefore impor-
tant to give here a brief introduction to the centre and its work.
At the RTC we use negative experiences to create positive outcomes.
In my view, if patients (both children & adults) are to be helped to
overcome highly stressful experiences, their views and perspectives
will need to be treated as a source of learning and strength, not weak-
ness. Arguing for a view of children as at least potentially resourceful
is not to sanction their exposure to adversity, nor to deny that some
children, and indeed adults, may be rendered very vulnerable. The
resilient approach I am employing in my practice, widely used by other
clinicians at the RTC, questions normative ideas about childhood weak-
ness. We question whether a focus on children’s vulnerabilities is the
most effective way of supporting their self-esteem and self-efficacy in
adverse circumstances.
The Refugee Therapy Centre was established in 1999 to respond to
a growing need for a specialist therapeutic service for refugees and
asylum seekers, which worked with individual’s cultural and linguis-
tic needs. The Centre’s central purpose is to help refugees and asy-
lum seekers deal with their psychological difficulties. The RTC offers,
where possible, the choice between therapeutic support in the client’s
language or English. The RTC offers psychotherapy, counselling and
support in individual, couple, family, or group settings; prioritising
children, young people, and their families. The Centre endeavours to
provide a safe, supportive, and containing space in which people can
feel empowered to reconsider, understand, and work through their
experiences; rediscover their abilities; and rebuild their confidence to
be active members of the society they are living in.
CHAPTER ONE
Overview
E
xamining theoretical approaches to working with children of
refugees and unaccompanied minors, I will map several use-
ful psychoanalytic concepts for working interculturally with
children therapeutically. The discussion aims to present several key
concepts that underpin the development of effective psychotherapeu-
tic treatment: an understanding of the self and others in the context
of mourning; prior experience and capacity of resilience, dissociation
(healthy and unhealthy), and repression (Freud, 1915d); the concept
of the True and the False Self (Winnicott, 1965a), dissociation, and the
development of resilience (Alayarian, 2011).
In this chapter and throughout the book, clinical vignettes and case
studies are presented and discussed. These invigorate and stir the
diversity of the experiences of unaccompanied minors and children of
refugees while also demonstrating the impact of appropriate therapeu-
tic intervention. They further explore a resilience-focused approach to
working with children of refugees or unaccompanied minors.
Torture and other adversities inflicted on children around the world
are critical factors in the development of psychopathology. The aim
of this book, therefore, is to specifically look at and seriously contem-
plate the torture of children, with specific focus on its psychological
1
2 HANDBOOK OF WORKING WITH CHILDREN
impact, but also looking at the legality of the situation and international
conventions, and regulations for prevention and protection. The discus-
sion around this socially and politically urgent situation will be through
the lens of psychoanalysis with a view toward furthering human rights
and will seek to develop a much-needed agenda for future lines of
research to clarify the relationship between exposure to torture and
human rights violations on children and young people, and the impact
on development of psychopathology in future generations.
I use the word “torture” to refer to a severe form of ill-treatment of
children. Torture in children is a worldwide problem, but there are as
yet no official or reliable independent statistics for measuring the scale
of the problem. The definition of torture in the Convention against
Torture and Other Cruel, Inhuman or Degrading Treatment or Punish-
ment of course applies also to children. But torture of children usually
happens during political violence and military conflict. The high-risk
children are frequently those impoverished children living in the street,
children deprived of parental care, children in conflict with the law and
in detention. During political aggression and war the high-risk children
are the children detained during party-political violence, child soldiers,
children internally displaced in refugee camps, and so on.
Torturing children, or adults, cannot be justified as a means to pro-
tect public safety or prevent emergencies. Neither can it be justified by
orders from superior officers and public officials. The prohibition of tor-
ture applies to all territories under a party’s effective jurisdiction and
protects all people under its effective control, regardless of citizenship
or how that control is exercised. Since the convention’s entry came into
force, this absolute prohibition has become accepted as a principle of
customary international law.
Children of refugees and unaccompanied minors

There has been an increase in the number of people seeking asylum
each year in the UK, of whom approximately a quarter are children.
The stressors to which refugees are exposed are described in three
stages: those experienced first while in their country of origin; second
during their flight to safety; and third when having to settle in a new
environment.
Prior to arrival in a country of resettlement, unaccompanied minors
or children of refugees are exposed to a range of experiences that
OV E RV I E W 3
could be extremely traumatic, impacting not only on an individuals’

psychological health but their physical health as well. To illustrate and
discuss the extreme level of violence and brutality experienced by such
children, here, I will present the vignette of a young girl I shall call
“Emely”.
Emely
Emely was referred for an assessment and possible therapy with a his-
tory indicating that she was only twelve years old when she was tor-
tured by the authorities due to her parents’ involvement in a peaceful
protest. In our first meeting she told me:
They came to our home and took me and my sister who was two
years older than me. She was fourteen. They covered our heads
and brought me to an interrogation room separate from my sis-
ter. This was the second time they had arrested my sister but was
the first time for me—I was very scared. They beat me with a belt.
It was painful and scary. I didn’t say a word. The angry police-
man pulled out a gun and pressed it against my forehead and said:
[If you don’t tell me who your parents meet and how they organise
people for demonstration, I will kill you and your sister immedi-
ately]. I was really scared. I didn’t know what to do. I went silent.
He shouted something. Some man brought my sister. I looked at
her and she looked at me in silence for few seconds. He put his gun
on my sister’s head and shot her and he sat in his chair […] I was
screaming and I fainted […] I do not remember what happened
next […].
The immediate reaction to the brutalities that Emely experienced at

such a young age pained me as well as making me angry, but I was
aware that I needed to focus on supporting her here and now. As a
mother it pains me to think that children as young as twelve years old
experience such violence and torment. Although I was very aware
that Emely’s experience, tragically, was not unique. I am still devas-
tated every time when I hear that these atrocities are inflicted on chil-
dren. Working in the field that I have for three decades, I am aware
that torture is an everyday reality in many countries around the world.
It is used as a weapon against opposition by authorities to perse-
cute and intimidate adults, young people and, indeed, children who
are campaigning for human rights. We cannot continue to look at the

tragedy of such abominable and atrocious treatment with mere sympa-
thy and regret. It is vital that as local, national, and international com-
munities we develop robust systems of accountability for those who
perpetrate violence against children. Equally, we must advocate more
appropriate, accessible intervention and rehabilitation services that can
help the recovery process for those who have endured such extreme
and traumatic abuse. As clinicians, we are faced with the need to under-
stand and recognise the complexity of the individual situations of chil-
dren subjected to unimaginable abuse while also refining our practice
through recognising what effective and containing treatment can do
and how it can be implemented.
Physical health of children of refugees

In my experience as a clinician and as a human rights campaigner,
I have found evidence that the children of refugees are not only exposed
to traumatic experiences but that their physical health is often also at
risk. They suffer from overcrowded living situations, and are often
subject to poor nutrition, poor hygiene, as well as a lack of access to
clean water, immunisations, and other primary health care services. As
a result of these factors, children of refugees under the age of five have
an extraordinarily high mortality rate, especially in some developing
countries.
During the settlement period in a new country, some children are
under pressure as the main link between their parents and the new soci-
ety. Due to substantial cultural differences for many refugees, including
Turkish, Kurdish, some Middle-Eastern, African, and Asian ones, the
process of settlement can be challenging. Adjusting to new environ-
ments can be difficult and people’s cultural differences may be very
great and can therefore create resistance to Western culture. Therefore,
the process of adaptation, integration, and acculturalisation can be
lengthy and at times undesirable. Children of refugees from families
that are unfamiliar with the West and do not speak English can conse-
quently experience a role reversal, becoming in a sense parents for their
parents, and can also find themselves juggling the demands of two very
different cultures at home and in society. In the process, for that rea-
son, they may become insecure about their identity and, in many cases,
completely lose the experience of childhood.
OV E RV I E W 5
Although there is a scarcity of research on the impact of multiple

traumas on children of refugees, my clinical experience evidently
implies that there are severe physical and psychological problems that
require specialist therapeutic interventions.
There are many consequences of trauma for children, some with
long-term pathogenic effects, while other consequences can be less
severe due to provision of a reasonably caring and containing envi-
ronment by carers or parents. Having said that, it is important to rec-
ognise that children are more vulnerable than adults, and their future
relationships may be threatened if there is no appropriate intervention
and treatment is made available to them in a timely manner. There can
be many psychological scars, and below I will discuss some symptoms
that my colleagues and I have identified in children who have been
tortured or endured other forms of traumatic violations.
I intend to examine the emotional impact of the experiences that chil-
dren of refugees and young people face as they flee from their home
countries and settle in the UK. The following should be considered in
identifying factors detrimental to the emotional well-being of children
and in devising strategies for appropriate care provision and support:
• The experiences of children and young people

• The psychological impact of trauma and loss
• Risk and protective factors
• Problems children and young people may encounter in the host
country
• The importance of appropriate support and access to education
• Cultural backgrounds, early development, and coping mechanisms.
Reaching to adult age and homelessness

For young refugees reaching the age of adulthood, usually eighteen,
living independently brings many challenges. Amongst them is home-
lessness, which can affect anyone at any time, and young refugees are
no exception. So the knowledge and confidence to help a young person
feel empowered when handling difficult scenarios and cases of home-
lessness is important. This includes some understanding of:
• What is considered as homelessness?

• Eligibility criteria
• Who is in priority need?

• Intentionality and local connection for refugees
• Section 184 homeless decision letters and right to request a review of
the §184 decision
• Homelessness flow chart and who provides housing
• Single non-priority and the private rented sector
• Non-priority cases
• Tenants’ rights and obligations.
Indeed, looking at the interface with the asylum and immigration sys-
tem in relation to the protection of children of refugees, a range of issues
affecting young refugees who are in need of protection should be con-
tinually addressed:
• The current UK legislation and court processes in child protection

• The roles of different agencies in the child protection system
• Identification and referral systems
• The impact of the asylum system on separated refugee children and
their families.
It is important for clinicians to be aware of children and young people’s

welfare entitlement, but the frequent changes to asylum and immigra-
tion legislation and other policies make this difficult. It is also challeng-
ing for other professionals involved to keep up to date, and to ensure
that they are offering the most effective advice and practice. One of the
main issues is that many families of migrants and people granted ref-
ugee status, humanitarian protection or discretionary leave are often
not aware of their rights and entitlements and so may not get access to
the support networks they need. Consequently, young people reaching
the age of eighteen and over are more likely to end up homeless and
without appropriate support, as they are not aware of the legislative
framework and routes to access housing and other services available
to those granted asylum (refugee status, humanitarian protection, and
discretionary leave) and other migrants.
CHAPTER TWO
Traumatic experiences of children

of refugees
I
t is not uncommon for children of refugees to experience the violent
death of one or both parents. Some witness the massacre or casual-
ties of friends and close relatives and members in their communities.
They go through the experience of forced separation and displacement.
Some suffer extreme poverty, starvation, physical injuries, and disabili-
ties, as well as sexual, physical, and emotional abuse. Often children
are exposed to direct combat; they may be kidnapped, arrested, impris-
oned, tortured, sexually abused or forced to participate in violent acts.
Some children are born or conceived in prison as a result of their moth-
ers’ involvement in opposition parties or human rights activities. In our
clinical work we have the evidence from children’s narratives of young
children being raped or massacred and of other children being made to
witness these horrific events.
In some cases, specifically in African countries, children are forced to
join the army and become child soldiers to participate actively in armed
conflicts. They are often given extremely dangerous tasks, for instance:
mine detection, spying, messengering, or taking valuables from corpses
in conflicted and military areas.
The therapeutic and legal framework for children in host countries
requires attention. In the health and social care intervention of caring
7
for, and protecting the child, there often exists a lack of understanding
between professionals involved and care and protection can therefore
be challenging. There is a need to gain insight into the issues affecting
child soldiers, and indeed, need to value specialist therapeutic inter-
ventions and use of experts to better understand the difficulties that
such children face. It helps both the children and professionals involved
to facilitate constructive professional links between these often dispa-
rate perspectives of the legal and therapeutic worlds.
War experiences and post-war environments are associated with
psychological difficulties that can lead to poor mental health. The child
soldiers are commonly subjected to some unimaginable traumas which
are due to the contexts of what is going on in their community (i.e., it
being a post-war environment or one which allows child soldiers in the
first place). Although there are some studies linked to depression, anxi-
ety, and post-traumatic stress (PTS), the long-term effects on psycholog-
ical health within the psychosocial trajectory that influence children’s
mental health and the precise causes of stressors are not yet researched
appropriately. The relationship between the war experiences of children
who endure trauma with depression, anxiety, and PTS has been docu-
mented, but the data available is as yet insufficient to fully establish a
direct causal link. Interventions to reduce long-term problems should
therefore address both stressors in the short term, by psychosocial inter-
vention, and in the long term, by specialised therapeutic intervention,
and should also consider both models of intervention as complemen-
tary to each other.
Many males in the family are imprisoned or forced to participate in
combat in which they may die. Consequently, many refugee families
lose the male head of their family. This results in children of refugees,
particularly boys, losing their childhood prematurely as they have to
take up the responsibilities of their fathers. They become the breadwin-
ners, protectors of their younger siblings and are actively involved in
finding food or shelter for their remaining family.
Regression can be exhibited by the loss of previous skills, patho-
logical dependency towards parents and siblings, clinging behaviour,
thumb sucking, baby talking, temper tantrums, bed wetting, and sepa-
ration anxiety (often seen in school-going children), amongst others.
Depressive syndrome presentations can take the form of loss of appe-
tite, lack of energy, severe apathy, feeling sad all the time, loss of interest,
an increased either passive or aggressive behaviour, social withdrawal,
T R AU M AT I C E X P E R I E N C E S O F C H I L D R E N O F R E F U G E E S 9
lack of confidence, survivor guilt (especially amongst older children),

suicidal ideation or attempt, refusal to attend school or declining school
performances or a change in attitude toward school. Psychosomatic
problems such as stomach-aches, headaches, and constipation are also
reported in the literature from several cases (e.g., Cunningham, 1991;
Richman 1993; Pynoos et al., 1996). It is also suggested that children
have sometimes been found to express their traumatic experiences by
mimicking the symptoms of their parents (Raphael, 1986).
As the primary focus of this book, I will explore the traumatic expe-
riences of children and the psychological effects common to these
experiences. Within this context, I will discuss the role of parents, pro-
fessionals, and particularly clinicians who intervene to support the lives
of young adult refugees and children. Drawing on more than thirty
years’ experience working with children, particularly children of refu-
gees, I will outline what I consider to be the effective and appropriate
therapeutic intervention through the resilience focus intervention, that
has always been at the centre of my research and clinical work. In the
current world we live in, despite regional variations, child torture and
ill-treatment is widespread, which is something that cannot be ignored.
Children are supposed to play, to laugh, and to be protected; to enjoy
their childhood as opposed to having to face the gruelling conditions
many do, including begging for food, being chained or enduring vio-
lence and neglect.
As I indicated in the introduction, the cases I am presenting here are
from the work that I have carried out at the Refugee Therapy Centre.
Our clinical data from the two years April 2010–April 2012 shows
that, of our patients:
• Fifty-eight per cent of girls and forty-two per cent of boys had experi-
enced at least one traumatic event in their lifetime. Of those children
and adolescents who have experienced trauma, between ten and fif-
teen per cent of girls and three to six per cent of boys could easily
be diagnosed by the psychiatric services with post traumatic stress
disorder (PTSD).
• Ninety per cent of sexually abused children are presented with PTS
symptoms; seventy-seven per cent of children who had violence
inflicted on their loved ones in their community are also presented
with symptoms of PTS and thirty-five per cent of children of refugees
who were exposed to community violence also presented with PTS.
• The above differences are related to the risk factors associated with
the individual child and mainly to the severity of the traumatic event
itself and parental reactions and physical proximity to parents or to
the traumatic event?
• Fewer than twenty per cent had accessed other types of mental health
service in the past year.
Death or the threat of it, separation, loss of fundamental functions, and

the irrevocable reality of certain life-altering events make up the range
of experiences that can impact the psychological well-being of the child
to cause symptoms of PTS. Very young children of refugees, especially
those under seven years of age, with whom we work at the Refugee
Therapy Centre often present symptoms of post-traumatic stress, mainly
nightmares and social anxiety. The majority (over ninety per cent) also
present with a range of symptoms such as generalised anxiety, fears,
loss and separation, avoidance of situations that may or may not be
related to the trauma they have endured, sleep disturbances, disor-
ganised attachment, over-dependence and preoccupation with words
or symbols that may or may not be related to the trauma. Although
young children of refugees may not present generally with major post-
traumatic symptoms, they will display post-traumatic symptoms in
their play and drawing in which they repeat themes of the trauma they
have experienced. Therapeutic response to trauma-related play and
drawing in a caring and containing environment will facilitate a process
of working through these unpleasant and violent memories. In cases
where help is not available, a child can lose an acquired developmental
skill, such as toilet training, talking or walking, as they may become
wholly enveloped in the traumatic memory with no appropriate space
to process their experience.
We have observed that developmental delays in children of refugees
may very possibly be related to parents’ mental health. This confirms
that the internal trauma which is the result of the developmental pro-
cess is different from the effect of trauma from external environmental
impingements. This means that effects of the traumas of refugee parents
are influencing their children in the process of their development with-
out them having been tortured directly. External events happen objec-
tively and internal events happen subjectively, both of which interplay
to construct the specific structure and presentation of the trauma for the
individual.
Internal events are often triggered by an external event, but the

historical fact is negligible compared to the fantasy that it triggers; they
are events which are synthesised by the psyche. Internal events can be
distressing but do not have the traumatogenicity of external events. For
them, the building block is the signifier or representation.
Some events can trigger positive emotions that the child enjoyed
in the past which have been worked through, and a link can be made
between the present event and the past, such as a cuddle in earlier child-
hood by a loved one (mother or the primary carer). The events which
cannot be linked with any previous positive experience can leave the
child’s psyche vulnerable. Therefore, the child struggles to integrate the
experience within the landscape of their own internal world.
In my view (Alayarian, 2011), there are two distinct types of disso-
ciations: first, an unhealthy dissociation which can lead to detachment;
and second, a healthy dissociation which may manifest as amnesia
to prevent suffering. Healthy dissociation can keep psychic functions
intact but unhealthy dissociation dominates personalities as a reaction
to unpleasant intermissions of memories. Children who are not able
to dissociate healthily can feel fragmented by the memory of trauma,
and can become vulnerable as a result. I argue that healthy dissociation
and resilience can take the form of a loving and containing memory in
the past. So, healthy dissociation in a resilient child can create much-
needed distractions from the integration of memories or perception
of the details of a certain memory, associated with a coherent sense of
self. Keeping a good-enough psychic space to process memories of a
particular time, which may involve feeling loved, can have a calming
effect and provide mental capacity for healthy dissociation from those
unbearable memories, therefore providing a coping strategy to deal
with trauma-related memories. I here present a vignette.
Amar
Amar, at age eleven, was referred by the special needs teacher at his
primary school. Although bright intellectually, Amar seemed to have
no capacity to socialise with the other children in his class. He seemed
sweet and compliant in individual conversations with adults, but with
his peer group and in the playground he would quickly become very
irritated. He seemed to have no capacity to understand or to learn
the school rules, specifically ideas of personal space, privacy of other
children, and of sharing the teacher with other children, or sharing in

play. Amar’s class teachers had found him impossible to manage, but
on occasions when his ordinary class teacher was away and supply
teachers took over, he would always behave very well. Amar’s mother
had come with him to Britain when he was a toddler to seek asylum.
The school knew nothing of the details of Amar’s background but
referred the family to us as refugees because of the persistent difficul-
ties for this young boy.
Both Amar’s form teacher and the special needs teacher came—they
were happy to liaise and contribute to the process of helping Amar.
They reported their concern that Amar’s behaviour did not change,
even after they had provided clear reasons, explanations, and guidance
for behaviour modifications to Amar and his mother. We suggested
having a meeting with all involved, but it proved difficult to set this
up. After some time we began to think that there was a communication
difficulty between the school and the mother, who did not speak suffi-
cient English. The first meeting arranged was attended by Amar and his
mother only, though we had explicitly said to the school that it would
be helpful if they came too. Amar’s mother was very tearful about her
past and did not want to talk about this to Amar. She was clear that
her son had no difficulties except that he experienced racist abuse near
their home and at school, but was not telling her. She said that she felt
extremely vulnerable and did not know where else to move. She wished
they had family members who lived in London, too, so she would not
feel so lonely and isolated. She said that she had spoken with Amar’s
class teacher and that he was doing fine at school; only his previous
teacher had difficulties with him. She agreed she would work with us
if necessary but said she could see no point, as she wasn’t sure how we
could help.
My conclusion from a developmental perspective was that Amar
seemed much less mature than his age. We wondered whether he was
experiencing encouragement to develop and grow up, or whether per-
haps his mother unconsciously needed him to remain immature and
childish to help her maintain a sense of purpose and control.
After a challenging period, we were finally able to arrange a meeting
between Amar’s mother, school representatives, and ourselves to clar-
ify the perceived problems, so that we could begin to address them. We
encouraged clear communication between Amar’s mother and school
representatives through regular meetings. We encouraged the support
teacher to communicate clearly with Amar, setting specific goals and
expectations to be communicated clear to help him to interact in a more

mature way. We offered weekly therapy to Amar and very quickly he
started to discuss his past and present confusion and mistaken assump-
tions about his family history.
Amar’s mother also began to attend therapy, and in this way it
became apparent to us that there were issues regarding Amar’s attach-
ment to his mother, and that her needs and fears seemed to be con-
tributing to Amar’s behaviours. She was worried about managing the
consequences of Amar adolescence, at which point he might start to ask
questions about his past. She was also was terrified of thinking of the
possibility of her son’s leaving her in the future.
We acknowledged Amar’s mother’s fears to speak with her son about
their past, but encouraged her to do so. We tried to help her under-
stand that it was OK for Amar to know that his parents were brave and
had stood against the repressive authorities in their country, which had
resulted in his parents both being imprisoned and hurt by the soldiers,
as well as his father’s death. We also encouraged them to talk about
family life at home, the grandmother who had taken care of Amar and
his other family members while his parents were in prison, and also of
the long and good relationship of his parents. We also encouraged the
mother to not hide her emotions from Amar, and him to be emotional
and feel able to mourn his father of whom he had clear memories. Amar
needed to feel safe in the knowledge that he was not hurting his mother
by remembering.
All these interventions together, over a period of fourteen months,
enabled Amar to move forward in his development. Communica-
tion between Amar and his mother had been blocked as both were so
afraid that they might be overwhelmed to the point of not being able
to function, and their fear prevented them from talking about the pain
and pleasures of their pasts which resulted in them being unable to
function in the present. As they were able to communicate more simply
and directly, Amar began to understand his past and his history. By
practising communication more openly in his family, he became better
able to manage in school.
Amar’s teachers in the process learned how best they can support
and encourage him without allowing him to disrupt lessons or get
their attention inappropriately. His teacher was able to explore the fact
that the initial anger she felt, and her impatience with Amar and his
mother, was the result of her feeling that she was failing as a teacher.
As a result, she then began refusing to respond to Amar demands for
instant attention, but felt guilty about it. However, she was genuinely
interested in him and, when she managed to give him attention at
appropriate times, she was able to overcome these guilt feelings and set
realistic limits to his disruptive demands.
The dialectical, synergistic interaction between the development
of relationships with others and the development of self-definition is
also demonstrated and exemplified by Erikson’s (1950, 1963) epigenetic
model of psychosocial development. Erikson’s view on childhood and
personality development is important in that he believed that personal-
ity continued to develop beyond five years of age. He accepted many
of Freud’s theories, including of the id, ego, and superego, as well as
his theory of infantile sexuality. But he rejected Freud’s attempt to
describe personality solely on the basis of sexuality, and, unlike Freud,
all of the stages in Erikson’s epigenetic theory are covertly present at
birth and evolve according to a combination of an innate scheme and
the child’s environmental upbringing. Each stage builds on the preced-
ing phases. So, in many ways, his values are exactly in line with what
Freud’s (1930a) discussions in Civilisation and its Discontents suggests is
not good for separation-individuations, each stage of Erikson’s theory
is characterised by a psychosocial crisis that is based on physiological
development, but also on demands put on the individual child within
the environment by parents and/or society. Ideally, the crisis in each
stage should be resolved by the ego in order for development to pro-
ceed correctly. The outcome of one stage cannot be permanent and
can always be altered by later experiences, with a mixture of the traits
attained at each stage. The personality development will succeed to a
healthy one if an individual has enough psychic space and a good sense
of self, indeed resilience, for the righteous attributes, that the deprived
and vulnerable ones do not have, to be created. Here, I have summa-
rised the different stages that a child might need.
Many children of refugees have need of continued acceptance by
teachers and peers at school, which is sometimes stronger than the need
for that of their parents or carers with whom they already have some
level of relationship, be it supportive and benevolent or of animosity.
From intercultural perspectives it is important to look at all aspects
of development psychologically and anthropologically. Looking at
Sullivan’s (1953) formulations of the psychosocial developmental stage
of cooperation versus alienation is helpful. His construct is drawn up
around the time of the initial resolution of the Oedipal crisis and the
initiation of cooperative peer play (usually around four to six years).

He places this at the appropriate point in the developmental sequence,
between the phallic stage and of latency. Erikson’s epigenetic formu-
lations of psychosocial development are also important. He illustrates
the complex transaction between interpersonal relatedness and self-
definition in normal personality development.
Though Erikson (1950) presented a linear developmental process,
without the addition of an Oedipal phase to his formulations; it is
implicit in his view that normal personality development involves the
simultaneous and mutually facilitating development of both interper-
sonal relatedness and self-definition. Erikson’s (1950) model defines
two primary developmental lines: first, a relatedness developmental
line which progresses from trust–mistrust, to cooperation–alienation,
to intimacy–isolation, and second, a self-definitional developmen-
tal line which progresses from autonomy–shame, to initiative–guilt,
to industry–inferiority, to identity–role-diffusion, to generatively–
stagnation, to integrity–despair. He emphasises interpersonal relat-
edness in his discussion of trust vs. mistrust, followed by two stages
of self-definition, autonomy vs. shame and initiative vs. guilt. This
is followed by the freshly identified Oedipal stage of interpersonal
relatedness, cooperation vs. alienation, and then by two stages of self-
definition, industry vs. inferiority and identity vs. role-diffusion. The
following stage, intimacy vs. isolation, is a stage of interpersonal relat-
edness, followed by two more stages of self-definition, generativity vs.
stagnation and integrity vs. despair. The identification of a relatedness
within the developmental line is inherent in Erikson’s psychosocial
epigenetic formulations. Franz and White (1985) discussed this as an
insufficiency, arguing that they have observed that Erickson’s (1950)
predominant emphasis on the development of identity is neglectful in
the development of interpersonal relatedness.
The importance of attachment (e.g., Bowlby, 1988; Ainsworth,
1969) and the capacity for intersubjectivity, empathy, and mutuality
in personality development (e.g., Kohut, 1966; Stern, 1985) also dem-
onstrates some of the shortcomings of Erikson’s model. It is impor-
tant to note that an emphasis on relatedness has been an inherent part
of Freudian and psychoanalytic contributions. The articulation of an
attachment and object relation theory and a relational developmental
line helps to broaden Erikson’s model and enables us to note more
clearly the dialectical developmental transaction between relatedness
and self-definition. Relatedness and individuality (attachment and

separation) both evolve through a complex interactive developmen-
tal process. The evolving capacities for autonomy, initiative, and resil-
ience in the individuality developmental line is in parallel with the
development of a capacity for relatedness to engage with and trust
another, to cooperate and work together in activities with peers (play),
to develop a close friendship with a same-sex companion (Sullivan,
1953), and to experience and express feelings of mutuality, intimacy,
and reciprocity in a mature and intimate relationship. Development
normally progresses through coordination of the evolving capacities
along these two fundamental developmental lines. One needs, for
example, a sense of basic trust to attempt an opposition to need-grat-
ifying; and the other is in asserting one’s autonomy and independ-
ence. In the later life there are needs for autonomy and independence
to initiate cooperative and collaborative relationships with others. This
elaboration of Erikson’s model illustrates the dialectical, transactional,
hierarchical (Shor & Sanville, 1978; Werner, 1948; Werner & Smith,
1992) nature of the developmental integration of interpersonal related-
ness and self-definition.
Various forms of psychopathology can be conceptualised as emerg-
ing from disruptions of the normal dialectical developmental process
and can be regarded as arising from an exaggerated overemphasis on
either relatedness or self-definition and a defensive avoidance of the
other. An exaggerated and distorted preoccupation with one of these
developmental dimensions can typify two manifestly diverse configu-
rations of psychopathology; each can contain several types of socially
unacceptable behaviours—ranging from relatively mild to relatively
severe forms of psychopathology.
From a clinical and developmental viewpoint, one correlate for this
is co-dependency and a strong emotional dependence on a (m)other,
especially to the extent of exhibiting serious developmental and
psychological disturbances. In such position the person may be seen
to involve a primary preoccupation with interpersonal issues such as
trust, care, intimacy, and sexuality, and to be intensely preoccupied with
issues of relatedness at different developmental levels, ranging from a
lack of differentiation between self and other, to dependent and primi-
tive infantile or disorganised attachments, to more mature types of dif-
ficulties in interpersonal relationships. These difficulties share a basic
preoccupation with libidinal issues of interpersonal relatedness; people
and especially youngsters may also use primarily avoidant defences,
such as withdrawal, denial, or repression, to cope with psychological

conflict and stress.
The second correlating issue can also be identified as a series of intro-
jective psychopathologies in which the person is mainly preoccupied
with establishing and maintaining a sustainable sense of self at various
developmental levels. This can range from a basic sense of separateness
around concerns about autonomy and control, to more complex inter-
nalised issues of self-sufficiency. Patients with such thought processes
are concerned with creating, protecting, and maintaining a sustainable
sense of self for development of interpersonal relations and for attain-
ing feelings of trust, warmth, and affection. There are major difficulties
in young patients who are presenting anger within therapeutic relation-
ship and toward themselves or others around them outside of therapy.
These difficulties are related to shortcoming in the developmental pro-
cess and include paranoia, the schizotypal behaviours, over-idealisation
of what has been lost, obsessive-compulsive behaviour, introjective
depression (which is usually related to surviving and referred to as
survival guilt). Other symptoms within psychoanalytic theory concern
are phallic narcissism, which relates to a stage of psychosexual deve-
lopment during which a young child’s sexual feelings are concentrated
on the genitals. Young patients with these difficulties can develop pre-
occupation with issues of self-definition and an instinctual focus on
assertion and aggression. The child may also use primarily remedial
defences such as projection, rationalisation, intellectualisation, doing
and undoing, reaction formation and overcompensation in transference
which can help transforming their conflicts within therapeutic relation-
ship rather than avoiding them. These processes can potentially open
more psychic space for development of a better sense of self and there-
fore increase their resilience.
In contrast to the medicalised diagnostic schemata that primarily
focuses on differences in manifest symptoms (e.g., DSM-IV, DSM-V,
and ICD-10) psychoanalysis, specifically, from an object relations per-
spective; the differentiation of relating to dependency on (m)other and
the projection, introjection, and projective identification are derived
from differences in primary instinctual focus (libidinal vs. aggressive).
The nature of conscious and unconscious conflicts, different types of
defences used (avoidant versus counteractive), and predominant char-
acter style (relational object orientation vs. narcissistic self-orientation,
and balance on affects and cognition) are results of developmental
environment.
Abraham (1924) referred to associations between infantile and

hysterical disorders as attention to the interplay among paranoia,
obsession, compulsion, and guilt-ridden depressive symptoms. These
are clear examples of nature and varieties of clinical presentations.
Although there is a massive amount of literature evidencing the effec-
tiveness of psychoanalytic interventions, there is not yet enough sta-
tistical evidence within statutory services to demonstrate the value of
psychoanalytic and psychodynamic intervention. The psychoanalytic
formulations of a dialectical model of personality development and the
identification of the two primary configurations of psychopathology
for understanding a broad range of clinical phenomena are important
for assessment and treatment of children who have endured trauma.
This includes the differentiation among the various types of person-
ality, though the theory of certain psychoanalytic formulations isn’t
supported by ticking boxes for statistical evidence, the effectiveness of
the practical work is well-supported by the theoretical effectiveness of
psychoanalytic intervention given evidence to the effectiveness of the
theory and practice.
Talking about diagnosis and prognosis of personality disorder, the
clinical and research findings about personality disorder and some
other enduring mental health problems, such as severe depression, hold
important implications for psychoanalytic theory, but psychoanalysis is
criticised for failing to be explicit about its assumption that develop-
mental events contribute in an important way to an individual’s mental
health. Similarly it is a useful approach for some, if not for all, patients
with some forms of psychopathology.
Critics of psychoanalysis think this is far from reality and make the
assumption that it is not as empirically tested and validated as CBT
(Cognitive Behavioural Therapy). This type of false assumption is often
partly based on lack of knowledge of a wide range of research in psy-
choanalytic theatrical formulations and the outcome of interventions,
which usually are presented by case illustration and discussions as
compared to numbers and ticking boxes.
There is scientific evidence that the fundamental assumptions of
psychoanalysis, psychoanalytic concepts, and psychoanalytic formula-
tions afford considerable understanding of anxiety, depression, and the
personality formations. This contributes to a further understanding of
the therapeutic process that I will be discussing in more depth in later
chapters.
CHAPTER THREE
Anxiety, depression, post-traumatic stress,

and dissociation
I
n this chapter I focus on anxiety, depression, and post-traumatic
stress.
Anxiety
Anxiety is a warning signal that may present in the form of
overwhelming emotions and feelings which give rise to a sense of
unmanageable helplessness. In it, the threat may be perceived as arising
from either external or internal sources and be the conscious response
to a variety of powerful fantasies in the unconscious mind.
Anxiety’s physical symptoms include butterflies in the stomach,
a pounding heart, unpleasant sensations or a persistent sense of unease.
Anxiety is certainly not just a product of irrational fears. If we look at
the cases of anxiety in people that have encountered traumatic events,
it is clear to see that their anxiety is often justified and in many cases
it is existential. Some of the existential causes of anxiety in refugee
and asylum seekers include: being in a new culture, struggling with a
new language, not knowing what to do, not knowing the Home Office
decision about immigration matters. Some of these are enough to make
anyone anxious—in fact I would be more concerned if patients in such
19
circumstances did not present anxiety. This type of anxiety is a normal

reaction to a pressured and abnormal situation. Although individual
fears may appear irrational, it is easy to see that the base of that fear is
perfectly normal, rational, and to be expected.
Titus
At the age of twelve, Titus attempted suicide. He was found by his sis-
ter, taken to hospital, but refused to talk to any professionals, whether
clinicians or social workers. Titus’ parents were killed in the war when
he was eight, and his sister, six years older, became his carer before
they eventually came to Britain, escaping further persecution. A child
psychiatrist decided that Titus should be referred to the RTC. We talked
over the phone about Titus’ possible referral and the sensitivity and par-
ticular attention this child might need as he had previously presented
as at risk of self-harm. The child psychiatrist agreed that he would be
on call, if needed, which allowed us to accept the referral based on this
arrangement.
In our first meeting with Titus and his sister it became clear that he
was often left alone and that, although he received material care, no
one was involved in his life at the level of his emotional need. Titus
was not able to connect to his past or present; he seemed to be existing
rather than living. His memories were distorted and perplexed and he
had strong fears of hurting or losing his sister. His sister was very keen
for both of them to focus on their education and advance their future
prospects, with the hope of forgetting their painful memories.
Titus’ presentation was cooperative and he longed for adult atten-
tion. In communication with his school staff I encountered quite a dif-
ferent view. They found him to be a difficult child with severe lack of
responsiveness to anything. They reported that, when one of the aggres-
sive boys in his year was strangling him, he would not move or retali-
ate and, when they wanted Titus to say what had happened, he said
nothing. They also said that some of his peers found him frightening
because he refused to engage with anyone; others were irritated with
him. What struck me was his lack of response to bullying and its rela-
tion to his suicide attempt.
In individual meetings with him, he revealed that he was completely
bewildered and anxious about teachers in Britain allowing children to
“mess about” in class. He said he knew he was supposed to be “good”
A N X I E T Y, D E P R E S S I O N , P O S T- T R AU M AT I C S T R E S S , A N D D I S S O C I AT I O N 21
but could not manage it, as he could not manage the confused feelings
inside him. He would try to pay attention but his mind would wander
and before he knew it the lesson would finish without him having learnt
anything. He did not have a vocabulary for all the related concepts such
as feeling different, afraid, terrified, anxious, sad or confused. It became
more apparent that Titus needed a key adult who could set firm and
clear boundaries with him to help him to feel contained at school and
with whom he could slowly build a trusting relationship.
Titus’ sister took the view that he simply had to get on with life.
She needed help to change her behaviour towards him. Moving away
from this view seemed to raise too many difficult memories for Titus’
sister. So I suggested that she sees a therapist who spoke in her own
language in order to successfully engage. Titus would be seen by an
English-speaking child psychotherapist and that we could all meet once
a month and work together on their losses. She agreed. She admitted
that she was keen on the idea and very grateful for the offer. She later
told us that she did hesitate to ask for help as she saw Titus as priority
for receiving help and she did not want to “spoil the system” and take
advantage, but she was very aware that managing Titus’ behaviour as
well as her own strong feelings was becoming more and more difficult
for both of them.
As the therapy progressed, Titus became able to verbalise his
feelings and thoughts. In one session he said:
I used to think I always will have a happy life with my mum, dad,
and my sister. I have lived a bitter life, filled with suffering. The
suffering started when my parents died. I didn’t want to stay alive
because, for me, life was over. I didn’t want my life without mum
and dad. Do you think I am selfish? I feel bad trying to kill myself
because of my sister, but I cannot be happy with my life; my sad
feeling is too strong for me to beat. […] I would be happier to stay
at home; going to school is painful, everyone is talking about their
mums and dads. My sister told me that she wanted me to go to
school.
Four months into therapy, Titus’ depression and anxiety lessened. He

settled quite well into school and was attending regularly without
retaliating or suffering. He became able to make friends at school, and
he was able to tell them that he had lost his parents, if they asked him.
He learned that he could say “I don’t want to talk about it”, if his fellow
pupils were asking more. Gradually, Titus reached the stage where he
was looking forward to going to school. His guilt feelings decreased
and his attachment to his sister became healthier, rather than confused
and ambivalent.
Just over a year in therapy, Titus became a charming adolescent—
a very tall and attractive fourteen-year-old. He developed the ability
to show his appreciation for the help he had received in reaching that
stage. In one of his last sessions Titus said:
A number of people helped me to find myself after my parents

died. With the advice of my psychiatrist I got a bit better. But a light
and great hope for me was the Refugee Therapy Centre, where I
come every week and my sister comes every week. It is like a fam-
ily home. I think I can come and visit all my life and you have to
promise me you never die on me—OK? Never-ever. […] I want to
thank you because you helped me like a good mother […]. My sis-
ter also feels good and happy and I have a brand new, happy sister.
I want to thank everyone who helped me to live and enjoy my life.
I thank the English people for being so kind.
Offering some recognition of Titus’ complex feelings and allowing him

some continuity in relationship with supportive adults provided him
with some containing environment for his development. Our monthly
meeting with Titus and his sister along with her therapist and I proved
to be helpful. Together in the group, we facilitated the possibility of talk-
ing about their experience and the loss of their parents and other loved
ones. As a result, Titus began to settle down. But, during the process,
though there was progress, it was much more back and forth. Because
as soon as his equilibrium was disturbed, by, for example, the change of
his teacher or social worker to whom he had become attached and on
whom he had come to rely, we found him once again in a withdrawal
mood; but we did manage to work it through.
Historical context
The study of anxiety is at the root of psychoanalytic exploration of the
human condition. Freud’s (1920g) notion of anxiety derives from the
helplessness of human infants, dependent for survival on parents or
carers for longer periods of time than any other species. The experience
of helplessness over such a long period and the role of the primary carers
in reducing the danger of hunger, thirst, poor hygiene, and other needs
increases the importance of the object or the primary carer, as an essen-
tial attachment and for the protection an infant needs. It is, therefore,
the biological factor that creates the vulnerability and need for relating
which is carried with us through our whole lives. The experience of
helplessness is seen as a prototype of any situation of trauma. Freud
recognised that, because of this, in any situation when an organism can-
not regulate its own state and thus becomes overwhelmed, trauma will
occur. In his topographical model, the ego is the aspect of personality
that deals with reality, and has to cope with the conflicting demands of
the id that seeks to fulfil all wants, needs, and impulses and the super-
ego which puts pressure on the ego to act in an idealistic and moral
manner. When the ego cannot deal with the demands of one’s desires,
or the constraints of reality as well as moral standards, anxiety acts as
a signal to the ego that things are not going right. The ego then, if capa-
ble, can employ a defence mechanism to help reduce the anxiety. Freud
identified three types of anxiety: first, the neurotic anxiety that is the
unconscious fear of loss; second, the reality anxiety that is an existential
fear of real-world events and third, the moral anxiety that is a fear of
violating one’s own moral principles.
Freud placed the loss of a loved object as one of the most central
anxieties. For children, emotional regulation through a relationship
with a parental or primary attachment figure is crucial for develop-
ment. In situations of continual exposure to trauma in infancy or child-
hood where emotional regulation fails to reduce instinctual tension, the
infant remains hyper-aroused and hyper-vigilant to danger, resulting
in the failure to develop essential neurological structures necessary
for healthy development. Anxiety, therefore, has a crucial signalling
function for real or imagined dangers in trying to prevent the organ-
ism from being overwhelmed by emotion. The idea of anxiety implies
the possibility that the emotion experienced may be overwhelming and
traumatic to the person experiencing it. If the emotion can be recog-
nised in our adult life, it can be bound or attached in some way to our
anticipated defensive response. Meaning: if we can name a fear, we can
begin to think about it and work through it, somehow reducing the
anxiety. For example, knowing what the fear is reduces the uncertainty
and helplessness that can cause anxiety.
Here I will present a brief case study of a vulnerable young boy,

whom I shall call “Erik”, to demonstrate a defensive form of dissocia-
tion and the healthy therapeutic emotional distance appropriate for
meaningful support.
Erik
Erik, a twelve-year-old boy from Africa, was referred to the RTC for
assessment and possible therapy. The referrer indicated that Erik was
unable to concentrate; he was withdrawn, unable to relate to his peers
and struggled with academic achievement. The referrer indicated that
his IQ was borderline low and he therefore was marked as having a
mild learning disability, and also that he was self-harming and recently
his wounds had become infected as he constantly re-opened them.
Erik, for the first few months, was unable to talk in therapy, although
at times he became tearful in the sessions. The intensity of sharing his
pain was too great for this young boy and, indeed, became challeng-
ing for me in countertransference. I so desperately wanted to help him,
and so desperately wanted to work towards strengthening his ego, for
both of us to survive the torture he endured. I communicated with him
verbally, but always doubted whether I was able to convey to him a
clear meaning he could relate to his experience. I was very aware that
I did not know much about him, and that I had to be very careful not
to give him the wrong impression that I was intending to explain him
to himself.
He eventually started talking and told me about how he had wit-
nessed his father being killed by machete in front of him and his
mother. His mother was then raped, beaten, and killed and he was
taken by those men. He was eight at the time he was recruited as a
child soldier and forced to serve those people. He was beaten regularly
and deprived of food and sanitation, Erik was attending his sessions
well but kept silent a lot. I would interpret his silence and, although he
continued to be silent, he would look at me and shared his tears ses-
sion after session. He did, however, always have a polite greeting upon
his arrival and goodbye on his departure, and this was a regular clear
verbal exchange between us. He was gradually showing much more
eye contact with me and that was the limit of what he was able to relate
to me at that time. With gentle encouragement, I intended to estab-
lish a meaning, and not merely confirm, reject or add something—to
remain in tune in containing and regulating his anxiety and fears. I kept
talking to him and about him and tried to find words that had mean-
ingful connections to his experience. Erik’s regular attendance and his
ability to share his tears with me confirmed that we were starting to
develop a therapeutic relationship. Having me as his “listening other”
in his on-going silence seemed to be helpful to Eric as his eye contact
was becoming more frequent and longer. I continued focusing on
transference–countertransference interpretations. Erik by this stage
(three months of weekly therapy) was consistently looking at me
when I kept talking to him about our relationship—I could observe the
warm and connecting affect in his gaze. In a session I decided to be more
direct and said to him how terrifying it would be if he started telling me
what had happened to him and I wondered about his possible fear of
relating to me and that I would let him down by leaving him: part of
him unconsciously related to me by his gaze and his tears, and indeed
by his coming to every session. In tears he said: “Yes, I am scared, very
scared”. He became more verbal about his emotions after that session.
For a tortured child such as Erik, the stress of associating with his
memory was too much to bear, so, although longing for relationships,
he needed to dissociate himself from any engagement with the past
memory in the here and now. His type of dissociation is a very con-
crete and bodily one, where the psychic pain and symbolic represen-
tations are denied. Consequently, there was no psychic space and no
room for him to symbolise his relations with me as his therapist at the
early stage of therapy. The defining factor was the experience of reality
and representation of reality, and his pain. This was due to the fact that
humanity had been denied to Erik too early in his life and as a child he
endured severe torture directly and indirectly by witnessing his parents
being killed, watching his mother being raped, and losing everything
familiar to him. As his own humanity was denied, the details of the
sensation related to the traumatic experience and the images that could
come to be the symbolic representation of his experience were blocked
and denied to his conscious function, at least temporarily, due to the
fragmentation of his mind.
Erik’s type of dissociation and consequent disintegration occurred
too frequently, resulting in his total helplessness and hopelessness.
He could not finish the disturbing memory of torture and trauma he
endured; he could not articulate them or finish his thought and he
could not entirely dissociate from the thought and memory of it either.
As a result, his whole existing psychic structure was shattered by

re-experiencing the trauma in a fragmented way which could go on for
too long without finding direction—hence his self-harming behaviour.
I hypothesise that, regardless of the intensity of the trauma in his earlier
life, Erik in therapy gained enough psychic space and resilience to build
sufficient object relation with me as his listening other. By so doing, he
then became able to dissociate in a healthy manner and to turn his atten-
tion to something positive. After this process, he would talk regularly
in therapy without feeling under pressure and together we worked to
explore his issues to find meaning for his thoughts and feelings.
I observed that Erik’s psyche, in its protective and defensive state,
retreated into dissociation to deal with his unbearable memory. This
happens because a child has broken confidence and reliance with the
consistency and resilience of their core to deal with some of their expe-
rience and memory of it. In the process we discovered that Erik’s core
self-support systems, agency, continuity, and cohesiveness were tempo-
rarily disconnected by dissociation during the actual trauma when he
was tortured and could not be reconnected. This was part of his psycho-
logical disturbance, he could recall a fraction of his memories, but they
were so unclear and fragmented that he could not connect with them
fully. Despite this, he had an awareness that he had lost the familiar
ground by which he tolerated and stood before the atrocities of losing
his parents in the way he did at such a young age. It had been a shock
and a sudden shift from his ordinary everyday life to horror which led
him into a kind of confusion of mind, restricting his ability to sublimate
his experiences or to be creative. This is partly because memories expe-
rienced by him presented as broken thoughts, feelings or images, not
revealing themselves as memories. They may at times have come to his
mind, but seemed relatively disconnected and meaningless. At other
times, they overwhelmed his consciousness and led him into a vividly
remembered past, but, he was unable to make any sense of them, as his
memories could not emerge into consciousness clearly. But as therapy
progressed and he began to develop some psychic space, he could have
pause for thought and reclaim his memory. He therefore developed
some level of resiliency and started having a better sense of himself.
As the result, he gradually lost his severe anxiety; his depression was
subsiding as he was developing the capacity to verbalise his past and
present experiences with me in a coherent way as his listening other. He
then started to build a better relationship with his foster carer, began
playing and making friends with his peers; he became academically

proficient, and to his teacher’s surprise, a bright outstanding student by
the time he moved up to secondary school.
Erik’s periodic, interrupted, and broken representation of his pre-
vious state of consciousness was leading him to an intense and vivid
moment of fragmented recollection, without him being able to form
self-defining memories. It would be challenging to fully connect with
some of his past experiences. His state of consciousness in the here
and now on those occasions could be reinstated and associated with
an awareness which unexpectedly placed his consciousness in the
past. This caused feelings of revelation, recognition, confusion, and
indeed triggered an intense sense of himself in the past that created an
extreme anxiety and fear for him without a clear direction or elasticity
of his mind to move forward. But this was not manageable for him,
and he was unable to dissociate healthily before getting to the state of
fragmentation—there was no capacity to dissociate healthily and, as
a result, he would experience ego fragmentation, leading to a state of
disintegration, due to the fact that he could not dissociate himself from
the memory of trauma and take his attention to another matter, nor
could he stay with the memory and finish it.
Depression
What causes depression? Why do some children, whether in general or
of refugees, become depressed, while others do not? There are various
explanations—some focus on biological reasons, others psychosocial
reasons and some on the role of both—for different children.
Biological factors of depression

The effectiveness of antidepressant drugs points to the existence of
biochemical changes in the brains of depressed children, regardless
of whether these changes are the primary cause of the depression, or
simply a response to the environmental impingements. This makes it
hard to judge whether medication can be of any value or is ineffective.
There is some evidence of a genetic predisposition to depression, par-
ticularly for the more severe forms, such as Major Depression Disorder
(MDD) that is considered one of the most common mental health prob-
lems. The MDD lifetime prevalence estimated from a minimum of five
per cent to a maximum of seventeen per cent (Weissman, Bruce, Leaf,

Florio, & Hlozer, 1991; Wilcox, Faraone, Su, Van Eerdewegh, & Tsuang,
2002; World Health Organization, 1990).
I am not arguing against the idea that biochemical changes occur and
agree that depression can certainly be triggered by biochemical changes.
My argument is based on the need to focus on the environmental causes
for such a change and the need for preventative measures. Some of the
well-known features of certain illnesses, such as malignancies and viral
illnesses like influenza, as well as conditions such as hypothyroid-
ism and adrenal dysfunction relating to the endocrine glands or their
secretions, which could cause depression, as well as many hormonal
changes that occur in adolescence—or following childbirth and dur-
ing the menopause. The depressive side effects of certain drugs such
as antihypertensive, for example, beta-blockers, reserpine, recreational
drugs, and alcohol, also point to a biological basis for depression.
Severe depression (clinical, manic, and bi-polar), in particular, is
often said to be caused by a chemical imbalance in the brain. This
is what most drug treatments are based on. In some cases, there
is a reduction in the amount of certain neurotransmitters found
(e.g., monoamines, such as serotonin and norepinephrine). Having
said this, a low serotonin level is a symptom of depression, and it is
not a cause of it. This is very much related to children of refugees and
anyone that has endured trauma, as the more negative introspection
that exists within one’s life (young or old), and the fewer pleasurable
activities that a child of refugees has the opportunity to participate in,
the lower the serotonin levels become. So, this simple fact that there
are unusual levels of neurotransmitters in the brains of depressed
people is evidence that children of refugees and others with depres-
sive symptoms who have endured trauma are quite unlikely to have
a biological disposition to depression prior to the traumatic events
that they have encountered. So, exposure to traumatic events can be
the cause of depression in some children who have endured trauma
without a genetic predisposition.
Teasdale et al., (2000) indicates that antidepressants are considered
to be worse at preventing relapse than appropriate psychotherapy. This
is a valid and, indeed, obvious point when you consider that drugs are
treating a symptom of depression, not its cause.
Here, similarly to before, I am not denying that there is some evidence
that some depression has a genetic basis, manic depression or bipolar
disorder in particular. In spite of this, it is important to know that most

depression is learned, not genetic and we now know that most family
depression is learned. It is now well known that it is implausibly hard
not to be affected by a depressed person, and as children, much of the
behaviour is learned from depressed parents and people and the com-
munity around. It is a learned behaviour with specific ways of thinking,
behaviour, and interpersonal relationships associated with it. There is
much scope for depressive characters and patterns to be passed down
in families within the environment as part of a child learning. Even
for those patients who may have a genetic predisposition to depres-
sion, this is no more than a predisposition; there are as yet no genes for
depression.
To understand the link between physical causes of depression in
children, especially children of refugees and other traumatised young
people, and its psychological causes, we need to look at the thinking
styles associated with depressive behaviour and symptoms, to assess
how these cause on-going physical changes In such an observational
assessment approach, it is possible to establish an important insight
into depression in traumatised children and how it is maintained as an
existential matter and a normal reaction to abnormal situations, rather
than a mental disease.
The experience many children of refugees endure is a strong and
valid cause of depression, and so it is crucial to understand it when
we are looking for ways to help them. In my view, there is reason to be
concerned if a child who has had a severe traumatic experience is not
affected at all. There are events outside the range of the individual’s
usual experience that constitute exceptional mental and physical stres-
sors. However, the range of events traumatic to individuals can be as
diverse as their trauma responses. Regular life stressors, in different
areas of human experience, are ordinary, but traumas are the out-of-
ordinary stressors. Emotional trauma can result from occurrences such
as a car accident, the break-up of a significant relationship, a humiliating
or deeply disappointing experience of a relationship with a loved one,
the discovery of a life-threatening illness or disabling condition, rape,
persecutions, torture and other violent events. This includes responses
to chronic and repetitive experiences such as child abuse, neglect,
warfare, urban violence, concentration camps, racism, and prejudice,
relationships such as ones involving domestic violence, and enduring
deprivation (Alayarian, 2011).
A number of biochemical correlates of depression have been reported,

and most research has focused on the role of the monoamine neuro-
transmitters noradrenaline and 5-hydroxytryptamine (also known as
serotonin). It has been postulated that levels of these neurotransmitters
may be deficient, or that receptor sensitivity may be abnormal in suffer-
ers of depression. These hypotheses are based on the knowledge of the
effects of antidepressant drugs. Monoamine oxidase inhibitors (MAOIs)
and tricyclic antidepressants (TCAs) both enhance neurotransmission
at serotonergic and noradrenergic synapses. MAO inhibits biochemical
degradation of the neurotransmitter, while TCAs prevent reuptake of
serotonin and noradrenaline into neuronal terminals. The efficacy of
the recently developed selective serotonin re-uptake inhibitors (SSRls)
suggests a particularly important role for serotonin in the pathophysi-
ology of depression.
Pitchot et al., (2005) found in their study of 5-hydroxytryptamine
1A receptors that the 5-HT1A receptor is a subtype of 5-HT receptor
that binds the endogenous neurotransmitter serotonin (5-HT). It is a
G protein-coupled receptor (GPCR) which is coupled to Gi/Go and
mediates inhibitory neurotransmission. “HTR1A” denotes the human
gene encoding for the receptor. The G protein-coupled receptor fors-
erotonin is belongs to the 5-hydroxytryptamine receptor subfamily.
Serotonin has been associated in a number of physiologic processes as
well as pathologic conditions. The gene in mice resulted in increased
anxiety and stress response and alterations in the promoter of this gene
have been associated with menstrual cycle-dependent periodic fevers.
Pitchot et al., (2005) in their study of major depression, and suicidal
behaviour indicated that their study tends to confirm the role of 5-HT
and more specifically 5-HT1A receptors in the biology of suicidal behav-
iour in major depression. They reported that there is a clear relationship
between serotonin hypo-activity and suicidal behaviour across several
psychiatric diagnoses. To explain the possible specific role of 5-HT1A
receptors in the biology of suicidality in their study they make use of
a neuroendocrinal strategy to test their hypothesis of a role for 5-HT1A
receptors in the biology of suicidal behaviour. They looked at the hor-
monal (adrenocorticotropic hormone, cortisol, prolactin) and tem-
perature responses after administration of flesinoxan, a highly potent
and selective 5-HT1A receptor full agonist, and assessed this in forty
patients with major depression, divided into two subgroups (twenty
suicide attempters and twenty non-attempters), compared with twenty
other patients that they categorised as “normal” matched for gender

and age. Their comparison with non-attempters, suicide attempters
exhibited significantly lower prolactin (PRL) (p = .01), cortisol (p = .014),
and temperature (p = .0002) responses. Prolactin (p = .007), cortisol
(p = .04), and temperature (p = .00003) responses were also decreased
in suicide attempters compared with normal control subjects. They did
not observe any significant differences in hormonal or temperature
responses to flesinoxan between depressed patients without a history
of suicide attempt and “normal” control patients.
Jacobsen, Medvedev, and Caron (2012) also looked at the serotonin
deficiency theory of depression and the perspectives from a naturalistic
serotonin deficiency model and indicated that decreased level of brain
serotonin, which is theorised as a core pathogenic factor in depression,
arose from clinical observations that drugs enhancing extracellular lev-
els of 5-HT have antidepressant effects in many patients. They stated
that a number of anomalies in putative biomarkers of central 5-HT
function have been repeatedly reported in depression patients over the
past forty years, indicating that 5-HT deficiency is present in depres-
sion, specifically in suicidal patients, but whether such drugs helps a
primary deficit is yet unanswered. In their study, they reviewed the
related literature of five decades and assessed the evidence for serot-
onin deficiency in depression and the possible role of polymorphisms
in the TPH2 gene as a causal factor in serotonin deficiency; the latter
investigated from a clinical as well as preclinical angle.
Post-traumatic stress and post-traumatic growth

It is important to recognise the fact that some of the reactions that chil-
dren of refugees who have endured trauma and adults alike present
after traumatic experiences are normal reactions to abnormal situations
and cannot always be viewed as a serious mental illness or a patient’s
psychopathology. The World Mental Health Report (1995) provides
a table summarising eleven studies of post-traumatic stress disorder
(PTSD) prevalence rates in different populations that have suffered
natural or man-made disasters, war, torture or political repression. The
occurrence rates vary from a low of three and a half percent among
flood victims in Puerto Rico and four per cent among refugees at a
health-screening clinic in the United States, to eighty-eight per cent in
Laotian refugees attending an Indochinese mental health program in
the United States. These wide-ranging differences can be attributed in

part to diverse assessment methods, scales, and interview programs
and to differences between child and adult populations. However, it is
generally accepted that certain refugees, and in particular some indi-
viduals who have experienced torture, are at particularly high risk of
developing mental health problems. Another common finding noted in
these studies is the high frequency of comorbid psychiatric conditions,
primarily major depression.
In contrast to a medical view, I will take into consideration social suf-
fering and its effect on traumatised children of refugees. This is in line
with Kleinman & Goods (1985), who elaborates the traumatic experi-
ences in a meaningful manner, allowing a humanistic understanding
of the challenges that we all face in our lives. He described suffering
(1997) as a social experience that connects the moral, the political and
the medical, and health and social policy.
Bowlby (1973, 1988) indicated that psychodynamic formulations
have led to the differentiation of two major forms of depression, a differ-
entiation that is now strengthened by extensive research conducted by
both psychoanalytic and, primarily, cognitive-behavioural researchers,
amongst others. The differentiation of these two primary configurations
of psychopathology, however—based on fundamental psychodynamic
concepts (i.e., primary instinctual focus, conscious and unconscious
conflicts, type of defensive organisation, and predominant character
style)—has also contributed to more differentiated examinations of the
therapeutic process, with suggestions that these two types of patients
react differentially to distinct types of therapeutic intervention and that
they transform in diverse ways throughout the treatment process.
The following respond to the treatment process: first, aspects of the
interpersonal relationship, and second, interpretation and insights
which indicate the relative ineffectiveness of time-limited treatment for
people affected by trauma and the relative effectiveness of long-term
intercultural psychoanalytic approach which has a positive outcome for
patient resilience. Intercultural psychoanalytic intervention shown to
be effective for a patient’s interpersonal relationships and their ability
to reflect on experiences, either to gain insight into events or in relating
to others.
Thus, despite extensive claims to the contrary, in my experience
of the field of trauma, based on the outcome indications it is clear to
me that psychoanalytic theory continues to make vital contributions
to understanding of the nature and aetiology of various types of

psychopathology and to a fuller understanding of the dynamics of
therapeutic processes in contemporary society.
The patient’s (child and adult) political and psychosocial back-
ground can create extreme vulnerabilities that can lead to depression,
and stressful life events can precipitate the onset of a depressive epi-
sode. Political and psychosocial factors include poverty, bad hous-
ing, and long-term unemployment for adults in the family; aggressive
divorce and separation; loss of one parent or loss and separation from
both parents and the total community; other reasons such as civil war
and political oppression, constant arguments and unsatisfactory rela-
tionships between parents or within other family relationships; exces-
sive use of alcohol and addiction to drugs, matters arising from torture
and from asylum applications and immigration matters, chronic psy-
chological or physical illness in parents or older siblings as the result of
imprisonments and torture, inflicted torture directly to the child, execu-
tions, death of close relative or friend, major financial crisis, being sub-
jected to prejudice, racism, street crime or accident or being bullied at
school for being different.
Major defences
Continuity of their culture in the West, for many children of refugees,
depends on the effective transition of their shared previous cultural
beliefs, the ease in the process of resettlement, and adjustment of ways
of life, from one generation to the next. Continuity of the culture in
the new environment depends as well on the ability and willingness
to communicate and to adapt to the new environment. This dynamic
interplay of culture growth often reflects and is reflected in the relation-
ship between parents and their children. Parents represent the old and
children the new. There is a need to help children of refugees to find the
best way to overcome their fear of loss of culture or their sense of iden-
tity. One way of working with such issues is to bring about awareness
gradually in a respectful manner in wider and more impersonal situa-
tions, until, bit by bit, the child increases his or her understanding of the
new environment. This helps the child to develop knowledge, develop
confidence, gain resilience, and see that his or her life is increasingly
merging with universal life, rather than being stuck on a particular
traumatic experience. The individual experience of a child is initially
scarcely contained inside his or her sanctuaries; they preserve the

information, and race strongly to the progression of cultivated psychic
space and resilience indefinitely. In the extremity, devoid of noticeable
breaks, they aggregate and amalgamate and they can move ahead of
their individual being in a healthy manner. The foundation of resiliency
is, that the child who is provided with the opportunity to preserve and
appreciate life in this way, will not endure the fear of relating to others
and fear of loss or death, in view of the fact that many things he or she
cares for will maintain and carry on. Providing continuity and security
in the life of a child in this way assuages their fears of loss and annihila-
tions, as these fears are no longer substantiated. This is the foundation
of resiliency.
Classical psychoanalytical views have as paradigmatic defences that
primarily come from an intra-psychic perspective, placing conflict at
the heart of psychic life. The conflict between wishes and external real-
ity produces inner tension and anxiety. The conflict therefore develops
between the different agencies of the mind; pushing back of unac-
ceptable wishes from consciousness is the classical primary defence
mechanism. When Freud (1894a) first wrote about defences in the
“Neuro-psychoses of defence”, and consequently Breuer and Freud in
Studies on Hysteria (1895d), he indicated what became known as repres-
sion which, later, Freud (1935) defined to be one of the defences to
include all procedures that have the job of protecting the ego against
instinctual demands. Anna Freud (1926) indicated how defensive aims
may make use of the most varied activities with both phantasy and
intellectual activity, and how defence can be directed counter to eve-
rything which is liable to give rise to the development of anxiety, emo-
tion, and superego demands. Her list includes repression, regression,
reaction-formation, isolation, undoing, projection, introjection, turning
against the self, reversal into the opposite, sublimation, and identifi-
cation with the aggressor. Identification with the aggressor is one of
the most important defence mechanisms to bear in mind when we are
working with children and adolescents who have endured trauma.
Melanie Klein (1946) argued for the importance of primitive
defences and listed them as splitting of the object, projective-identi-
fication, denial of psychic reality, omnipotent control over the object,
idealisation and devaluation, and indicated that identification is self-
representation. She explained that projective identification is a splitting
into good and bad parts in the infantile self. She introduced her concepts
as theory about good breast and bad breast, referring to projection as
the mental mechanism underpinning the process, and the projective

identification as the specific phantasy expressing it. The projective
identifications here are defensive, intrapsychic, and solipsistic; a mental
operation comprising the self and a perception, but not the participa-
tions of the other.
Bowlby’s (1973) attachment theory suggests the propensity of
human beings to make strong affectional bonds to particular others,
also explaining the many forms of emotional distress and personality—
including anxiety, anger, depression, and emotional detachment—to
which unwilling separation and loss give rise. He introduced three inter-
linked stages: first, Protest; second, Despair; and third, Detachment.
Bion (1973) saw defences as a complex area in social systems and
groups, and called them “destructive interactions”, and, as I indicated
before, looked at a positive form of projective identification underlying
empathy and processes by which the mother who contains projected
painful and hostile feelings “detoxifies” them and returns them to the
infant in a more favourable form at an appropriate moment.
Rosenfeld (1964) described defence systems as narcissistic organisa-
tions, and saw that they manifest an internal devaluation of love and
truth. Steiner (1993) saw defences as pathological organisation. Thomas
(1995) in “Psychotherapy in the context of race and culture” gave a clear
picture of the dynamic process between client and therapist and puts
forward black clients’ defences as “proxy-self”. He indicated that some
white professionals have great difficulties in hearing the racist experi-
ences of black people, probably because of their fear of hatred in the
transference. This fear usually mobilises defences in the therapist.
Splitting
The term “splitting” refers to a division into a good object and a bad one.
A child, in his mind, will split his mother into two separate persons: the
bad, frustrating, hating mother, and the good, idealised, loving mother.
This is an ambivalent conflict for a child between loving and hating a
mother who is, in reality, one and the same person.
Projection, identification, and projective identification

Projective identification as a method of control of the object and of
unmanageable feelings is important. In this attribute of projective
identification whole aspects of the ego are split off and projected onto
another person, who then represents and becomes identified with the
split-off parts. Control of those split-off parts is attempted by asserting
control over the other person (Sandler, 1987). Klein (1946) combines
these two notions in a highly specific way. She suggests that projective
identification is assimilated to a phantasy in which the bad parts of the
infantile self are split off from the rest of the self and projected into
the mother or the mother breast. Klein (1946) describes what she con-
siders to be primitive defences as splitting of the object, projective
identification, denial of psychic real, omnipotent control over object,
idealisation, and devaluation. The identification is self-representation
and projective identification as split in good and bad part in the infan-
tile self. Projection, therefore, is the mental mechanism underpinning
the process; projective identification is the specific phantasy adopted as
defensive intrapsychic and solipsistic self-belief—a mental transaction
involving the self and a perception of the self, but not the participation,
of the other.
Reaction formation, identification with the aggressor

Reaction formations often appear during latency and act as a bridge to
more mature defences such as sublimation. Like all defensive patholo-
gies, it can be highly specific. Reaction formations alter the structure of
the ego in a permanent way, so that the defence will be used even if the
danger is no longer present.
Identification with the aggressor was first described by Anna Freud
(1936) in her book The Ego and the Mechanisms of Defence. She drew a
distinction between defences directed against drive—a derivative that
is to protect the ego against instinctual demands—and defences against
affects. These included defences such as repression, regression, reaction
formation, introjection, projection, isolation, and undoing, as well as
fluctuations of instinct, such as reversal and turning against the self,
which still need the intermediation of the ego for their operation. To
these mechanisms Anna Freud (1936) adds sublimation and displace-
ment of instinctual aims.
Internalisation and incorporation

Internalisation is a superordinate term which subsumes introprojec-
tion, incorporation, and identification, and refers to all those processes
by which an individual builds up their inner representational world
by taking in and modifying the external world. Incorporation is the

psychological interact of eating, and refers to the “swallowing whole”
of identification without modification or assimilation, and can be part
of a psychotic form of internalisation or introjection. This is a condi-
tion of incorporation of norms and values; varieties of inscription in
the objective structure of the social world of the child which could be
incorporated and reproduced as the general state of a child’s suscepti-
bility to disease that is itself the incorporation of temporal structures. If
the child’s missing of the idealised figure is preserved through gradual
internalisation, becoming ideals and incorporated into the child’s self-
esteem and psychic equilibrium providing gradual internalisation of
values.
Intellectualisation and rationalisation

Intellectualisation covers a range of sub-defences, including thinking
instead of experiencing and paying undue attention to the abstract in
order to avoid as well as rationalise.
Rationalisation similarly offers logical and believable explanations
for irrational behaviours that are prompted by unconscious wishes.
Repression, denial, and disavowal

In contrast to repression, which aims to remove an aspect of internal
reality from consciousness (Freud, 1915d), denial or disavowal deals
with external reality and enables an individual to repudiate or to con-
trol effectively their response to a specific aspect of the outside world
Denial involves splitting in which there is cognitive acceptance of a
painful event, while the associated painful emotions are repudiated.
Mature mechanism of sublimation

Freud saw sublimation as the vehicle on which a society is based and the
way in which deepest desires—as well as aspirations—gain expression,
through, for example, carnival, drama, music, poetry, and religious or
political aims. Reliable measurement of many of the defence mecha-
nisms is now possible. Studying their change during psychoanalytic
treatment may allow a better understanding of the interventions needed
to help children overcome trauma, achieve psychological health, and
develop into a mature and positive member of society. So, sublimation

is a defence mechanism that allows a child to act out unacceptable
impulses by converting these behaviours into a more acceptable form.
For example, a child experiencing extreme anger might play football
or another sport as a means of evading frustration. Freud considered
sublimation to be a sign of maturity that allows people to function in
normal and socially acceptable ways.
The main features of defences may be normal and adaptive as well as
pathological; they may be a function of the ego and are usually uncon-
scious; they are dynamic and ever changing, but many unite into rigid,
fixed systems in pathological states and in character formation are asso-
ciated with different psychological states, e.g., repression in hysteria,
isolation and undoing in obsessional neurosis; are associated with lev-
els of developments, with some defences being seen as primitive and
others as mature; splitting; projection, identification and projective
identification; repression, denial, and disavowal; reaction formation,
identification with the aggressor; isolation, undoing; internalisation
and incorporation; intellectualisation and rationalisation; and mature
mechanisms.
Before World War I, there was no awareness of what become known
as “traumatic war neuroses”. Freud initially wrote little about war
neuroses, yet the subject had a profound impact on psychoanalytical
theory and resulted in his publication of Psycho-Analysis and War Neu-
roses (1919d). He attempts to reconcile the existence of what he calls
“danger-neuroses” with his view that neuroses are caused by a conflict
between repressed libidinal impulses and the “ego instincts” of self-
preservation. In it, he suggests that:
In traumatic and war neuroses the human ego is defending itself

from a danger which threatens it from without or which is embod-
ied in a shape assumed by the ego itself. In the transference neu-
roses of peace the enemy from which the ego is defending itself
is actually the libido, whose demands seem to it to be menacing.
In both cases the ego is afraid of being damaged—in the latter
case by the libido and in the former by external violence. It might,
indeed, be said that in the case of the war neuroses, in contrast to
the pure traumatic neuroses and in approximation to the transfer-
ence neuroses, what is feared is nevertheless an internal enemy. The
theoretical difficulties standing in the way of a unifying hypothesis
of this kind do not seem insuperable: after all, we have a perfect

right to describe repression, which lies at the basis of every
neurosis, as a reaction to a trauma—as an elementary traumatic
neurosis. (p. 210)
In Beyond the Pleasure Principle, Freud (1920g) introduced the concepts

of repetition compulsion and death drive to account for the impact
of trauma on the mind and suggests that the trauma is repeated and
repeated in order to master the stimuli and bring it under the domination
of the pleasure–pain principle. His analysis of children’s games showed
further that the trauma is mastered through a process of symbolisa-
tion, thus hinting at a theory about the origin of human language itself.
Pat Barker, in Regeneration (1991), tells the stories of Siegfried Sassoon,
Wilfred Owen, and Robert Graves, who were poets and soldiers during
the war and others who were receiving therapeutic treatment for shell
shock by the psychiatrist and anthropologist William Rivers at Craig
Lockhart Hospital in Scotland. Rivers, although influenced by Freud,
disagreed with Freud’s view that neuroses were caused by sexual fac-
tors. Freud’s principle merit, he felt, lay in his belief in a process of
active suppression of unpleasant experience—that is to say, repression.
Rivers also used a rather old-fashioned form of dream analysis, which
Freud had already moved away from (by World War I) towards analy-
sis of the transference neurosis.
Dissociations
In psychiatry, dissociative disorders are an acute or gradual, tran-
sient or persistent, disruption of consciousness, perception, memory
or awareness. The distinction between these types of dissociations is
blurred, particularly when patients exhibit symptoms from more than
one type. However, from a psychoanalytical view, dissociation can be
considered as an unconscious separation of a group of mental processes
from the rest of psychic function, resulting in an independent function-
ing of these processes and a loss of the usual associations. Dissociative
identity disorder is considered pathological in psychiatry; in psychoa-
nalysis, it is the separation of affect from cognition. It is a state of acute
mental decompensating of certain thoughts, emotions, and sensations,
and memories may be compartmentalised because they are too over-
whelming for the conscious mind to amalgamate or assimilate.
At its meeting in Vancouver, BC, Canada (1994), the Executive

Council of the International Society for the Study of Dissociation (ISSD)
adopted the Guidelines for Treating Dissociative Identity Disorder
(Multiple Personality Disorder) in Adults. The Guidelines (1994)
presented a broad outline of effective treatment. A first revision of the
Guidelines was proposed by the ISSD’s Standards of Practice Commit-
tee 1 and was adopted by the ISSD Executive Council after substantial
comment from the ISSD membership and several revisions in 1997. Sep-
arate Guidelines developed for the Evaluation and Treatment of Disso-
ciative Symptoms in Children and Adolescents (2004) were published
in the Journal of Trauma & Dissociation. The American Psychiatric Asso-
ciation has published Practice Guidelines for the Treatment of Patients
with acute stress disorder (ASD) and post-traumatic stress disorder
(PTSD) (DSM-IV, American Psychiatric Association, 2004), based on the
assumption that patients universally suffer from co-morbid PTSD.
The ISSD Adult Guidelines is for the treatment of dissociative iden-
tity disorder (DID), and dissociation in children may be seen as an
elastic and pliable developmental phenomenon that may accompany
a wide variety of childhood traumas and their after-effect presenta-
tions. Symptoms of dissociation are seen in children and adolescents
with other psychiatric diagnoses such as post-traumatic stress dis-
order (PTSD) (Putnam, Hornstein, & Peterson, 1996), obsessive–
compulsive disorder (OCD) (Stein, Forde, Anderson et al., 1997b;
Stein, Montgomery, Kasper et al., 2001), reactive attachment disorder
(Weissman et al., 1994) and delinquent adolescents (Carron & Steiner,
2000). These treatment principles which are intended for children and
adolescents with diagnosed dissociative disorders, or other symptom
presentations accompanied by dissociative features, identify general
principles applicable to dissociative processes regardless of the child’s
socioeconomic or anthropological situations and the nature of the
child’s world. There are studies suggesting that young children appear-
ing to meet the criteria for DID have been described (Putnam, 1997;
Riley & Mead, 1988), though the prevalence of DID in childhood is cur-
rently unknown. The diagnosis of Dissociative Disorder Not Otherwise
Specified (DDNOS) is the most common in populations of dissocia-
tive children and adolescents (Putnam et al., 1996), but no diagnostic
criteria have been set for this and some individual cases of children
with atypical dissociative presentations are sometimes described as
cases of Depersonalisation (Allers, White, & Mullis, 1997) as well as
Dissociative Amnesia (Coons, 1996; Keller & Shaywitz, 1986) or DID

(Jacobsen, 1995). There is no valid and tangible consensus about the
typical case or about diagnostic criteria.
There is, however, a need for a strategic process that aims to increase
empathic support for children of refugees for integration and reduction
of on-going trauma and stress which can be effective and preventative
and engages the child with relating and developing resiliency in addi-
tion to preventing destructive and disruptive behaviour in vulnerable
children. Without consideration and development of such an approach
and creation of simple working models of care, children of refugees may
potentially develop into a more troubled life since their needs might
not be met appropriately in a timely manner. Early prevention of good-
enough care is beneficial socioeconomically, providing huge savings to
the National Health Service (NHS), as well as supporting children for
a healthier, integrated future and benefitting the community at large.
If the alluded models of care aren’t developed, then the children’s lives
may become more troubled.
Psychotic-like symptoms with an early onset can be a manifestation
of dissociation from the memory of trauma that children have endured,
and, if not attended to, can lead to neurological conditions, as well as
schizotypal personality.
Children who dissociate from their memory of trauma in the long
term without any tangible pathway for psychic integrations can
develop both auditory and visual hallucinations, conversations with
imaginary friends or family members who might have been killed,
unexplained ritual behaviour, unusual changes in patterns of eating
and sleeping, or fluctuating academic and intellectual performance.
Although our knowledge of dissociative conditions in children is, at
this time, elementary and undeveloped, unhealthy dissociative symp-
toms that have resulted from traumatic aetiology should alert clinicians
and other care professionals to the appropriate need for early inter-
ventions. In some of the cases I worked with where there were audi-
tory hallucinations, dramatic play with imaginary friends, and sudden
change of behaviours, I observed that in order to help the child and their
carer I needed a combination of techniques in assessment from an inter-
cultural perspective to be able to measure the level of the individual
child stress and to measure how much of the presentation of problems
were internal and how much were external. I usually do this by taking a
careful history as well as carrying out intellectual assessments to attain
a coherent picture that includes the types of dissociations, symptoms,

presentations, if any, and insight.
It is my hope that healthy dissociations become more known
and accepted among child psychiatrists, psychologists, and other
professionals in social care services and that the many complexities
facing children of refugees will be better understood and treated more
effectively.
The fact that children of refugees from different cultural and anthro-
pological backgrounds often do not fit with Western approaches to nor-
mativity as well as indigenous children of the host country does not
indicate that the child is mentally unwell or has less intellectual ability.
Some children of refugees are taught that they should not be expressive
or exhibit play or display dissatisfaction or unhappiness in the pres-
ence of an adult. Clinicians or other professionals working with the
child must not assume a mental illness based on a particular behaviour
that deviates from that of other children of the same age in the host
country.
Children may not have a strong sense of self, sense of continuity or
the flow of rhythm or of time. The sense of time passing is not easy
for children to recognise. It can be hard for them to understand or to
distinguish between the sense of sadness, of mourning the loss of the
loved one and awareness of the temporary feeling of devastation. Even
well into adolescence, children may not recognise time’s having passed
and may find their discontinuity of experience unexpected and particu-
lar or uncharacteristic experiences. This disjointedness, cutting-off or
dissociating of experience is most likely the behaviour of young chil-
dren; it is consistent with the cycle through sleep and lethargic states
and is developmentally appropriate for children to find themselves
in new or changed surroundings without cognisance and alertness of
channel of time. This is qualitatively distinct from the loss of time of
dissociation in adults, during which the individual is conscious.
Dissociation, therefore, reflects distractions or commotions in the
integration of memories, perceptions, and a particular memory’s
uniqueness into a coherent sense of self, due to lack of psychic space to
process them. Distraction from this particular memory may assume the
blurring of boundaries between a child’s self and imaginary and unreal
characteristics of the new self in that particular time and may involve
phantasy. It is important to note, however, that in young children of
refugees who have endured or witnessed trauma, dissociations of those
unbearable memories can easily be viewed as a coping strategy to deal

with those trauma-related memories.
In my view (2011), dissociative phenomena are divided into two
categories: first, an unhealthy dissociation which presents in the form
of detachment and compartmentalisation which has been widely docu-
mented in psychiatric literature; and second, a healthy dissociation in
which the person has diverse natures that may be manifested as a form
of dissociative amnesia with the aim of getting on with ordinary life
and preventing psychological disturbances. Healthy dissociation keeps
the person intact at present and the memory of any given moment, and
unhealthy dissociation is one that dominates the personalities most of
the time that are inconsistent and often seem to be conflicting with the
environment, rather than the good integration of particular traumatic
events and its memories and its social relationships that control an
individual’s function during the invasive and disturbing, unpleasant
intermissions of memories. Transition from one memory to another is
sudden, often dramatic, and usually precipitated by stress and, if the
child can dissociate from it and engage with other activities, such as
reading, playing, talking to someone, then the manner of dissociation
is a healthy one.
Children who are unable to do this for a stretch of time and are
trapped in the memory of trauma can become detached and vulner-
able, and may develop associated borderline personality, somatisation,
major depression, PTS, or suicidal tendencies. Other, more subtle, signs
of dissociation, such as episodes of amnesia or blackout, sleepwalk-
ing, and automatic writing, are other symptoms of unhealthy dissocia-
tions. A child who is experiencing dissociative symptoms may appear
withdrawn, frightened, distant, detached, and disinterested in commu-
nicating, relating to others, or getting involved with activities. Often,
the child is identified as having intellectual inability, presenting chal-
lenging behaviour, or being different from other children by the refer-
ring clinicians, social workers, caseworkers, foster carers, and support
teachers who feel at a loss to understand the differences that a child
of refugees is presenting. Children with unhealthy dissociation may
exhibit an overabundance and excess of inconsistent abilities, moods,
fears, anxieties, shifting of preferences in interests, unpredictable and
varying knowledge, and may present access to information and skills
which can cause confusion in the professionals and/or carers involved
in the child’s life.
Both visual and auditory hallucinations may present in most

children of refugees, indeed in adolescents with unhealthy dissocia-
tions. Conversely, stressful phobic hallucinations do not necessarily
indicate an enduring psychotic disorder, and, in many children that I
and my colleagues have worked with, seemed to be, instead, transient
phenomena related to emotional reactions and self-perceptions related
to traumatic events and their psychosocial complications in the child’s
mind and disruption of their psychic space. We found differences in the
aggregate quantity and extent of presentation and reported narratives
for different age groups and that the highest incidence of unhealthy
dissociations that can lead to psychopathology was observed to be in
children aged eight to fourteen, with specific reactions of fluctuating
anger and hostility as well as guilt and shame. The younger age groups
do not present these characteristics; neither do they present with
clinically significant pathology.
Having said this, the younger group who have been sexually abused
or witnessed the sexual abuse of their carer’s, present inappropriate
sexual or over-familiar behaviour and may therefore be more likely
than older children to experience yet further sexual abuse due to the
effects of their social functioning. Such children may also present with
school difficulties, truancy at a very young age, running away, and
other delinquent behaviour.
In the process, as some therapeutic work progresses, we observe that
unhealthy dissociations lead to some emotionally engaged reactions, the
development of better psychic space in which to process, and percep-
tions of self and others which may lead to presentations of depression,
anxiety, or tension for a period, but not in the long-term. The impact of
the therapeutic relationship on interpersonal relations reduces the diffi-
culties a child may have with parents or carers. Their difficulty in trust-
ing others, their fear and hostility, and their sense of betrayal by others
will also lessen gradually and turn into trust, care, and love. In older age
groups of children with inappropriate sexual behaviour, their promis-
cuity, prostitution, and substance abuse will subside. These transient
dissociative episodes are, in my view, therefore normative phenomena
during the childhood of refugee children who have endured and/or
witnessed trauma which generally decrease to relatively low levels in
early therapeutic intervention and disappear as therapy progresses.
The clinical research on resilience and vulnerability that I have been
carrying out for decades has firmly established a connection between
trauma and the development of dissociations in children and in adults.

There is also increasing evidence that dissociative phenomena repre-
sents a significant unrecognised form of psychopathology in both trau-
matised children of refugees and adults. Unhealthy dissociation is a
complex psychobiological process that results in a failure to integrate
information into the normal stream of consciousness and can be pre-
sented in a range of symptoms and behaviours such as amnesias, dis-
turbances in the sense of self, trance-like states, rapid swings in mood
and behaviour, perplexing alterations in access to knowledge, memory,
and skills, auditory and visual hallucinations, and vivid imaginary
companionship in children and adolescents. Many of these symptoms
and behaviours are misjudged and misdiagnosed as attention deficit
disorder, learning disability, conduct disorder, or psychoses. This is in
part due to lack of clear knowledge of the assessor about the particular
child or young person and is partly due to the culture of medicalising
people’s psychological difficulties and their social and economic dep-
rivations. One might argue people don’t medicalise economic depriva-
tion and it is the culture which assumes that psychological difficulties
must have medical reasons and not an economic or social cause. It is my
view that early identification and therapeutic intervention are the most
appropriate ways of helping these children to a healthier adulthood,
although I feel I have to acknowledge that systematic studies of treat-
ment and outcomes are currently neglected and deficient.
Janet’s (1903) therapeutic approach to traumatised patients and his
classic contribution to the understanding of obsessive–compulsive
disorder developed a grand model of the mind in terms of levels of
energy, efficiency, and social competence. He sets up at the end of a
double reflection and experiences of depersonalisation, obsessions, and
phobias in which he defined psych-asthenia as the lack of psychologi-
cal strength. This still stands as the most authoritative work on obses-
sional and related symptoms yet written, but, unfortunately, it remains
unavailable in English; indeed, his later work in the Major Symptoms of
Hysteria (1907) and Janet’s dissertation ‘L’Automatisme psychologique:
essai de psychologie expérimentale sur les formes inférieures de la vie
mentale in 1889; that was published later in From Anguish to Ecstasy
(1926) is helpful in understanding the dissociative presentations in
children of refugees as well as other traumatised children. Janet (1903)
asserts a connection between traumatic events in the subject’s past life
and the present day and by doing so he created and devised the words
“dissociation” and “subconscious”. He considered the suspension of

fixed ideas as indispensable to alleviation, and I am saying this process
is not automatic and it may not be possible for an individual without
therapeutic intervention. He suggested that special attention is needed
to help a patient in achieving higher levels of functioning and person-
ality organisation and that, if they persisted at a lower level, the emo-
tions could become overwhelming, leading surrendering to fixations
and unhealthy dissociation. Janet described many hypnotic and non-
hypnotic techniques aimed at nurturing a patient’s mental level. He
determined that hysterical patients usually needed long-term treatment
to address the complexity of resuming a tolerable and acceptable level
of functioning. His study of the “magnetic passion” and the importance
of rapport between the patient and the therapist foreshadowed the
work of transference. Janet recognised a developmental model of the
mind in terms of a pyramid of nine different psychic tendencies of ever
more complex organisational levels.
The levels of Janet’s hierarchy of mental functions are: first, the real-
ity function; second, disinterested activity (habitual, indifferent, and
automatic actions); third, functions of imagination (abstract reasoning,
fantasy, daydreaming, and representative memory), which are consi-
dered the superior functions; forth, emotional reactions; fifth, useless
muscular movements that are inferior and which require a lesser degree
of involvement with reality in order to be accomplished; sixth, reflexive
to the elementary intellectual; seventh, language and a social world;
eighth, the ergotic world of work; and ninth, experimental and progres-
sive tendencies.
A reduction in psychological tension or lowering of the mental level
denotes the decreasing of one’s ability to use one’s psychic energy at
a high level of perceptive and integrative functioning; it also refers
to the diminished two-fold ability of the individual to first, recog-
nise and observe the details of reality here and now, coupled with the
self-awareness of feelings and ideas, and second to act on reality with
deliberate impending behaviour.
Neurotic or anxious behaviour in children of refugees could be the
result of a failure to integrate to the new environment, or a regression
to earlier predispositions and biases. Janet (1903) defined this state of
being sub-conscious as an act which has kept an inferior form amongst
acts of superiority.
Therapeutic intervention for children who have endured trauma

therefore needs to be based on not generalising and must focus on the
experience and the result of things seen, experienced, or believed by
the child. It must focus principally on helping each individual child
resolve their emotional and relational issues. As well as, indeed, aspects
of undesirable behaviour and cognitive effects of the trauma which
reduces children’s resiliency and which may affect the psychic space
and lead to a confusing and conflicting sense of self. The focus should
be on resilience to reconnect with the unhealthily dissociated part of
memory and ego states to reclaim resiliency for integration and a good
sense of self. We, from an intercultural psychoanalytic perspective,
adopt a model which is not based on psychiatric assumptions about
dissociations, which have at their core psychopathology and preva-
lence presenting a wealth of data on various forms of dissociations that
are, by and large, funded and supported by drug companies.
The common view of refugees and children of refugees who have
endured trauma and atrocity is based on a deficit, disorder, and
problem-oriented hypotheses and therefore the focus of any thera-
peutic intervention is on vulnerabilities. The emphasis in this para-
digm is on what is wrong, what is missing, searching for abnormality
in a child. The viewing of children of refugees, or indeed other trau-
matised children, through the deficit approach dismisses their resil-
ient qualities and their potential strengths. One example of this is the
use of the term “dissociation” which is determined by—and inter-
preted as—vulnerability and illness to negative life events. This is
without consideration of the biological, psychological, cognitive, or
environmental factors that hamper normal developmental processes,
and, indeed, often lacks clear understanding of the different types of
dissociation. It also pathologises the children of refugees’ reaction to the
external trauma, which really is a perfectly understandable reaction to
an extraordinary, unpredictable, scary, and shocking situation.
My clinical approach is to focus on capacities, competencies, and
resources that may exist within the individual child who has endured
trauma. The theoretical basis of this perspective does not subscribe to
one discipline but is a culmination of work in the areas of development
and constructionist narrative, but is mainly owing to work on child
development and psychoanalysis, with a specific focus on resilience. The
literature on resilience can be divided into two camps: one camp defining
resilience as a cluster of an individual’s skills and competencies, while

the other states that resilience is more about the outcome result of an
individual’s efforts to overcome adversity (Werner, 1992, 1994, 1995;
Garmezy, 1995; Rutter 1995; Kaplan, 1999; Alayarian, 2004, 2007, 2011).
This false dichotomy between internal attributes and external results
does not take into account the interplay between the individual’s per-
sonality, abilities and developmental factors, and interrelated construc-
tion within which a resilient outcome result is determined.
I argue that resilient people can control the impact of their environ-
ment within their internal world as they have a good-enough sense of
self and enough psychic space to process their experiences. They can
easily adopt reversal of roles and responsibilities if needed without too
much stress. They are more aware and more tolerant of their negative
feelings, and the negative situation around them. Another important
factor is that a resilient child may not experience the survivor’s guilt
commonly identified in survivors of trauma; and, where there is some
feeling of guilt, they are able to channel and sublimate their guilt feel-
ings into good causes, such as academic and social achievement or
helping parents, carers, grandparents or other children.
I claim that healthy dissociation is a conscious strategy for manag-
ing powerful negative emotions. This is different from the psychoana-
lytical concept of splitting, in which thoughts, emotions, sensations,
and memories are split off from the integrated ego. Healthy dissocia-
tion is something that we all do in ordinary day-to-day life with con-
scious choice. Unhealthy dissociation, however, is the result of psychic
malfunction. Psychoanalysis acknowledges the conjectures of disas-
sociation along the unconscious, but relates them differently to each
other and traces mental life back to interplay between forces that prefer
or hold back from one another. If one group of ideas remains in the
unconscious, psychoanalysis does not have conjecture that there is a
constitutional incapacity of the idea for fusion which may lead to the
particular types of dissociation that I discussed in my study (2011). Psy-
choanalysis also maintains that the isolation and state of unconscious-
ness are caused by an active opposition on the part of other groups as
repression, and as something like an unaccommodating judgement in
working with refugee types of trauma and the types of dissociations
that may be employed by a refugee. Psychoanalysis uses concepts of
repressions which play an important part in mental life. But, if we think
in terms of repression as the precondition of the formation of symptoms
presented by patients, repression is not enough, as it can frequently fail

in assessment and treatment of refugees and refugee types of trauma.
The types of dissociation presented by children of refugees and other
children who have endured trauma span the whole spectrum of healthy
and unhealthy dissociative reactions. If we assume that dissociation is
the disruption of the usually integrated functions of consciousness,
memory, identity, or sensitivity to the environment, then how is it that
some refugees through the act of dissociation survive massive trauma
and human right violations? When one is faced with life-threatening
situations, a common trauma response for us is to dissociate. When we
are overwhelmed with a sense of danger and don’t have a way to protect
ourselves, our nervous systems can automatically go into dissociation
and we may lose our ability to accurately perceive what is happening
in our environment. It is a response to situations which threatens our
survival. This helplessness is a normal reaction to an abnormal situa-
tion, so it is healthy dissociation.
I have argued (2011) that dissociation is a defence mechanism and
coping strategy consciously adopted by refugees (although there are
always unconscious connotations). The occurrence of dissociative phe-
nomena in the clinical treatment of traumatised refugees may mani-
fest in hysteria, memory loss, depersonalisation, identity diffusion,
fear of death, disruption of ego functioning or disruption of the self.
I explored the relationship between two fundamental experiences:
first, the verbal reflection on non-verbal experience; and second, the
experiences that have not been reflected on or verbalised. I am espe-
cially interested in the process of the unformulated experience which
is deeply felt and needs space, openness, a sense of wonder, mystery
and curiosity, and the sense of explicit verbal experience as it con-
tinuously emerges and constructs and can lead to dialogue between
dissociation (both healthy and unhealthy), curiosity, and imagination.
The goal of psychoanalytic treatment is to provide the freedom to be
curious, and to break down defences, such as denial, disavowal, and
dissociations, specifically unhealthy dissociations that defend against
fear of what one would think, that is, if the person allowed themselves
the freedom to think it. The unconscious can be reconceptualised by
interpretation of transference and countertransference and the inter-
personal therapeutic relations, continually moving, between the ther-
apist and patient together and the kind of interpersonal relatedness in
which they are in.
Psychoanalytic constructivism posits that the therapist interventions

is unavoidably embedded in and unconsciously participates in the ther-
apeutic process in the therapist–patient dyad. Experience is not fore-
shadowed but rather is unclear, uncertain, ambiguous, and created in
interaction. Understanding this process requires that the therapist and
patient have some proficiency in a shared language. This is the con-
dition for verbalising and communicating experiences for reflection in
order to gain insight by expressing the experience. A refugee patient
with limited English or who has no English at all will be excluded from
such therapeutic intervention, unless a professional speaks the refu-
gee’s language. The uninterrupted form of raw materials of conscious
and reflective experience may eventually be assigned verbal interpreta-
tions and thereby brought into an articulated form, including the seeds
of words and of emotions that help put feelings into words in a coherent
language. Therefore, the nature of what is possible to formulate very
much depends on the creativity and the limitations of the interpersonal
relationship. Defensively motivated, unformulated experience is not
the repression that keeps unconscious thoughts out of awareness, but it
is an attempt to cope with the anxiety of not being able to articulate and
formulate the trauma endured by a refugee. Progress in therapy is not
simply the removal of distortion to reveal pre-existing memories, but it
is, rather, a reflection of an increased willingness and ability to interpret
new experience—to have greater curiosity and freedom of thought. In
a sense, one could surrender and allow language to take its own shape
and to allow vague, inchoate senses to take their own meaningful form,
rather than forcing them in a particular direction because it is famil-
iar and therefore safer. The patient’s sense of safety can only be estab-
lished by the development of a relationship with the therapist, which
will be the beginning of a collaborative relation and process. Therapist
countertransference is embedded in the realm of experience that is not
often directly held, but can be left unattended, and the patient will find
that kind of authentic experience without the therapist knowing how to
make authenticity happen.
By humanising the uncertain feelings regarding the inhumane atroc-
ities that many refugee patients have suffered, and following the lead of
the refugee patient’s dissociations (healthy and unhealthy), the thera-
pist may create a safe space by bringing what has hurt the patient into a
meaningful relation with an experience that the patient already identi-
fies as their own.
Freud’s (1919d) notion of trauma fits into an economic

perspective—an experience which within a short period of time pre-
sents the mind with a stimulus too powerful to be dealt with or worked
off in the normal way. This can result in permanent disturbances of the
manner in which the associated mental energy activates and operates.
Freud’s view of dissociation was the removal of ideas from one com-
partment to another. His earliest notion of the aetiology of hysterical
symptoms was based on his hypothesis of the importance of trauma
dissociation, upon which he began to construct his first theory of neu-
rosis. Soon, his conception of trauma narrowed to apply only to sexual
trauma, and later only to childhood experiences of sexual abuse that
may be the result of an actual sexual trauma that has been accrued or
the phantasy of sexual scenes due to the instinctual drives. He (1917e)
devised the term “repression” to account for a patient’s resistance to
improvement and used the term both loosely to mean any ego defence,
which Anna Freud (1936) later discussed in detail, and specifically to
refer to the defence in which the idea is pushed into unconsciousness to
be forgotten. He indicated that the associated apprehension of such an
experience will remain in consciousness (that is to be aware or to under-
stand as well as to fear)—the conscious ego turning away undesirable
thoughts and memories to the realm of the unconscious as a way of
surviving unacceptable material. For example, in Freud’s famous case
study of Anna O, she developed an occasional stiffening of her arm as
the result of her phantasy that her arm would not be able to protect her
father from a snake. Anna O’s bodily symptom spoke of a relationship
to her father and her death wish toward him that she was fearful to
admit. However, neither Freud’s original theory nor his later develop-
ment of repression is enough to explain the types of dissociation I pre-
sent in the study (2011) in relation to refugees.
The dissociation (both healthy and unhealthy) I am referring to
is neither perception nor affect, but it is the thinking of experiences
pertaining to perceptions: the thoughts to which affect is attached. In
healthy dissociation, a resilient refugee can sublimate into positive
action, while, in unhealthy dissociation, a vulnerable refugee may
feel strong fragmentation, which may lead to destructiveness towards
themselves and others. These types of dissociations are quite dif-
ferent from repression, which works by actively severing affect and
thought, but affect can remain when the thought to which it is linked
is repressed. For example, in hysteria, where the affect persists when
the thought has supposedly been forgotten, something similar may

occur. In obsession, the thought—as it pertains to a childhood event—
can be accessible to consciousness, but the affect is not. The theories of
resistance, repression, and the importance of infantile experiences are
principles that constitute the theoretical structure of psychoanalysis,
and which are all related to internal trauma, conflicts, and splits to
contain and balance of one’s wish, will and desire. However, it cannot
provide an explanation of the effect of external trauma in adulthood.
This is the foundational issue for understanding the effects of refugee
types of trauma.
Freud (1915d) suggests that repression is a normal part of human
development; the analysis of dreams, literature, jokes, and slips of
tongue illustrate the routine by which our desires continue to find out-
lets. In the case of a refugee who is faced with obstacles due to their
external reality that may combine with fixation on earlier phases of
development, there is a conflict between libido and the ego and/or
between the ego and the superego. The combination of these experi-
ences in refugees may result in vulnerability and a lack of resilience
in adulthood. One can use Freud’s concept of repression and theory
of the unconscious to show how his case studies fail to examine how
people can repress thoughts; although offering insights on the use of
language and discourse which is illustrated in his cases of small words
of speech, it is clear some of his classic case histories such as “Dora”
and the “Rat Man” seem to fail to examine how people actually repress
fearful, shameful, or otherwise unbearable thoughts.
Early development: healthy and unhealthy dissociation

We know that it is within a secure relationship that children begin to
regulate and integrate a distinct sense of self, which will be directed
by various emotional systems. This can remain structurally dissoci-
ated due to the neglect and trauma a child may suffer. In the context
of chronic traumatisation, these elementary states eventually gain
higher degrees of dissociation, which is very dependent on the emo-
tional systems directing them. Dissociation, therefore, becomes the
defensive system of a child which is chronically activated by neglect
and trauma. Such a child may adopt a simultaneous or proximate alter-
nation of defence and emotional vulnerability, manifesting in inabil-
ity in relating to others, and intense disavowal of any relationships
with constant mistrust. The earlier and the more chronic the trauma,
the more extreme the maladaptive, unhealthy, dissociative behaviours
will be for the individual in adult life. Secure and appropriate care in
childhood enables the individual to alternate between good relation-
ships, while being autonomous and resilient, and having the ability to
healthily dissociate from an unbearable situation.
For a child who is coming from a neglectful environment, the pro-
gression of the series of disapproving intrusions brings the psyche to
the discarding of the self and ego function—the function of integra-
tion which leads specifically to develop a sense of self. The disrup-
tion of self-function at the level of primary affect and the sequence of
unhealthy dissociation in a traumatised refugee can be at a very high
level—it could be presented as if the person has slaved over some task
and eliminated their own soul. To bring out the underlying truth that
represents what the psyche does to itself when it dissociates in this way
and resists reality brings home the consequence of the lost attainment
of a psychic structure that has poisoned everything within. In expos-
ing the truth of this process, the objective correlation reveals the way
in which each stage of life has affected who the person has become in
the present and provides insight into what has actually occurred in the
person’s psyche.
Freud’s (1895b) discussion on hysteria and specifically in his paper
“aetiology of hysteria” (1896) described how “memory repression” or
“traumatic amnesia” can be indistinguishable. Sometimes it has a more
conscious connotation like that intended here; for instance, Fonagy
(2002) calls it going into “pretend” mode of mentalizing. However, this
is not quite how the term is considered in this work.
Healthy dissociation is redirection of attention away from something
traumatic which might otherwise interfere with or overwhelm psychic
structure, functions, or psychological well-being. The traumatic experi-
ence is temporarily dispelled from consciousness. It is an adaptive and
effective defence mechanism used to cope with the pain and fear of
overwhelming trauma. Children usually have great capacity to disso-
ciate to some degree in the face of overwhelming experiences; it is, as
I indicated earlier, a normal reaction to an abnormal situation. These
types of healthy dissociative processes can allow one’s feelings, memo-
ries, thoughts, and perceptions of the traumatic experiences to be sepa-
rated off psychologically, allowing one to function as if the trauma had
not occurred. By dissociating from a particular experience temporarily,
the child gives the psyche a break to process and digest the occurrences
within a safe and sound psychic space.
As a clinician who has worked and is working with both children
and adult refugees, I have acquired the knowledge that there is a
need for an expanded concept of dissociation and for distinguishing
the effect of a single trauma and the effects of prolonged and repeated
trauma, which may include denial and disavowal, and in some ways
may present alternations between extreme passivity and outbursts of
rage. Although strong dependency and dissociation has been related to
chronic traumatisation, there is no literature on the relationship between
resilience and dissociation, specifically in relation to the memory of
trauma. Alternations between healthy and unhealthy dissociative per-
sonalities may involve ambiguities between excessive dependency and
counter-dependency or between the degrees of actual helplessness and
hopelessness. This essential relationship between healthy dissociation
and disparities of self-doubting is vital to understanding people who
have survived trauma, with or without the pre-traumatic personality
fragmentation due to the developmental process.
The distinction I am drawing is between helplessness, passivity, and
active defensiveness on the one hand, and the way one can divide up
the unbearable experience of trauma by one’s psychic activity which
cannot be dealt with at that particular time on the other. Once having
fallen apart (passively), some people can re-associate to integrate, while
others remain passively un-integrated—and what makes the differ-
ence between these is a good-enough early developmental process and
object-relations.
The early pathway of developmental processes may encumber the
natural progression toward integration of emotional development.
Many children of refugees with unhealthy dissociative behaviours have
experienced not only human right abuses, but they have also experi-
enced considerable neglect and disruption in their environments. This
deprivation of love and care in early life can create an inherent weak-
ness as the result of being a helpless child.
The experiences of children of refugees and

the creation of psychic space
In many cases, the devastating effect of traumatic events on a child
results in the disruption of ordinary life. People may have been forced
to leave their home country and lost the opportunity to carry on with
their lives, or to say goodbye to their loved ones. But, coping with these
losses very much depends on the person’s resiliency or lack of it. The
way in which the individual child becomes a refugee, how they recount
the memories of trauma and experiences before that, and their connec-
tion with life stories in the present are vital. The observation and con-
ception that children have of their experience is a central factor in the
way in which they handle their experiences, which is a process that
could contribute to creating psychic space. The ways in which a child
of refugees may relate their stories in the present is seen as a function
of the interplay of these components. The countless ways in which
some children experienced physical and psychic invasion is made all
the more moving by the accompanying description of their capacity for
creating a psychic space.
In spite of the extreme and overwhelming external circumstances
designed for punishment by the authorities, sometimes the life histo-
ries of many resilient children allow for the creation of psychic space,
enabling them to regulate their experiences either in phantasy or by
action and to move on in life, rather than being stuck in the aftermath
of the traumatic experiences. The ability to create a space for thinking is
linked to the quality of object representations. The capacity for a poten-
tial psychic space has recognisable associations with psychological for-
mulation, such as asking for help when there is a need. This is to create
more psychic space, which has been lost temporarily due to an unbear-
able traumatic experience but can, in therapy, be recreated. The creation
of psychic space will allow healthy dissociation: a defence mechanism
that, I argue, fosters resilience. The effect of trauma, irrespective of pre-
vious personality structures, influences people and their mental capac-
ity. The ways in which affects are regulated during recall are related to
a narrative according to whether the traumatic association is direct and
full or dominated and fragmented. This is not always an either/or ques-
tion, as both forms of association can potentially be present at different
times. It seems less likely that someone would be filled with a sense of
adventure and excitement while peering out at wild animals in a deten-
tion camp, or when their mother, sister, or other member of family or
community is being raped. Many other examples can be cited where the
children of refugees have been at a severe disadvantage; the concept of
resilience and survival strategies, therefore, is not intended to overlook
the fact that refugees are deeply affected by massive trauma, regardless
of how well they may have been able to compensate for it. However,
the movement from isolation and helplessness to connectedness with
the self and others by use of healthy dissociations, seeking therapeutic

help on time, being creative in support networks, and using a sense of
humour as a coping skill are characteristic qualities of resiliencies of
many people who have experienced trauma.
Trauma symptoms as adaptive

Two primary configurations of psychopathology derive from indi-
viduals’ attempts to cope with severe disruptions of normal dialectical
developmental processes. Some individuals attempt to cope with severe
developmental disruptions by becoming excessively preoccupied with
one of these developmental issues—relatedness or self-definition, and
defensively avoiding the other. This psychodynamic formulation of
psychopathology as deriving from distortions and disruptions of nor-
mal psychological development provides a paradigm that organises
various forms of psychopathology in different form. When we see the
presentation of symptoms as a result of trauma in a child, it is important
to observe the adaptation strategies that a child may develop after trau-
matic exposure, whether in order to survive or as the coping strategy.
Then it is easier to intuit and discern a sense of what rationale this per-
formance serves in terms of helping a refugee to cope at some point in
the past and in the present, and, with further exploration derived from
the patient, to look at those patterns and understand how those behav-
iours are an adaptation as the result of trauma experience and whether
the child is anxious, depressed, or combination of both, or experiences
post-traumatic stress. The most characteristic symptomatic indications
of PTS are re-experiencing associated symptoms, including depression,
generalised anxiety, shame and guilt, which both impact the function-
ing of the child.
Psychoanalysis and trauma

Freud (1886–1933) provides awareness of three powerful forces and
their stresses on people as follows:
1. When it was thought people were rational, he indicated some of our

behaviour was based on biology, and when it was believed people
as individuals are responsible for their actions, he presented the
influence and power of society; indeed, when it was thought male
and female are determined by God, he showed the dependency of

individual on family unit and its dynamics.
2. He created the basic theory of certain neurotic symptoms as caused
by psychological traumas. Although for neuroses there is no longer
need for re-experiencing the trauma to get better, Freud’s theory
helps us to understand that a neglectful and abusive childhood lean
towards an unhappy adulthood.
3. His ideas of ego defences, the unconscious, and the way we engage
in manipulations of reality and with our own memories to pool
resources for our own needs, especially when those needs are strong,
indicate our need to learn and recognise our defences, name them
and notice them in ourselves and others.
CHAPTER FOUR
Rationale for development of

new measures
Intercultural psychoanalysis and its implications

in provision of therapy for children
Theoretical approaches to working with refugees
I argue that drive theory and its development—the object relations
theory, the concept of the self, and some aspects of attachment—
constitute important factors in working with refugees.
Psychoanalysis continues to make important contributions to the
clinical understanding of psychological development, its disruptions,
and its consequences. In this section, I draw on important theoretical
conceptualisation useful in working with children of refugees. Starting
with a reading of Freud’s “Mourning and melancholia” (1917e), and
its development, including the major tenets of a revised model of the
mind that he later termed object-relations, and which Klein (1946) and
other contemporary psychoanalysts developed further. Freud’s funda-
mental contributions have provided the skeleton for a wide range of
contemporary psychoanalytic formulations and understanding of vari-
ous forms of psychopathology deriving from disruptions to a child’s
normal developmental processes. My main focus and attention will be
given to object relations theory, taking into consideration both internal
59
and external reality and the intra-psychic relationship as it relates to

working with children of refugees and other children who have endured
trauma. A perception of self and its relation to the external world, along
with a distinction between secure and insecure attachment in early
development, will also be discussed. The self (true and false) and dis-
ruption of self in relation to trauma, vulnerability, re-traumatisation,
and resiliency are also considered as major tenets.
Much has been written on attachment and its socio-political impor-
tance and how politics can directly be related to object relations and
attachment theories. In my view, that ideas of affection inspired not
only these theories within the psychoanalytic realm and in many other
therapeutic approaches, and also the formation of new political ideas,
which is very good. However, children, and specifically children of
refugees, are completely passed over in the literature. Social respon-
sibility presents the mother–child dyad within the psychoanalytical
realm and the necessary encounter for bonding processes that is needed
for a better functioning society. Yet, again: what about children who
have lost their mother or their primary carers to politics due to opera-
tions and persecutions?
Freud (1926d) in Inhibitions, Symptoms and Anxiety indicates that the
essence of a traumatic situation is an experience of helplessness on the
part of the ego in the face of accumulation of excitation internal or exter-
nal (p. 81).
One of the most important consequences of trauma is that the event
appears to have an immediate as well as long-term effect on the child
and may alter the person’s (both child and adult) capacity for sym-
bolic thinking at least temporarily and this has a great impact on any
therapeutic intervention if the therapist is not an expert in the field.
The lack of expert knowledge can of course lead to the wrong diagno-
sis, and can therefore also lead to inappropriate treatment for the child
or young person. In theory it is quite clear to all of us working in the
field of mental health that when the capacity for symbolisation is hin-
dered, the person in treatment is poorly available for real engagement
in the process and is not able to gain insight to the situations by work-
ing through them. Fonagy and Target (1996) approached these issues
from a developmental perspective and write that “our understanding
of the mental world is not a given, is radically different in the young
child and crucially depends for its healthy development on interaction
with other people who are sufficiently benign and reflective” (p. 218).
R AT I O N A L E F O R D E V E L O P M E N T O F N E W M E A S U R E S 61
Thinking of children, therefore, is inherently inter-subjective, requiring

relationships between subjects for the individual to develop a capacity
for self-reflection.
The development of the psychoanalytic theory of mourning advanced
from Freud’s (1917e) original formulations. Despite the extensive the-
oretical and clinical literature on the attachments and object relation
theories, a primary emphasis on decathexis and identification related to
object loss has remained consistent regardless of school of thought and
clinical method. Mourning is essentially the transmuting internalisation
of the structure and function of the lost self-object. Interpretation of the
stages of mourning as formulated by Bowlby (1980) and Parkes (1987)
with, an emphasis on the transformation of the lost self-object’s narcis-
sistic function, brings helpful dimensions as the primary goal of the
work of mourning. Bowlby’s (1980) description of how the object plays
a crucial role as an activating stimulus and terminating stimulus, thus
playing an important part in self-regulation, is helpful in working with
children of refugees and others who have endured trauma. The self-
object experience as a circular system requiring the attuned presence,
actual or potential, of both self and object mourning therefore ensues
when this bond breaks; indeed, the regulatory system may partly or
completely break down, leaving no psychic space and resiliency for the
child to have thought processes.
Having said this, the attachment theory is, in my view, an integral
part of object relations, or a different way of presenting the object rela-
tion theory, and it is important in the treatment of children of refu-
gees and asylum seekers who have experienced multiple separations
and losses. Bowlby’s attachment theory (1969, 1973, 1980, 1982, 1988)
is integrated with ethology, socio-biology, psychobiology, the theory
of control systems, and the structural approach to cognitive develop-
ment, which are, by and large, embedded in the general theory and
improvement of behavioural systems and psychoanalysis. As a psycho-
analyst, Bowlby integrated these disciplines to understand the origin,
function, and development of the child’s early developmental relation-
ships. His work with James and Joyce Robertson (1989), observing and
filming children in the second and early third year of life while they
were undergoing complete separation from their mothers as their pri-
mary carer and other attachment figures, has been influential in guid-
ing the care of children in hospitals. Robertson (1989) observed that,
unless young children were receiving responsive substitute primary
care when separated from their primary carer, they typically turned
through three successive stages. Bowlby referred to these as protest,
despair, and detachment. Bowlby (1980) regarded detachment as a psy-
chological defensive process that occurs in mourning. He (1980, 1988)
discussed the predisposition to depression, from an object relations
and ethological perspective, in anxiously attached and compulsively
self-reliant individuals. According to this, anxiously attached individu-
als seek interpersonal contact and are overly dependent on others and
compulsively self-reliant individuals are excessively autonomous and
avoid interpersonal relationships.
Bowlby’s (1969, 1973, 1980, 1988) exploration of groups of instincts,
libido, and aggression, and how they are expressed in striving for
attachment and separation, and also how they provide emotional
substrate for personality development, is in line with object relations
theory. However, although Bowlby’s attachment theory has made a
major contribution to contemporary psychoanalysis, neither he nor his
followers explain what the difference is between a good internalised
object and a secure attachment. My understanding, as I mentioned
before, is that attachment is simply another way of explaining the object
relations; in the context of the child of refugee’s life, it is a feeling at
home. Relatedness and individuality, and attachment and separation
both evolve through a complex interactive developmental process.
The evolving capacities for autonomy and resiliency in the develop-
mental process are in parallel with the development of a capacity for
relatedness, a capacity to engage with and trust others, a capacity to
cooperate, play, and collaborate in social activities, and a capacity to
develop mutual intimate relationships.
Sullivan is known for his theory of interpersonal relations, though he
is also well known for his system of psychotherapy, to which it is closely
related. His (1953) theory on human experience consists of interactions
between people, whether the people are real, imaginary (as in many
dreams and psychotic experiences), or a combination of both. Sullivan’s
theory tends to assimilate with social psychology, although he rejected
the psychology of individual differences; arguing that individuality
cannot be scientifically understood, since no individual will be with-
out her or his relationships with others within the social environments.
From intercultural perspectives this is quite important, because, in a
given sociocultural context, what a person has in common with others,
as it is manifested or made manifest in behaviour, can be the object of
scientific investigation. Sullivan did not profess to know the extent to

which human behaviour embodies principles or laws which transcend
any given sociocultural setting. If there are such principles of human
behaviour, they appear to be as yet little understood, if at all. Sullivan’s
(1953, 1954, 1956) intellectual legacy included Freudian psychoanalysis,
the psychiatry of Adolf Meyer, and American social psychology going
back to Charles Morton Cooley, as well as anthropologists Edward
Sapir and Ruth Benedict.
The sense of self and the process of development

An individual’s interpersonal relations begin at birth and are signifi-
cantly correlated with the orderly sequence of biological maturation.
Sullivan (1953) refers to interpersonal relations that require an under-
standing of the development of their personalities. His theory of per-
sonality development is primarily elaboration and modification of the
individual’s social relations in connection with the demands, limitations,
consideration, and opportunities of his society. Positive and construc-
tive or disconsolate and ominous influences modulate development at
any stage of development. The quality of interpersonal relations that
individual’s can experience at home, school with teachers and amongst
peers, friends, and family are important. Although human life has ever-
changing dynamics, some changes are too saddening and fast and can
be shocking which could have a cumulative effect on individual psyche.
Hence, significant personality change, for better or for worse, can occur
at any time in life, depending on the nature and course of the events in
the person’s interpersonal relations and life in general. Therefore, social
structure and social change that we encountered directly or indirectly—
indeed, in the life of the children of refugees very much depend on an
individual child’s life experience prior to the traumatic events.
Development of a sense of self for a child is largely by means of their
environment and facilitations; opportunities of a society are interceded
in personality. The development of the sense of self will start from the
beginning of one’s life and grows through several stages, including
infancy, childhood, preadolescence, early adolescence, late adolescence,
and a period of preparatory developmental process towards maturity.
But, these stages of development are not instinctually determined and,
before one can enter into any stage after infancy in the normal course
of development, a child must navigate and cope with the previous
stage, for an engaging development within a reasonably positive and

containing environment help and advantage a child’s growth—and
abusive and neglectful environment can severely hinder and disadvan-
tage a child’s further growth.
Understanding the self and others in the context of mourning

There are structural sets of internal needs. When a child has delusional
projections, the other is always seen through the distortion of emotion-
ally loaded internal relationships which can lead to projecting onto oth-
ers the qualities the person wants to see that will fulfil these needs. At
that psychological juncture it is possible that the child:
1. Will have no realistic perception of self as object to other.

2. Will be unable to perceive the real other without contamination by
the self-internalised other that includes the relationship with the
other, in a distorted form.
3. Will be less able to perceive others as they are, the more they deviate
from the healthy associations; so, instead of a relationship that should
exist as a dialogue, any communications would exist as projections.
Understanding these concepts is helpful and relevant to working with

children of refugees, as a child of refugees can experience a total loss of
social environment, as well as a total loss of the self or at least of a part
of the self. The child may go through a consolatory or disconcerting
and insufficient model of caring which leads to a constant reminder of
loss of their parent/s or their primary care giver, with some force, as
they might be too young to understand that they have to acknowledge
the socio-political morals and principles that are involved in their loss.
Many children who have lost their loved ones may fail to grieve and,
therefore, by confusion or lack of understanding, dramatise the pathol-
ogy of melancholia—a less loving, ambivalent, distractive, and violent
grief.
In violent or oppressed societies, such as the ones children of refu-
gees often come from, aggression confuses the purposes of private and
public pain. Reflection on the issue of consolation and apprehension of
the problem of bereaved aggression are integral concepts in working
with children of refugees who have endured trauma and loss beyond
their understanding.
The development of personality throughout the life of such a child

is the result of a complex dialectical transaction between two funda-
mental developmental forces. The development of an increasingly dif-
ferentiated, integrated, resilient, and mature sense of self is contingent
on establishing satisfying interpersonal relationships, and, equally, the
development of mature, reciprocal, and satisfying interpersonal rela-
tionships depends on the growth of a mature self-definition and resil-
ience. Relatedness and development of new attachment can enable the
child to note more clearly the dialectical developmental transaction
between relatedness and self-definition.
The relational development accounts for the child’s experience is
simultaneously a ground for two different and mutually exclusive
visions of life; the ground which constitutes two incompatible visions
of life and the basic nature of human experience. This indicates that the
good object comes from the ego and resiliency needed for any child’s
developments to a healthy adult.
Freud (1919d) suggested that the notion of trauma fits into an eco-
nomic perspective—that is, an experience which within a short period
of time presents the mind with an increase of stimulus too powerful to
be dealt with or worked off in the normal way that may result in perma-
nent disturbances of the manner in which the energy operates. He (1917e)
indicated that the associated effect of such an experience, however, will
remain in consciousness; and that the conscious ego turns away unde-
sirable thoughts and memories to the realm of the unconscious, as the
way of surviving unacceptable material. He (1915d) described a precur-
sor of repression proper; and referred to trauma (1920g) as the cause of
the mental organisation. He subsequently (1923b) invoked the super-
ego as an additional agent to secure the repression of id material by the
ego, and to inhibit part of the self—the id—by another—the superego.
So, repression from his point of view is an active process and the model
depends on a flat split between consciousness and unconsciousness.
The theories of resistance and of repression of the unconscious and the
significance of sexual life and the importance of early developmental
experiences form the principal and the theoretical structure of psychoa-
nalysis that are related to internal trauma, conflicts and possible splits
to contain and balance of one’s wishes, will and desires.
Freud’s (1917e) view is that the act of entering into civilised soci-
ety involves the repression of various archaic primitive desires, and
his model of psychosexual development includes going beyond the
previous “love-objects” or “object-cathexes” that are entwined to

earlier sexual phases of the oral and the anal-sadistic. Consequently,
even well-adjusted individuals will still be disloyal to the insistent force
of those earlier desires through dreams, literature, or slips of tongue;
hence the return of the repressed. In not-so-well-adjusted individual
children, who may remain fixated on earlier libido objects or who are
driven to abnormal reaction formation or substitute formations, two
possibilities exist: first, perversion, in which case the individual child
accepts and pursues his or her desire for alternative objects and situa-
tions of sadomasochists; second, to neurosis, in which case the child’s
prohibited and disallowed desires may still be functioning but some
repression forces the repudiated libidinal trends to get their way.
Freud’s (1915) theory of repression is a normal part of human devel-
opment; indeed, the analysis of dreams, literature, jokes, and slips of
tongue illustrates the routine that our desires continue to find chan-
nel. However, when we are faced with obstacles to satisfaction of our
libido’s cathexis, or experience traumatic events, or when we remain
fixated on earlier phases of our development, the conflict between the
libido and the ego or between the ego and the superego can lead to
alternative sexual discharges. The source of our sexual discharges is the
libido which seeks to cathect or place a charge on first one’s own bod-
ily parts. For example, the lips and mouth in the oral phase and then
external objects the breast and then the mother in the oral phase. Freud
terms this “object-libido”, which can get caught up in the ego and lead
to narcissism; so a normal part of psychosexual development therefore
is the overcoming of early childhood narcissism.
Freud’s (1915d) concept of repression and his theory of the uncon-
scious, however fails to examine how people actually repress shameful
thoughts as well as children’s lack of ability to associate with the memo-
ries of trauma and inability to articulate them. Although the importance
of small words in speech is clearly identified and examined in some of
Freud’s classic case histories such as “Dora” and the “Rat Man”; which
offer insights on the use of language and discourse.
Although they differed significantly, the fundamental common
ground between Freud (1895d) and Janet (1892) was their interest in
deeper, explanatory theories of hysteria and of the nature of the mind.
Their main difference was in their methods: eliciting unconscious
reminiscences (Freud, 1895d), as opposed to suggestion or persua-
sion (Janet, 1899), as well as the origin of the unconscious (Freud) or
the subconscious (Janet). Janet thought that, under stress, parts of the
conscious mind became severed from the rest of consciousness (disso-
ciation), while Freud described an active process of the repression of
certain contents of the mind, due to traumatic experiences in the past
(Janet, 1899; Breuer & Freud, 1895d).
Dissociation, both healthy and unhealthy, involves different charac-
teristics and is, in my view, a better term for repression as it refers to
those discontinuities of the brain, the disconnections of mind that we
all harbour without direct awareness which let us step aside, split off
from our own knowledge, behaviour, emotions, and body sensations,
and indeed our self-control, identity, and memory. There are, of course,
always dialectical relations between two selves in terms of autonomy
and connection. As a basic function, people need to have the ability to
function and manage their day to day life. In an oppressive and abuse
environment where the function is against common humanity due to
political oppression and violations of basic human rights, people’s psy-
chological problems are a normal reaction and an existential reality of
their external world. This must be considered as such, rather than medi-
calising and diagnosing people who suffered oppression. In these types
of environments of conflict in which trauma is inflicted onto people,
people need to keep their prior self in order to continue to see them-
selves as human. So, the self and the sense of self has to be both autono-
mous and connected to the prior self that gave rise to what the self
became to continue to function. The potential splitting-off due to the
traumatic experience and the part that potentially disassociates in order
to survive are the principles that help the self to succeed. For the rea-
son that it is inclusive and could connect with the entire environment
when and where needed and disconnect with the part as needed: it is
rendered coherent, and gives form to various themes and mechanisms
at the same time without psychologically falling apart.
This type of splitting and dissociation has a life–death dimension in
which the self may be perceived by the perpetrator as a form of psy-
chological survival in a death-dominated environment. In other words,
people can have the paradox of a killing self being created on behalf
of what one perceives as one’s own healing and survival. So, dissocia-
tion has a function which is likely to be the avoidance of guilt; they
dissociated from others or part of the self that can be the one perform-
ing the fraudulent but successful work of surviving—this process may
involve both an unconscious dimension taking place largely outside of
awareness and a significant change in moral consciousness as well as

conscious connotations for surviving traumatic endurance.
These dissociating (healthy and unhealthy) characteristics in response
to trauma construct and encompass what psychologically goes on in
the splitting-off and dissociation from what is, at that particular time,
unbearable. The principle difference between dissociation and the tra-
ditional psychoanalytic concept of splitting is that the latter term has
had several meanings but tends to suggest a holding off of a part of
the self so that the split-off element ceases to respond to the environ-
ment or is in some way at odds with the remainder of the usual self.
This type of split is similar to what both Janet (1892), and Freud (1895d)
originally called dissociation. Some explanations are stronger or more
robust than others, however as regards to how to explain the autonomy
of that separated part of the self-confusion, my view on healthy and
unhealthy dissociations makes it possible to identify what splits in the
splitting of the psyche of a child of a refugee patient. However, either
splitting or dissociation can thus denote something about the psyche
of a traumatised child, refugee or otherwise, who has endured exter-
nal trauma. It is important to recognise that the cognitive unconscious
contains material that would be deeply disturbing if it did rise to con-
sciousness without the appropriate way of somehow working through
the unbearable experiences being available. The enduring material that
much of it is not linked to the internal trauma and earlier childhood
environments need to be split off and repressed in order to survive the
external atrocity.
Drawing on the pioneering work of Janet, Freud, Sullivan, and
Fairbairn, and by making use of recent literature, we can say the dis-
sociations can engulfs the trauma of everyday life into a relationally
structured endurance strategy that arises out of the mind’s need to allow
interaction with frightening but still urgently needed others to survive.
The dissociated self-states in my clinical work with children of refugees
are among other trauma-stress-related clinical presentations that I work
with as part of my everyday work, including patients’ expression of
dreams, projective identifications, and enactments. I am not denying
or ruling out that pathological dissociation may result when a child’s
psyche is overwhelmed by trauma and signals the collapse of relating
to others that can unfold into unhealthy dissociative tendencies.
Clinical phenomena that I have observed in my clinical practice
associated with splitting are consistent with the model of relational-
based dissociation in which alternating dissociated part of self develops
along an alignment of relational trauma. There is also dissociation in

relation to pathological narcissism, the creation and reproduction of
gender, and psychopathy. However, for a traumatised child of refu-
gee who endures sadistic and violent abuse, dissociation provides a
means to sanity and survival by splitting off their sentiments, permit-
ting healthy dissociation and compartmentalisation of experience. It
is a motivated forgetting which provides temporary protection from
the stress of horrific experiences—a manifestation in an effort to cope
with prolonged traumatic demands to contain and manage the effects
of massive trauma and paradoxical realities which may engender a
compartmentalised, dissociative structuring; it is not out of mind, but
parallel within it to keep the mind going. In conflict, unconscious inten-
tion, and personal meaning in understanding the kind of healthy dis-
sociation, it is possible to see patterns of affect regulation and dominant
object-relational strategies that can be recognised and worked through
in discourse of therapeutic relationship, mainly through narrative and
interpretations dreams and of transference and countertransference. It
is important to recognise that trauma-based notions of human psycho-
pathology and the psychoanalytic contribution with its emphasis on
unconscious conflict and meaning are, for the most part, excluded from
the discourse on dissociation, and this often results in a wrong concep-
tualisation of trauma dissociations. But the phenomenon of dissocia-
tion has been a fundamental concept in the formation and development
of interpersonal psychoanalysis as well as the development of object-
relation theories (Sullivan, 1947, 1953; Winnicott, 1945, 1960, 1965a,
1971; Fairbairn, 1944, 1952). Breuer and Freud (1895d) originally recog-
nised dissociation as the central mechanism of hysterical symptoms as
the result of a traumatic event that affected the brain’s ability to process
emotions. Since then, researchers studying the impact of trauma have
linked the phenomenon of dissociation, or the splitting off of traumatic
affect from conscious awareness as a response to every type of traumatic
experience. Dissociation is posited as a form of psychical organisation
in which psychical conflicts and threats to a coherent sense of self and
self-preservation are regulated in the mind and can be considered as a
mechanism of de-repression when the mind cannot cope with repression
anymore. Dissociative communication is not necessary for emblematic
disposition but makes use of a warning sign augmenting pseudointe-
gration of psychological being, rather than true personality integration.
So, I consider this mechanism to be the foundation of the pheno-
menon of false self that may be observed in children of refugees or
other young people affected by trauma. In this type of dissociation the

child and adult alike skilfully create an obscured line of defence, the
effect of which is to compose a narcissistic field of omnipotent con-
structions. So, the traumatised child may transform the experience
suspended beyond their conscious mind. This process involves altera-
tions in consciousness as the person becomes aware of being in a state
of ailment and may need therapeutic help before it’s too late to make
sense of the self and the environment and, in the case of refugee child,
a totally new environment. This type of dissociation should be con-
sidered a normal reaction to an abnormal situation, a phenomenon,
potentially occurring as the result of external and existential reality.
This can be understood as an extreme and uncontrolled eruption of
these normal phenomena, often elicited in the face of traumatic stress
that a child suddenly encounters. In my work with both children and
adult refugee patients, I witness over and over how individuals seem
to have an unusual capacity to control their perception, memory, atten-
tion, and somatic functions, especially in certain systems available to
awareness and to reflect not so much being in or out of the conscious
state on mind and their mental functions. For example, if an individual
child is instructed to obstruct perception of a stimulus using persua-
sive imagining, changes can be perceived in response to those stimuli
which help the child to learn to increase or decrease the flow of man-
ageable levels of thinking of the past experience. The less dissociative
phenomena therefore can provide access to regulatory systems that
also can interrelate to the person’s mind. I consider that as a healthy
dissociation that is used as a defense mechanism in order to prevent
psychotic breakdown. This is not to indicate that such a division may
not create a momentary psychotic state of mind, but it does differ from
psychosis.
In my view, healthy dissociation must be recognised as one of the
most useful concepts in working with traumatised children. It is the
function of the mind to push certain experiences into inaccessible corner
of the unconscious that can later emerge into consciousness. Healthy
dissociation, and thus separation from the conscious reliving of a trau-
matic experience, is evidence of an individual’s capacity for resilience;
by being able to dissociate from the pain of the memory, while main-
taining, for all practical purposes, emotional and physical continuity
with daily life without psychological collapse.
The occurrences of various dissociative phenomena in patients who
have endured external trauma much depends on how an individual,
a person’s early good-enough environment, could build an ability to

dissociate from external trauma in a healthy manner, and manage to
survive atrocities. The mental capacity for this type of dissociation
depends on the early good environment and formation of resilient
personality.
Those who are severely affected by external trauma and not able to
dissociate healthily may develop what in psychiatry is referred to as
dissociative disorders. These include acute or gradual, transient or per-
sistent, disruption of consciousness, perception, memory or awareness
which is not associated with physical disease or organic brain dysfunc-
tion. In such cases instead of normal development, there may be lev-
els of depersonalisation, derealisation, identity confusion, perversion,
identity alteration or psychosomatic presentations. Four types of disso-
ciative phenomena are described in DSM-IV, and there is a miscellane-
ous fifth group (Table 27–1 in DSM-IV). The distinction between these
types may be blurred, particularly when patients exhibit symptoms
from more than one type.
The healthy dissociation that I am referring to is an adaptive defence
used to cope with overwhelming psychic trauma. It is commonly
encountered during and after external trauma such as civilian disasters,
criminal assault, sudden loss, torture, and war. In healthy dissociation,
the individual’s perception of the traumatic experience is temporar-
ily dulled or dispelled from consciousness (Alayarian, 2011). Healthy
dissociation can also prevent other vital psychological functions from
being overwhelmed by the traumatic experience. The capacity to disso-
ciate healthily, therefore, should be considered positive and the patient
should not be pressured to recall memories of trauma or be offered
trauma exposure therapy.
So, I assert that post-traumatic dissociation, as an alteration in aware-
ness in the context of a traumatic experience, is a healthy dissociation.
This is in contrast to the current conceptualisation of dissociation.
Methodical approaches are needed for studying dissociation, as well
as evidence for the purported relationship between dissociative reac-
tions and PTS, if we are to better understand the experience of and cop-
ing mechanisms and effective therapeutic treatment for children, and,
indeed, adults. I challenge the notion that a linear relationship exists
between dissociation and psychiatric morbidity, and, as an alternative
to the medical module, I argue that we must recognise the evidence of
resilience within an individual’s dissociative ability following experi-
ences of trauma.
I observed that dissociation is the separation and/or splitting

off: an intrapsychic defensive process operates automatically and
unconsciously and through its operation, emotional significance,
memory, and affect are separated and detached from an idea, situation,
or object. Within this partly unconscious process by which a group
of mental processes are separated from the rest of the thought proc-
esses and become an independent functioning of mind, in which the
mind possesses the power to separates the affect with use of cognition
in order to survive the unexpected trauma and its memories. This is a
state of mind in which some experience and memory of a particular
experience will be separated from the rest of one’s being so that one can
continue the ordinary functions of prior to the trauma. This very act of
dissociation I consider to be healthy in a child or adult with resilient
qualities, keeping the personality intact by separating the experience of
trauma, which one cannot handle psychologically at the particular time
without negative effects.
When we look at which psychoanalytic ideas are helpful for work-
ing with children of refugees who have experienced trauma, we can see
that psychoanalysis provides a model for understanding trauma and
how we can deal with it through the work of mourning, language, and
dialogue, specifically reflecting on the idea of aggression as a compo-
nent of human subjectivity in mourning. The work of mourning with
psychoanalytical work is a process of elaborating and integrating the
reality of loss or traumatic shock by remembering and repeating it in
a symbolic and dialogic manner. This process can happen when there
is enough psychic space and a clear sense of self and others in one’s
world. It is a process of adapting and representing loss which may
encompass a relation between language and silence. Mourning respec-
tively involves a process of obsessive remembrance of the lost other in
the space of the psyche, replacing an actual absence with an imaginary
presence by the individual mourner. The restoration of the lost other
can of course enable the mourner to assess the value of the relationship
and grasp what have been lost in the self, by losing the other. With a
very specific task to perform, if an ordinary mourning can be facilitated
for a child to mourn the loss, he or she can seek to transform a loving
remembrance into a memory and can engage with here and now, build
hope, aspiration, and resilience.
A deeper understanding of the resilient, and the dissociations
(healthy and unhealthy) carried out in response to trauma, along with
an appreciation of children’s emotions can help us to work better with

the children of refugees and those who have endured trauma. This can
further help us to take into consideration a new perspective of children’s
development and build better solutions to their presenting problems as
well as knowing where and when it is appropriate for a professional to
give their attention.
With the resilience approach in a therapeutic environment, the cli-
nician takes social responsibility and restores the psyches of children
and young people to create more psychic space for the development
of a positive sense of self for a purposeful and joyful life. It is possible
to help children bounce back from disappointment by just being there
and building a trusting relationship with them. Children who present
frequent anger, frustration, and resentment have usually lost trust in
adults. With an appropriate therapeutic relationship they can rebuild
their trust by relating to their therapist as a role model to idealise and by
being able to communicate their concerns without fear of being rejected,
humiliated or punished—with such a therapeutic encounter a child can
feel good about themselves and also care about the needs and feelings
of others.
When children are reluctant to talk, when they present their tantrums
and lack of motivation for doing anything, when they get attached
to violent computer games or movies, they need attention and, if left
unattended, it can alienate the child from building meaningful relations
with their peers or others. A compassionate, child-centred intercultural
therapeutic intervention focusing on resilience as well as engagement
with parents or carers is an integral part of building resiliency in chil-
dren, particularly after they have endured trauma.
Generally speaking, most refugee parents have so much to think and
fear that it affects the raising of children. In many cases I observed, they
try hard to get it right but, due to their own vulnerability, are never
quite certain if they are where they should be. So, there is a need to sup-
port parents and guardians of tortured children to offer a way of think-
ing about how best to manage the struggles that children may have as
the result of the atrocities they have endured. Parents or carers can learn
how to enlist their children or foster children in solving problems and
how to help their children get unstuck. Compassion, respect, and inspir-
ing care are vital component of good-enough parenting and caregiving.
Feeling guilty and as a result being too soft, too worried, or too dis-
tracted to raise kids is not helpful for parents or carers, they need to
have some insight into the emotional lives of children and what they
need to develop resilience, optimism, and the capacity to relate to
others. By understanding this, the job of caring can become enjoyable
and child-centred without indulging pain and suffering, or denying the
child’s experience. By acknowledging the child’s feelings, we can more
effectively help them develop self-discipline, autonomy, and resiliency.
Building the kind of warm, positive relationships with children that are
key to setting and enforcing the limits that they need is absolutely nec-
essary. With solid advice and solutions to problems as well as a sense of
perspective, levelheadedness, and self-control we can guide children in
an appropriate and effective manner into their adult years.
Understanding children of refugees, specifically those who have
endured torture and other forms of abuse, requires understanding and
responding wisely to the emotions that can occupy their everyday expe-
rience and that can result from the confusing and complex experiences
they have endured as well as the alienation that the child might feel in
the new society they have joined. There is a need to support children’s
emotional health through sharing their pain as well as their joys, offer-
ing comfort when they are sad or disappointed, and by addressing any
conflicts that may occur in their mind.
There is a rich potential for further research in psychoanalysis—
compared to the medical psychiatric model of illness—that can con-
tribute to an understanding of the health and well-being of children of
refugees. Unfortunately, historical coercion within the school of psy-
choanalysis has shown lack of participation in this area, which is limit-
ing the contributions that the field of psychoanalysis can make to the
mental health for both adults and children with provision of therapeu-
tic intervention, and indeed to a better future in society at large. One of
the major disputes and limitations in psychoanalysis is the traditional
use of single case illustrations, although case illustrations provide con-
siderable developments enhancing our psychological understanding in
progressive ways. Having said that, more comprehensive psychoana-
lytic research, focusing on the role of psychological processes in anxiety,
depression, and other psychological hindrances, will contribute to and
have an impact on future directions in caring for refugees, as well as
other groups of traumatised patients.
Dismissing the role of psychoanalysis in understanding psychologi-
cal trauma and the psychological consequences of it, especially during
the formative years, would be a great loss and would be a perturbing
and frustrating shortcoming in the development of services across

boundaries. These traumas come as no surprise in a field whose
origins lie in the understanding and treatment of patients with trauma-
related anxiety and depression, and in understanding human behav-
iour beyond territorial and emotional responses, indeed to ensure that
the psychotherapeutic insights gained from psychoanalysis and treat-
ment continue to be available in patient care.
It is true that a number of economic and political factors contribute
to this deterioration—including the flare-up of neuroscience research
over the past several decades and a financial predicament that has
resulted in an cut of psychoanalytically trained psychotherapists from
the NHS and a heavy emphasis given to Cognitive Behavioural Ther-
apy, mainly with Improving Access to Psychological Therapy (IAPT)
services, and there being no room or opportunities for psychoanalysts
in the NHS due to cost-cutting. However, these decisions are still made
without any discussion of any detail with those trained in the psycho-
analytic approach. Psychoanalysts, for a century, have been a potent
force within modern mental health services and have been engaged in
teaching psychiatry. These types of political decisions, in part, resulted
from a lack of engagement with clear evidence and outcome indicators.
There is, therefore, a need for a new commitment to the use of research
techniques within psychoanalysis to once again become credible con-
tributors to the present-day mental health service in every aspect. One
way of doing so would be to move beyond the historical emphasis on
the single case study approach.
There are also forces within psychoanalysis that must be addressed
and resolved if psychoanalytic research is to flourish. Kernberg (1993)
notes two major concerns regarding empirical research in psychoanaly-
sis. The first is that “research methods that ‘invade’ the clinical situa-
tion would unavoidably, and destructively, alter and interfere with the
psychoanalytic process”. He argues that, based on work already done,
this fear has proved groundless and, further, that this research has had
a positive influence on analytic technique. The second concern he notes
is that “operationalising key psychoanalytic concepts would not do jus-
tice to their complexity, and would produce a tendency to oversimplify
definitions and dilution of essential psychoanalytic concepts”. Kernberg
correctly states that the nature of all research is to break down ques-
tions and observations regarding complex processes into simple one-
dimensional questions that are more easily investigated. He states that,
in psychoanalysis, as in other areas of research, once a body of research

has been produced, the results can be “woven together” to eventually
“restore complexity to the research endeavour that does justice to the
richness and complexity of the psychoanalytic situation”.
Cooper (1993) suggests that:
The culture of psychoanalysis and the failure of our educational

system have inhibited the appropriate development of an appre-
ciation of the importance of empirical research for the continued
advance of the field. Without empirical studies we have no way
ever to discard a hypothesis. […] Psychoanalysts have leaned heav-
ily on clinical experience to give us confidence in our activities,
although the history of medicine is replete with tenaciously held
false beliefs based on clinical experience. (p. 389)
For the benefit of the children and the future of society at large, inter-
cultural psychoanalysis should be given space to thrive as part of mod-
ern mental health services, and psychoanalysts also must make some
changes, take new initiatives and apply the methodologies that have
already been developed over the last several decades to gather data, and
develop psychoanalysis as a new and contemporary approach. As an
active clinical researcher, I recognise this is not an easy process. None-
theless, it is essential if we are to take our appropriate position within
the ever-changing society and provision of mental health and psycho-
social care for children and adults. Psychoanalysis as a profession is in
difficulty because changes in the mental health field have exposed vul-
nerabilities inherent in psychoanalytic traditions. Therefore, outcome
studies of psychoanalytic treatment are important. In addition to case
illustration and explanatory tradition in psychoanalytic literature there
is needs to look at a set of reliable diagnoses and prognoses within psy-
choanalytic and psychodynamic approach, for measuring outcome.
Freud (1923b) suggested that psychoanalysis is a method of psycho-
logical investigation, a method of treatment for certain psychological
disorders, and a body of theory concerning the functioning of the human
mind (p. 235). Psychoanalysis is also a profession, currently under con-
siderable duress and undergoing rapid change. The pressure and threat
has sources in trends of Western culture that have influenced psycho-
analysis directly, but also indirectly, through changes in the broader
field of mental health. Cultural changes and changes in the field of
mental health have exposed vulnerabilities in the broader mental health

field and in the traditions of psychoanalysis. However, it is not new for
psychoanalysis to be criticised and to be censured to some level as not
being a scientific method and therefore of little treatment value. Freud
(1895b) considered himself a clinician and a scientist whose hypoth-
eses stemmed from his work with patients (1913f). He was a persistent
researcher. Indeed, historically, psychoanalysts and psychoanalytical
psychotherapists continue to view their professions as a form of treat-
ment for the development of the mind, within the province of scientifi-
cally based health professions and empirical orientation.
There are different idiosyncrasies to the research undertakings in “the
context of discovery” and in “the context of justification” (Kaplan, 1964;
Edelson, 1984). Psychoanalysis has been successful in discovery and for
generating hypotheses and testing them within the therapeutic dyad
and direct involvement with patients, testing and retesting within the
realm of transference–countertransference, and unconscious and dream
interpretations. Nevertheless, there is a need for further investigation to
refine hypotheses and set up procedures to decide between competing
hypotheses. Grünbaum (1984) suggests that treatment outcome studies
are a crucial element in accomplishing cumulative advances in knowl-
edge in the clinical field.
Advances in knowledge in psychoanalysis from intercultural per-
spectives depend on the same procedures as any other clinical science:
careful design of studies; hypotheses; data collections, replicable data;
empirical methodology for analysing data, indicating outcome; final
results; evaluating the management of the therapeutic relationship and
its effectiveness, which some may argue as a method of treatment; and
dissemination of data, with clear input, output, and outcome indicators.
One of the shortcomings in our profession is that generally psychoana-
lysts (or those who do not come from a medical or clinical background)
have by and large not been trained in these methods and find such
practices ambiguous and questionable.
If we accept that personal development is on-going throughout
our lives, and psychoanalytic treatment is an opportunity to pick up
where we left off to redress our development, it is therefore possible to
hypothesise that resilience and the ability to dissociate are important
components of analysability in treatment; so, in this context, the ability
to dissociate with thought and memory that one may at the time not be
able to process and to deal with.
In reference to the type of trauma a child of refugees has, the child’s

psyche in its defensive state retreats into dissociation to deal with an
unbearable situation. This happens when the child has broken con-
fidence and reliance with the consistency and resilience of their core
to deal with a certain experience or the memory of it. It is as if the
core self-support systems—agency, continuity, cohesiveness, and
affect—were temporarily disconnected by dissociation during the
actual trauma and cannot be reconnected without psychological dis-
turbances. Despite this, there is an awareness that the self has lost the
familiar ground on which it usually stood. It is a move of ordinary
everyday life into a kind of defence that may restrict sublimation and
creativity. This is partly because, as discussed before, memories experi-
enced by a vulnerable child who is traumatised may pose as thoughts,
feelings, or images that do not reveal themselves as memories. They
may at times come to mind but seem relatively meaningless. At other
times, they may overwhelm the child’s consciousness and go into a
vividly remembered past (in psychiatry this is referred to as symptoms
of flashback). While in the resilient child, these memories emerge into
consciousness clearly when there is enough psychic strength that can
give pause for thought.
A periodic, interrupted or broken-up representation of a previous
state of consciousness might lead to an intense and vivid moment of
recollection, present in resilient individuals in the form of self-defining
memories in which a previous state of consciousness may be reinstated.
In my observations and learning from patients, this often seems to be
associated with awareness, which unexpectedly places the conscious-
ness in the past. They may cause feelings of revelation, recognition
and confusion, and can trigger an intense sense of the self in the past.
However, the important factor here is that, where this is not manage-
able, a resilient child or adult can dissociate healthily before getting to
the state of fragmentation. But a vulnerable person does not have the
capacity to dissociate in this way. This can lead to ego fragmentation.
These feelings consequently lead to a state of disintegration in a vulner-
able person, while a resilient person who endured the very same or
even more severe external trauma can dissociate her or himself from the
memory of trauma and turn their attention to another matter.
This means that teachers, mentors, therapists, social workers, and
other professionals in health and social care should advance their prac-
tice of care by always taking into consideration the level of resilience or
vulnerability of a child at any given time. There is no doubt in my mind

that if the communities have systematic, informed plans to give appro-
priate support to those at risk early on, many psychological problems
could be prevented for young people, leading them to a healthy adult-
hood. And, of course, the NHS and social care and society at large could
save a lot. Support from teachers of refugee students is important. It is
important to listen to the child of refugees and validate their feelings
by demonstrating kindness, compassion, and respect which facilitates
and enhances resilience. For example, teachers’ high expectations can
structure and guide behaviour, and can also challenge students beyond
their ability at that particular time.
Healthy dissociation is redirection of attention away from some-
thing traumatic which might otherwise interfere with or overwhelm
psychic structure, functions, and general psychological well-being. The
traumatic experience and its memory is therefore temporarily dispelled
from consciousness, and a resilient child who has a reasonably car-
ing and containing environment and someone as her or his listening
other can process this easily by directing their attention to study, sport,
art, or play. It is an adaptive and effective defence mechanism used to
cope with the pain and fear of overwhelming trauma. Every child or
adult dissociates to some degree in the face of overwhelming stress; it
is a normal reaction to an abnormal situation. The dissociative process
can allow one’s feelings, memories, thoughts, and perceptions of the
traumatic experiences to be separated off psychologically, allowing the
person to function as if the trauma had not occurred. By dissociating
healthily to a particular experience temporarily, the person gives the
psyche a break to process and digest the occurrences, within a safe and
sound psychic space.
One of the main questions that I have been focusing on in my clini-
cal research (2007, 2011) is: “Why do some people respond to external
trauma with a successful act of dissociation, leaving the organisation
of their world otherwise relatively intact, whereas others react with
an experience of self- and world-dissolution?” The traditional psy-
choanalytical answer to this question will simply be in terms of such
concepts as ego strength. I claim that ego strength is closely connected
with intrinsic resilience, which exists inside the mind, dissociating in
various ways in response to trauma, although this cannot be general-
ised, as different minds respond differently to the same occurrences.
I also argue that if the object relation is considered as a formation of
social bonds and symbolisations—for a child of a refugee who may

lack resilience due to the traumas—the experience and the memory of
particular external trauma and the cultural shock of separation from
a familiar environment and unfamiliarity of the new environment in
the host country may break these bonds and can potentially leave the
child in a disarray of internal violence and anxiety, and can take away
the capacity to think and to relate. This is different from the innate ten-
dency to repress, a form of splitting in psychoanalytic terms. One of the
difficult tasks for the children of refugees, and indeed adults too, who
are affected by trauma is the feeling of loss, both internal and exter-
nal, and the mourning of the self which is lost, or at least partly lost.
This is also different from the case of childhood trauma and consequent
mourning in the process of development. The main focus of care for
such a child, then, should be in creating and developing relations in the
new environment. A therapist who focuses on resiliency while work-
ing with the vulnerability that the child can present at the time can
become the child’s listening other and facilitates the process of building
relationships.
The central point is that a resilient child or adult may have the mental
capacity and the ability to experience severe trauma or neglect without
a collapse of psychological functioning, and, although the person may
develop signs of depression and/or anxiety, there will be no evidence
of what is referred to as PTSD, which is a common diagnosis for chil-
dren of refugees and adult refugees, and, indeed, for others affected by
trauma. A successful act of healthy dissociation prevents psychological
collapse simply, by way of dissociating with the unbearable memory
of trauma. This is normal post-trauma dissociation which can be con-
sidered as an alteration in the extent of awareness in the context of a
particular traumatic experience in adult life. Hence, the discussion here
will challenge the notion that a linear relationship exists between dis-
sociation and psychiatric morbidity. Below I present the case of a young
patient I shall call Ahmed.
Ahmed
A ten-year-old African boy was referred to the RTC for assessment and
possible treatment because he was doing poorly in school. He was diag-
nosed with attention deficit disorder by an educational psychologist
and prescribed medication by a psychiatrist in Child and Adolescent
Mental Health Services (CAMHS). His teacher reported that he was

constantly getting involved in fights and had no companions when
he hurt others, and alienated himself from his peers by fighting with
them. His foster family told his teacher that, at home, he would mostly
watch action movies and cartoons or play computer games and had no
friends. Ahmed was raised in an impoverished inner-city neighbour-
hood. Violence surrounded his daily life. With a single mother who
involved herself in a series of relationships with abusive boyfriends,
Ahmed found himself beaten with a belt and may have been sexually
assaulted. His mother was not home that often, and he was forced to
sit outside on the steps so that his grandmother could sell her vegeta-
bles. Ahmed’s mother was not educated and had no income. Ahmed
has never met his father or his paternal family. He was told that his
father was with rebels and was shot to death when Ahmed was little.
His mother was killed one year prior to his arrival into the UK.
In the process of my initial meeting with Ahmed, I remembered
Erikson’s (1959) theory in which he indicates that we have to move
through stages of development to have our needs met. One needs to
be psychologically ready to move on from one stage to the next. This
of course much depends on the social environment the child is in. In
ordinary development, Ahmed at this stage should be ready to take
part in activities and make plans and goals for the future. However, this
is merely how it should be, but is not how it has been for Ahmed and
many children of refugees. Without a parental figure present, Ahmed
was forced to take on too much responsibility and make too many
decisions on his own. He felt no guilt in being independent, which he
should according to Erikson’s useful theory. Ahmed’s presentation also
did not correspond to Piaget’s (1983) stages of cognitive development,
which indicated that children should construct their knowledge of the
world through reorganisation in order to move to higher levels of psy-
chological functioning. So, I felt Ahmed’s vulnerability myself in my
not being able to find a theoretical framework in which to immediately
feel at home. I could not make a decision of what to do and I found
Ahmed’s presentation complex and somehow difficult. I considered
that, before making a decision about what would be the best way of
helping Ahmed, I had to ask myself the following questions.
What cognitive development stage is Ahmed in his current reality,

for example, his internal world?
Is he moving to a higher level of psychological functioning?

Has he developed appropriate social functioning; has he lost it in
some way?
Has he related to me well; what are the reasons that he has no friends
at school or home?
Why is he constantly getting into fights with his peers and yet here
with me he seems so cooperative, responsive, and polite?
What is his ability emotionally and psychologically?
What would be my intervention and why?
Though as therapy progressed, Ahmed showed a substantial reduction

in his psychopathological symptoms and also an improvement in his
functioning, he was still depressed and isolated. The individual ther-
apy helped Ahmed to show great improvement in the manifestations
of his post-traumatic stress, although unhealthy dissociations were still
one of his main defences. My concentration was on positive long-term
outcomes for Ahmed’s emotional well-being and development of some
resilience. This, I knew, could over time result in an improved sense of
self for him.
In the process of therapy, I constantly had to be aware of Ahmed’s
young age and his level of suffering. Children at his age usually begin
to express independence and confidence in their capability that may
extend beyond their direct experience. They usually have their parents
or other adult care givers for their well-being who are monitoring and
guiding the new dimensions in their life, such as their competitiveness
and its impact on relationships at school and at home. Ahmed’s reality
was that he had to cope with his traumatic memories while simultane-
ously having to deal with the broad range of emotional and social chal-
lenges in his new environment that are experienced by children as they
grow. He was expected to take on greater responsibility and, although
he would try, he would feel failure.
I worked almost two years with this young person. He slowly
settled in with his new environments and was doing well at school. In
discussions with him and his carer we decided to stop the therapy and
for him to see one of the mentors at the RTC. We came to this decision
as, for a long period, I felt he was developing an attachment to the RTC
and to me to some degree, but did not wish to talk or think about his
traumatic experiences. The difficulty for him was separation. When I
discussed this with him, he agreed and said: “But, I don’t want to stop
coming here.” I then proposed the idea of his seeing one of the mentors
to get academic help and to be able to talk about his day-to-day issues
in school and at home. He was very pleased.
Next, I will present a qualitative process analysis of the psycho-
therapy of a young refugee patient from Afghanistan whom I shall call
Wahid.
Wahid
Wahid had suffered extreme trauma but had an amazing ability to
relate to others and in the process of assessment with me he expressed
his feelings eloquently. I will give his case history as an example of data
for analysis and give an account of the way in which I worked with this
patient and will discuss the methods of interventions that I used. My
first task was to listen, receive, and organise an account of his experi-
ences together with him and try to interpret and make meanings out of
them in order to create a containing environment. However, in the proc-
ess I needed to do more than just make meanings with Wahid. I used a
narrative construction based on certain assumptions. Although Wahid
had some self-narrative, it was somehow concealed as I realised that
he needed to retreat from what had actually happened to him to keep
going; and had created another narrative which was not as painful for
him. Indeed, he did not really recognise it as his own. So, I worked on
the basis that the aim of therapy was to introduce Wahid to the non-self-
narrative which he had adopted and at the time was part of his psycho-
logical outlook and subjectivity. This, of course, is not a straightforward
science and one can question how I knew this was his subjectivity and
not mine, and how I knew that the hidden narrative of Wahid was really
there in him and that it just was not my assumption or expectations to
which he felt obliged to respond.
Working with this young person (he was fourteen years old at the
time) was not straightforward and many times I found myself getting
lost on all sorts of theoretical boundaries and getting anxious and con-
fused about what was going on, and had to search for some clarity in
the revising literature. I found the numerous works of Freud that con-
centrate on the elaboration of psychoanalytical technique and religious
and cultural history helpful in regard to Wahid’s narrative reconstruc-
tions. These include Totem and Taboo (1912–1913), “The theme of the three
caskets” (1913f) and “The claims of psychoanalysis to scientific interest”
(1913j), his metapsychological works “Instincts and their vicissitudes”

(1915c), “Repression” (1915d), and “The unconscious” (1915e) and his
essay “Thoughts for the times on war and death” (1915b) in which he
elaborates his ideas about the outbreak of the First World War and the
consequences of the conflict between culture and instinctual life. Freud
compared the analyst to the archaeologist in the way he “digs up”
a patient’s past in the form of memories, associations, and the like.
My therapeutic approach in intercultural psychotherapy is based on
psychoanalysis and relational interaction in the processes which lead to
improvement, greater integration, and development in patients. I find
this productive in working with people whose lives have been affected
by trauma and whose experiences have made them lonely, isolated,
and, in some cases, out of touch with others, and, in others, out of real
touch with their own experience because of the external trauma that
they have endured. This is quite important as, by and large, psychoana-
lytic literature discusses the trauma of birth and childhood, but not the
actual external trauma experienced by children of refugees and in adult
life. Of course, the patient’s childhood trauma is very important in
child development and personality formation, but a child of refugees’
patient may present extra and specific schemata that can be the result of
external trauma that can continue into their adult life, if it is left unat-
tended. I have also taken into account Erziel’s (1956) suggestion that the
methodology of psychoanalysis has to be clarified before the discipline
can be validated to ensure that I understand the process and have a
validated intervention. Erziel (1956) suggested a method of investiga-
tion in observation of events in the “here and now”, as opposed to a
history or archaeology that reconstructed particular events from the
past in order to explain present conditions. Psychoanalysis is widely
assumed to fall within the latter category. He (1956) indicated that
Freud compares the analyst to the archaeologist in the way he “digs
up” a patient’s past in the form of memories and associations, and so
misses the very “here and now” aspect of material which was “uncon-
sciously selected for (the analyst) by the subject of his investigation, the
patient […] presented to him […] both spontaneously and in response
to the analyst’s interventions” (p. 31). In attempting to understand a
patient’s behaviour, he asked himself what made the patient do and say
particular things in front of him at specific moments in time. Then he
passed interpretative comments back to the patient, which he said were
“a kind of reality testing and arguably the essence of psychoanalytic
therapy” (p. 39). He demonstrates how the use of recordings and the
playing-back of sessions made it possible to test hypotheses of human
behaviour through closely observing interactions between the patient
and therapist. He also noted the importance of transference in the
therapeutic process, suggesting that it could have both positive and
negative effects on the patient and result in either improvement or
deterioration in its “aim at avoiding frightening impulses towards the
analyst” (p. 47).
The other specific concept that I have taken into account as a relevant
concept in working with Wahid, as I do with many other patients in
general and specially with adolescents, is John Steiner’s (1993) “psychic
retreats”, which I understand to be states of mind into which patients
can withdraw in order to evade anxiety and mental pain. When this
happens, patients become restricted in their lives and “stuck” in their
treatment, or experience a total withdrawal from reality. The essence
of Steiner’s (1993) discussion is relational; that is, when a therapist is
able to successfully contain elements projected onto her or him by the
patient, the patient may feel understood.
In my clinical practice, since the object of the study is a therapeutic
dialogue, there will always be a journey from the reality of the speak-
ing, that is, the patient’s presentation and the therapist’s understand-
ing and interpretation. The process and the reflection on it helping me,
I have been through my notes of each session, transcripts of analy-
sis and working through, as well as my verbal communications and
reports in supervision and consultation with my peers, written periodic
progress reports, and the patient feedback of the process. The point of
this process is not to ground the text or the result as part of the valida-
tion process, but to acquire knowledge of appropriateness of the inter-
vention for the particular child. My intention wasn’t just to try and gain
evidence for supporting the text but rather to try and help the child at
hand. Consequently, my emphasis is on pragmatic validation, that is,
the usefulness of therapeutic interventions and tangible results. This is
in my view a useful process of monitoring and evaluating therapeutic
encounters and validating the result, as the psychoanalytic therapeutic
process is an open-feedback system, where both patient and therapist
are constantly making more or less explicit adjustments to each other.
Validating this process requires a methodology adjusted to this charac-
teristic. Therefore, the emphasis on the tentativeness of the conclusion
can be in qualitative methods as well as have some quantitative data
for empirical validation. We can simultaneously accept that conclusions

in psychoanalysis are always tentative, while still legitimately using
some of that information quantitatively. So, the qualitative aspects are
psychoanalytic data which are subtle and fluid.
My intention in the process was to broaden and deepen Wahid’s
knowledge about himself and his relations to others by focusing on
transference. In broadening his prospects, interpretations are made;
the use of language, text, and narratives to the level that would be
understood by Wahid in context and appropriate for his age, and by
acknowledging that my first interpretation may not be final, but only
something to get the journey of interpretation started. Wahid entered
therapy with problems at many levels of assimilation. It was within the
therapeutic process, that as his listening other, I, with him, developed
a continuous movement of thoughts and insights that created progress
for the change and the development of resilience. In our initial meet-
ings, I became aware of some aspects of resilience in Wahid’s presenta-
tion which provided a usable foundation on which to build and which
also provided possibilities for Wahid to exercise his ability to deal with
his vulnerabilities in the process, as he was getting more in touch and
could construct his real narratives without psychological disturbance.
The methods I used with Wahid, and, of course, with other children
and young people, are of a dialogical view on intercultural psycho-
analytical psychotherapy that is consistent with object-relation theo-
ries with constant focus on the encounters between the patient and
the therapist’s inner world, both at the conscious and unconscious
level and interpretations. Thus, all of our speech, including the inner
speech of the patient and myself, addresses me—the therapist as the
listening other—which will be constantly, both consciously and uncon-
sciously, part of the process as a second party by means of transference–
countertransference. This of course may be presented in the form of a
third party at the conscious level of the patient—that is to say, there is
always something beyond the immediate transference object. The dual
nature of responsive understandings allows the message to stay and
live with me as the therapist, the listening other, without being given a
final meaning, but instead allows a new meaning to appear as and when
the child will be ready for interpretation of transference. This is the inte-
gral part of the therapist’s position and the essence of being a listening
other whose job, by being a listening other, is to provide a holding and
containing environment for the patient’s anxieties and uncertainties, so

that they may develop their sense of self and be allowed creation of
more psychic space and resiliency.
Another important factor in intercultural psychoanalytic psycho-
therapy with specific focus on resilience as a method of therapeutic
intervention is that I, as therapist, make it my business to always take
into consideration my patients’ verbal communications when they talk
about an experience and, with the patient, make the transition from
the non-symbolised position—where, due to the trauma endured,
the patient’s experience is represented mostly as bodily signs and
behaviour—to an embryonic and basic ability to formulate traces of the
experience and verbalise it. So, when speaking about the experience,
the patient establishes the ability to place it in a temporal perspective
and also situate it in relation to different social and psychological con-
texts. I then, as the therapist, need to carefully observe words, sounds,
and expressions, and to make a distinction between them when the
patient is speaking about their experience—that is, speaking about a
particular experience—or reflecting on the particular experience to
identify the feelings and verbalise them so that I may gain insight into
what’s going on.
When reflecting on the experience, the patient and therapist are able
to explore the emotional meaning of the experience together. This will
provide the patient with the prospect of looking at the reorganisation
of the self and, therefore, of opening up a readiness for sublimation,
integration, and further resiliency. At each level, I, as the therapist and
as a listening other, am situated in specific transference positions by the
patient who consciously or unconsciously needs or demands a specific
form of responsive understanding. Therefore, my ability as the thera-
pist is to learn to make these distinctions as necessary in forming an
idea of the way in which the world is organised, articulated, and com-
municated by a patient such as Wahid. Patterns and sequences may
frequently be derived from the patient’s self-narrative, which is helpful
in suggesting how they relate to various aspects of themselves. One of
my main focuses in therapy is the communication patterns mediated
by non-verbal signs and the metaphorical aspects of meanings in the
patient–therapist discourse that need to be identified and addressed
in transference and countertransference interpretation to help gain
insight into the matter. My countertransference feelings and fantasies
are always other sources for identifying non-verbal communication

patterns. So, in order to observe and analyse each situation, I usually
take a number of steps in the process, which I briefly discuss below.
First, to define the patient’s position in terms of both explicit and
implicit object positions, meaning and presentation need to be observed,
identified, and clarified. The self-aspect presentation of I or Me, as well
as the use of You in verbal communications to understand who the You
the patient is referring to is, and ask clarifications from the patient to
have a clear understanding before making any assumptions or interpre-
tations based on my assumptions which could be wrong. My position
as a therapist is on the absolute need to learn what position the patient
is speaking from and to distinguish which I or Me is speaking to which
You—this is important for understanding whether the patient is refer-
ring to different parts of the self with which he can associate easily,
and/or the parts which may be difficult for him to make direct associa-
tions with. The ways in which a patient can or will relate to their wishes,
phantasies, and fears, and how these results are presented, along with
what is being addressed in terms of object relations perspectives. Fur-
ther, to follow the development of these positions through the identified
sequences and clarifications, I ask the patient to help me to understand
him. This will help to specify the I and the You positions as material in
the process of going further and help to clarify when more than one
position is presented in object relations. This is especially important
when working with children of refugees in general and, more specifi-
cally, with young children and adolescents who have been affected by
multiple traumas and who may have difficulties in expressing them-
selves due to cultural barriers or lack of a language or the fear of being
themselves in the presence of others. It is therefore, I find, important as
the therapist to clarify and understand the situation before offering any
interpretation for working through what has been said or presented by
non-verbal communications.
CHAPTER FIVE
Assessment
Assessing resilience and vulnerability in children

who have endured trauma
Although psychoanalysis is mainly practised privately, therapeutic
intervention for children of refugees, asylum seekers, and unaccompa-
nied minors is, by and large, catered for by CAMHS, social services,
schools, and other voluntary and statutory services. Within this context,
I see our tasks as therapists to be:
• To include culturally and linguistically appropriate workers in the

team as and when possible.
• To provide the opportunity for the child and parents or another mem-
ber of family to choose their therapist.
• To provide therapeutic models with philosophical and anthropologi-
cal reorientation and adjustment to take into consideration cultural
and linguistic differences as well as different phases in people’s lives,
taking into consideration the situation before flight, during flight,
and since the arrival in the host country.
• To analyse and implement the suppression or expression of the
trauma in cultural contexts.
89
• To make communication with the patient and with other agencies

involved essential, while respecting confidentiality.
• To focus on supporting refugee parents in the difficult task of raising
their children in a new cultural environment (as often, by the time the
newly arrived parents feel settled enough to involve their children in
wider society, it is too late).
Working to serve children and young people of refugees who typi-

cally have little faith or trust in themselves or their parents and whose
views are often not understood or valued in institutional settings
and in which they may be met with suspicion and even contempt is
challenging. Although it is not without challenge, the intercultural
therapeutic approach can be much more helpful for an effective out-
come. We need to accept that we all might have preconceived notions
about what is best for others and, working interculturally, we need to
constantly remind ourselves to come back to what people themselves
are asking for—and not what we want to give them. Putting this per-
spective into practice is essential for ensuring services are relevant and
meaningful for those we set out to serve.
As we review and evaluate our work there are several questions we
need to raise such as:
What role should we serve and what capacity do we have to

fulfil that role in the important job of being a listening other
to a traumatised child living in a totally new culture and
community?
Who can we ensure will provide appropriate therapeutic interven-
tion and be respectful of people differences?
How can we identify linguistic gaps and develop culturally appro-
priate communications and build our capacity to be able to pro-
vide diverse intervention within patient’s remit?
The initial meetings or interviews

It is central to successful clinical practice that the full range of distur-
bances in the individual is explored. This exploration can largely be
covered in the initial meetings. This brief chapter outlines some impor-
tant factors to consider in the initial assessment of the therapeutic set-
ting with specific attention given to refugee-related issues. Particular
ASSESSMENT 91
emphasis is placed on the importance of gender, and consideration is

given to the possible intercultural nature of the therapist–patient dyad
in transference–counter transference, free association, and interpreta-
tion. The nature of the refugee patients is outlined, highlighting the
difficulty and importance of differentiating between needs associated
directly with external trauma, and needs resulting from being treated as
a transitional object by mothers or other primary caregivers.
It is important to mention that there is an increasing body of research
on identifying, “diagnosing”, and “treating” psychological trauma and
trauma-related mental health problems and also on culturally deter-
mined means of communicating psychological distress and of articulat-
ing symptoms in relation to both adults and children. My discussion
calls for increased focus associated with the need for suitable services
available to a rapidly growing population of displaced peoples, immi-
grants, and refugees uprooted by the global problem of armed conflict
that shows no signs of ending or lessening, not just for children and
adults within the UK, but around the world. I would also like to note
that, since the 1980s, numerous non-analytic trauma treatment models
were developed which were collectively referred to as “trauma debrief-
ing models”. A common prescription of these models is to encourage
the person to re-tell the trauma story in as much detail as possible.
While I do not want to critically discuss these methods or their vari-
ants here, I want to emphasise that, in my view, based on my clinical
experience and observations, there is no convincing evidence yet as to
whether trauma debriefing aids or hampers the traumatised person’s
psychological recovery, or whether it is just temporary symptom relief,
or even sets the person up for breakdown.
So, that said, I would like to keep my focus on the psychoanalytic
approach in assessing children of refugees who have endured trauma,
which is to make no assumptions for treatment, but to explicitly verify the
patient’s explanations together with them, and to search for the underly-
ing rationale of clinical encounters—transference–countertransference.
It is important for the therapist to be aware of how the individual
child’s psyche may find hidden paths within the constraints imposed
by the patient’s cultural beliefs. It is also vital to recognise the contro-
versies of and to have constant awareness of them and to not resort to
“diagnosing” social and political problems related to violence, war, or
poverty as being psychological disorders. By giving a diagnosis of, say,
PTSD, which many clinicians feel at home with, especially regarding
refugees, we consciously or unconsciously consider the social suffering

as a disorder and adopt a medicalised model that pathologises people
who are persecuted under a repressive regime, or as a result of particu-
lar beliefs or principles, or of ethnic cleansing (i.e., what is generally is
happening in the external world).
Many asylum seekers, refugees, and their children, and, indeed,
unaccompanied minors too, experience both pre-migration and post-
migration adversities which are likely to affect them one way or another.
Pre-migration adversities include experiencing loss or separation from a
loved one or one’s cultural environment, fears or a witnessing of organ-
ised violence or persecution and torture. In the UK, post-migration dif-
ficulties include uncertainty and anxiety about asylum applications for
adults and young people at eighteen years of age, social and cultural
isolation, loneliness, exclusion, discrimination, poverty, lack of care or
stable housing after eighteen, and uncertainty about the future. Other
issues include dispersal, detention, and denial of the right to work or to
education (for adults over eighteen years old). A considerable concern
has been raised in the UK that the long periods taken to process asylum
applications leave a state of uncertainty for asylum seekers and refu-
gees that can certainly be detrimental to their mental health and can
destabilise the integration process.
These harsh conditions and the cultural diversity of refugee popula-
tions are likely to make meeting their needs a considerable challenge
for UK mental health services. The limited research so far published
about the mental health of UK asylum seekers and refugees has mainly
focused on the epidemiology of post-traumatic stress disorder (PTSD)
and the pre- and post-migration adversities of adults within refugee
and asylum seekers community originating from only certain regions.
So the children are missed out.
International research on the mental health of refugees (includ-
ing all of UNHCR’s and IRCT’s) from 1959 to 2002 comprises fifty-
six studies in total. A meta-analysis (http://www.ncbi.nlm.nih.gov/
pubmed/16077055) of predisplacement and post displacement factors
associated with mental health of refugees and internally displaced persons
suggests that: refugees were found to have moderately poorer psycho-
pathology in comparison to non-refugee groups. The post-displacement
environment was found to moderate mental health outcomes. For exam-
ple, worse outcomes were found for refugees displaced internally in
their own country, living in temporary or institutional accommodation
ASSESSMENT 93
and experiencing restricted economic opportunity. Refugees who were

older, more educated, female, and had higher pre-displacement socio-
economic status also had worse outcomes. The clinical characteristics
presented in literature and the medical model of diagnosis which is
complex, with a wide range of diagnoses and high rates of co-morbidity
is not best way of dealing with people with existential traumatic endur-
ance. The most frequent diagnoses were depression and PTSD. Many
had recorded psychotic symptoms but no diagnosis of psychoses. A high
proportion of patients suffered from physical health problems due to
injuries related to war or torture, or attributed to rape in their country
of origin. The post-displacement environment was found to moderate
mental health outcomes. Worse outcomes were observed for refugees
living in institutional accommodation, experiencing restricted economic
opportunity, displaced internally within their own country, repatriated
to a country they had previously fled, or whose initiating conflict was
unresolved. Refugees who were older, more educated, and female, and
had higher pre-displacement socio-economic status and rural residence
also had worse outcomes.
In my clinical assessment and intervention I have found that focus-
ing on resilience to identify vulnerabilities and looking for possible
healthy dissociation, or the lack of it, are useful indicators that help
to distinguish whether a child presenting with intrusive thoughts and
anxiety has serious psychological difficulties and trauma-related anxi-
ety in which somatic presentation involves inhibition of the sympa-
thetic nervous system, a restriction in the range of system variability,
and resulting physiological rigidity at rest and when confronted—or
whether it is simply an existential anxiety.
Freud’s (1900a) preference, in line with the influential philosophy of
Spencer and Darwin, was to think of resilience in terms of individual
and cultural developmental shifts in time as linear—back and forth
or up and down—identifying regressions as basic overlapping linear
events. We may prefer a different model but it is still hard to know
to what degree we are caught in a vicious cycle under the destructive
power of a repetition compulsion or, more optimistically, a progressive
distortion—taking into account our own resilience and its effects on the
growth opportunities for our patient and our self.
Theoretical formulations and my long-standing clinical observa-
tions indicate the value of viewing various forms of psychopathology
not as collections of manifest symptoms, but as disturbances of the
normal dialectical interaction of two basic developmental lines: the

development of mutually satisfying reciprocal relationships and the
development of a differentiated, integrated, positive, resilient, and
realistic sense of self.
In working with children and adults who have experienced horren-
dous trauma, we constantly take risks and offer ourselves to destructive
use within the often unsafe social reality of our patients, creating and
maintaining an analytic space for use when required. Through such
readiness we are providing a role-model as well as a life-affirming and
much-needed space to refugees and asylum seekers and indeed other
traumatised people.
By offering ourselves to be used by our patients in this way, we say
something important about ourselves and about those in therapy with
us. Working with severely traumatised people makes us re-focus on the
dynamics of destruction and survival. Resilience in ourselves or in our
patients provides the curve and frame for emerging from the void, and
enables us to give voice and shape to the unspeakable experiences that
the majority of our patients live with. To offer ourselves to be used in
this way is not straightforward and may bring many challenges, but
it is a moral stance, an act of humanity and generosity towards those
who need help. To be used in this manner, despite numerous and well-
known setbacks, is an indisputable necessity.
Steiner (1993) discusses psychic retreats in line with Freud’s ideas
of fetishism. Steiner explains how the hold of the psychotic part of the
personality is strengthened by perverse, lying relationships forged
between disparate parts of the self, permitting psychotic retreat from
reality by allowing a simultaneous acknowledgement and disavowal of
the truth of an experience. He talks about the nature of interpretations
and how they are likely to be received by the intensely frightened and
hostile patient, who fears the abrupt and permanent loss of the psychic
retreat. He located the psychic retreat between the “paranoid-schizoid”
and “depressive” positions.
Further, Faimberg’s (2005) ideas of generational influence in the
“transmission of narcissistic link” and Ferro’s (2004) discussions on
“seeds of illness” in traumatised people are useful concepts in working
with traumatised people, particularly with refugees.
Bearing in mind that the exiled self may develop from the earliest
developmental phase, as the emergent self-experiences repeated trau-
matic impingements, coupled with the absence of reparative moments
ASSESSMENT 95
and something good that could help to improve a bad situation as well
as the traumatic events later in life. The absence of these good moments
pertaining to or involving reparation is the pattern of the care-giving in
people with a history of trauma. Bowlby (1969) discusses the mother–
infant empathic attunement that results in the formation of secure
attachments which he called “secure base”. The absence of attunement
and those reparative experiences in early life could lead to a child’s
development of the sense of self. So, instead of developing a psychic
space to relate to the self and other with sense of self-esteem and relat-
edness, the appropriate developmental task at this stage—direct to the
path of vulnerability. Over time, repeated impingements can result in
a progressive detachment from the caregiver, precisely at those criti-
cal moments when the child’s emergent self needs to be connected for
the development of a bond and an interpersonal relationship. There-
fore, the vulnerable-self evolves from early phase of the emergent self,
a developmental phase prior to that of what Steiner (1993) calls the
“psychic retreat”.
This division and idiosyncrasy in early developmental stage can
have major implications for the development of later life difficulties
in adult life, indeed in treatment. The troubles of silence that may be
developed by an individual child due to an environmental impinge-
ment form characteristics that may lack interpersonal interactions. It
is for these reasons that the offspring of traumatised people witnessed
that silence, that intended exiled parents/care-givers, that very closely
influences their developmental processes. Children of such parents
are the bystander and intimate witness to the survivor’s intended
exile. They are also participant witnesses, precisely to those vulnerable
moments when hungering for relatedness becomes unbearable—where
instead they met their parent’s wall of silence. Hence, the relationship
between the parents with the child’s needs to related, is not handled
carefully, and could create an interpersonal trauma for the child, a dou-
ble exile, or cross-generational exile—and the moment that trauma is
transmitted. To go beyond the wall of silence, requires resilience for
hope to reclaim the experience and to return to relatedness. The dou-
ble pain of revisiting the trauma those parents’ experienced, to meet
and reclaim the child’s transmitted traumas, to revisit unspeakable
feelings, to give them names, to break the wall of silence—and to deal
with shame, humiliation, guilt, helplessness, confusion, and chaos
needs resilience, hope, and courage. To revisit the moments of trauma
transmission the person need to confront, to name those pains and to

dismantle the walls of silence, perhaps in therapy, which is threatening
and cannot be achieved without a resilient quality.
Epidemiological research by the World Health Organization (2000)
shows that one out of two people have been or will be seriously trau-
matised at some point during their life (by war, violence, rape, cruelty,
incest, etc.); one in four will experience at least two serious traumas.
The rest are also bound to fall on some hard times. Yet the notion of
resilience, which is a person’s ability to grow in the face of terrible
problems, has not been systematically and empirically studied. This
could partly be because people who endured trauma were considered
as victims and generally people do not cope well with victims, they
either love to help them and become over-involved and over-protective
or hate them and regard them as guilty of something and avoid a real
engagement.
Early childhood and the development of healthy attachments that are
classified as “secure”, “avoidant”, “ambivalent or resistant”, and “dis-
organised/disoriented” are important in identifying the development
of resiliency which can help the person surviving trauma. The expres-
sion of the emotions in children aged between eighteen months and
four years and the effects of separation from their parents are illustrated
by James and Joyce Robertson (1989), capturing the child’s intense reac-
tions of “protest”, “despair”, and “detachment”.
Mourning for losses, as I indicated earlier, is another important
factor in resilience. The fundamental issues of how mourning affects
people is discussed by David Aberbach (1989), who gives examples
of novelists, poets, and philosophers from Whitman and Lawrence to
Spinoza and Pascal, and provides revealing insights into individual
experiences of bereavement and the ways that loss can be both a force
and subject of creativity.
Josephine Klein (2004) wrote about an experiential group in which
her students became disoriented and uprooted. She described her
impression of the unanticipated impact of hearing the testimonies of
trauma which the students had been enduring in their lives. The memo-
ries of their trauma were discussed at length at their own pace in the
informal privacy of the group run at the Refugee Therapy Centre. Even
though the foundation of the course as whole had been particularly
literate and eloquent, after the experiential hours, both students and
teacher remained somehow inarticulate and speechless. A number of
ASSESSMENT 97
times they looked subdued and kept their silence as they left the Centre,
which is not unusual for this type of group. What was unusual in this
group was that the experience did not end in silence, but instead, fer-
mented into endless and relentless talking in the weeks to come: a talk-
ing which could not take place within the confines of the classroom but
which somehow had to break the very framework of the class and thus
emerge outside it at the Refugee Therapy Centre, a place which could
provide an elution (process of extracting one material from another) of
containments for these students and anyone feeling to be in exile and
seeking a real refuge.
CHAPTER SIX
Resilience
Resilience and vulnerability

This chapter focuses on the methodology and evaluation of the
development of a resilience approach. Using case studies, this chapter
further explores a resilience-focused approach to working with chil-
dren of refugees and unaccompanied minors. I will be illustrating two
vignettes, a boy and a girl, whom I shall call Abdul and Nastaran.
What is the problem?

The frequently held view has been on deficit, disorder, problem
behaviour paradigm with too much emphasis on risk factors that
define what is wrong, missing, or abnormal, rather than considering
the roots of a person presenting problem and how they can be helped
to make positive changes. Viewing people’s difficulties through a defi-
cit lens proscribes grasping and valuing strengths, resources, resilience,
and capabilities. This leads professionals to categorise individuals,
families, and groups only for their vulnerability to negative life out-
comes. Risk factors have historically been identified as biological, psy-
chological, cognitive, and environmental conditions impeding normal
99
developmental processes. Once normal development is delayed,

vulnerability is increased. This particular view labels people according
to their problems or deficits without recognising their resilience.
The approach I use in my clinical work is to focus on capacities, com-
petencies, and resources that may exist within the individual child of
refugees who has endured trauma. The theoretical basis of this perspec-
tive is not attributed to one discipline but is a culmination of work in
the areas of development, constructionist narrative, but mainly owing
to child development and psychoanalysis. The literature on resilience
can be divided into two camps; one camp defining resilience as a cluster
of an individual’s skills and competencies, while the other states that
resilience is more about the outcome result of an individual’s efforts
to overcome adversity (Werner, 1992, 1994, 1995; Rutter, 1995; Kaplan,
1999). This false dichotomy between internal attributes and external
results, does not take into account the interplay between the individ-
ual’s personality, abilities and developmental factors, and interrelated
framework within which a resilient outcome result is determined.
The approach I use focuses on and emphasises strength upon child’s
capacities, competencies, and resourcefulness that exist within and
outside of the individual, the family, or the community that the child
knows. The theoretical basis of this perspective cannot be attributed
to one source or discipline but is a culmination of work in the areas
of developmental resilience, the intercultural therapeutic approach and
wellness, and constructionist narrative through social support, clinical
psychology, psychiatry, child development and last but not least psy-
choanalytic theory and its applications.
Despite atrocities some individual children may remain competent
and psychologically well in the face of adverse traumatic experiences.
The successful negotiation of adverse conditions and circumstances is
not limited to a single explanation within or outside of an individual
child, but are developmental and process oriented. They identify and
reveal internal resources, strengths and resiliency, which exist within an
individual child, the family, or the community as they occur in specific
problem contexts.
By focusing on and emphasising strengths, the innate resilience of
an individual child of refugees will provide the ability to assist them
in their attempts to overcome the trauma they have endured. I am
not suggesting that we ignore the child’s vulnerability. I am uphold-
ing and disseminating the view that focusing on resilience rather than
RESILIENCE 101
vulnerability increases the abilities and inner resources that allow a

child to cope effectively. This will enable a child to work on vulner-
abilities with the challenges of living in their new cultural environment.
Many children of refugees who may initially be seen as helpless, hope-
less, and without resources are able to make significant positive strides
when their own strengths and abilities are identified, emphasised, and
built upon within the context of the adverse conditions they have been
in and from which they may continue to suffer. This implies that there
is great potential for change in the child which may get lost if we do
not bear in mind the importance of identifying some strength and resil-
iency in the child. As the therapist and the listening other for a child we
have the option to see their strength, even if much of their presentations
indicate the child’s vulnerability and change how the child will be per-
ceived. When children are seen differently by educators, mental health
professionals, and others in the helping profession, they are given the
opportunity to see themselves differently and can then easily respond
to our observation and interpretation. This is the best stage to work on
the child’s vulnerabilities without causing too much stress beyond the
child’s capacity to cope with it and to turn the child’s vulnerability to
resiliency step by step.
Methodology, monitoring, and evaluation

What methodological approach should be used?
The method of approach for enhancing or encouraging resilience
has to be examined carefully. One way is perhaps taking theories and
applying them to clinical observations, which is quite different from the
traditional method of psychoanalysis, which is to derive theory from
clinical observations. This method may contribute to show explicitly
the relation between the psychic systems at the level of the individ-
ual and at the level of social functioning; taking into consideration the
unconscious fantasies that mediate the interaction between the internal
system of parts of the individual and the external system of people in
society. It is necessary to explore the correspondences between internal
and external object relationships, and of projection and introjections.
But then these general system theorists would only have discovered
another psychoanalytic discovery. The alternative is for the psychoana-
lytic method and approach to continue to generate theory from clini-
cal observations, focusing on resilient factors in people’s personality,
specifically on mechanisms of defence, and mainly on denial and

disavowals.
So, the building or rebuilding of resiliency through therapeutic work
is a key ingredient for helping children to develop an ability to cope
with traumatic memories. It is this level of research, and others’ pio-
neering to develop robust scientific evidence around the issue of resil-
iency, that we, as clinicians, can build bridges with to collaborate and
share findings in an effort to improve the provision of the services for
children of refugees and other children who have endured trauma, who
are in need of having a good-enough listening other.
Indications of vulnerability and resilience

It is from cultural diversity, power, and status differences within child-
hood which determines why children of refugees are in danger during
armed conflict, also why children in different categories may adopt dif-
ferent coping mechanisms, predispositions, stamina, strengths, resil-
ience, and vulnerabilities. Most cultures have some social characteristic
and idiosyncrasies about children in different social groups, such as
gender, class, race, ethnicity, religion, and other cultural factors, that
play a significant position and function in the process of child develop-
ment within the child’s particular culture. Most children of refugees
are exposed to danger and put at risk not through chance but because
of who they are in terms of how they and their family are valued
and treated by their communities discriminating children in differ-
ent groups during war and conflicts as well as the political situations.
Armed conflicts often heighten differences between children, placing
inappropriate demands as well as removing pre-existent protective fac-
tors on those children who have less power or less social value. So, the
relationship between social power, children exposure to trouble and
hardship critical issues needs to be taken into account when we are
working with children of refugees. In countries experiencing conflicts,
either civil or political, children’s welfare is often neglected, through
abandonment, sale, and use in the army, some are separated from the
family home due to the job market, prostitution, and child slavery or
the militia. To reduce the economic burden on very poor families, such
children either have to generate income, or create political alliances that
are critical for the economic or physical security of the family. Due to
RESILIENCE 103
extreme poverty, some children are sold to traffickers who market them
into prostitution.
Longitudinal studies of risk and resilience (for example, Werner &
Smith, 1992, 1998), have emphasised the importance of gender in chil-
dren’s responses to adversity. Children who are affected by armed con-
flict often report to us within the clinical setting that they have been at
risk and exposed to a range of stressors, left feeling as though no one
would ever protect them and that they have been abandoned. This inse-
curity cultivated through these experiences, therefore, often influences
the child to adopt an active strategy to survive. Through this strategy
they become more resilient, becoming more independent and encour-
aged to unite with other children in the same situation taking oppor-
tunities to improve their lives. Such reports from children indicate that
the resiliency and social power that can be adopted, although often at
the expense of childhood, is not given sufficient attention in research
and clinical interventions. We need to make an effort to deal with this
oversight in order to be able to better understand risk, vulnerabilities,
and resilience among children and to better find a way to work with
this group as well as those who are most vulnerable.
I have to note that most of the research concerning children’s trau-
matic experiences and responses to conflict by and large focuses too
much within the biomedical and behavioural components’ which
in my view are insensitive, inflexible, and intolerant to the subjec-
tive clarification and understanding the experience of children. By
de-contextualising and privileging the individual as representing
the psychic unity of humanity, children from different societies and
cultures should be regarded as mere variables in their development,
adaptation, rather than as foundational Western interpretations of the
childhood and processes of development. We must examine the notion
that the meaningful nature of reality is something deliberated on by
representations running through individual minds and that trauma
disrupts the meaning of the world through its impact on these rep-
resentations. So, the way in which we give meaning is fundamen-
tally a product of our communal landscape influenced in the realm of
language and culture. Therefore, a particular child, with her cultural
background and language spoken, cannot simply be understood by
much of which simply cannot be understood by inkling, insinuation,
or quotation of universal theoretical schemata of child developments
from the Western cultural perspectives. An adjustment to trauma,

adversity, suffering, grief, and loss are all experienced in cultural con-
text and are patterned by the cultural meanings that the individual
is familiar with. So, thought similar processes may be experienced
in ways that are intensely personal, individual children understand
and engage with trauma and adversity through mechanisms that are
socially mediated. There are differences and inconsistencies between
the Western approach to mental health and illness and the belief sys-
tems of children of refugees. This gap should be taken into account
when working with children of refugees in general and in particu-
lar for the treatment of recently arrived children of refugees. Some
children from African, Middle-Eastern and other countries that I have
worked with during the last three decades grew up with the belief
that the centrality of the self should not exist and the individual only
matters within the family and larger community units—therefore,
the Western therapeutic interventions may cause these children more
stress and confusion.
The development of resilience and dissociation

In normal development, dissolution and disintegration may be experi-
enced by an infant as a transitory state. In good-enough environments,
the gratification by the external good object helps remedy these states
of disintegration and breaks through the infant’s schizoid states, which
increases the infant’s capacity to relate. To overcome these temporary
and transitory states of mind, one needs strong elasticity and resiliency
which is integral to the infant’s mind in the process of development, but
the idea of dissociation in the refugee’s mind who has endured trauma
differs from that of the infantile mind. However, refugees who have
been deprived of a caring environment in their developmental process
may not accumulate that elasticity in mind, and therefore not develop
resiliency.
For vulnerable children of refugees, unhealthy dissociation and
consequent dissolutions and disintegration may occur too frequently
due to external trauma or their memory of it, which can result in total
helplessness and hopelessness. This is where the person cannot think
or finish the disturbing memory of trauma in a coherent way, and can-
not dissociate with the thought and memory of the event. As a result,
the whole existing psychic structure may be totally shattered. This is
RESILIENCE 105
because re-experiencing trauma in a fragmented way often goes on for

too long without finding any direction. I hypothesise that a refugee
with such characteristics has not had a good-enough object relation in
their early developmental process.
There is a difference between the trauma of children of refugees,
indeed the dissociation resulting from those experiences, and trauma
in infancy. In infancy, there may not yet be a psychic structure in exist-
ence to be shattered. So, in effect, a cumulative trauma follows the dis-
sociation as the mental mechanism, providing some protection against
the effects of the trauma endured in mind, which is the foundation of
one’s resiliency or lack of it. This foundation of gain in the process of
development will provide strengths to mourn developmental trauma
and losses, and trauma that may be endured in later life in a more man-
ageable way is healthy dissociation in a refugee. In the psychoanalytic
concept, successful mourning is a necessity in the process of develop-
ment; I claim the process of development from infancy to adulthood
seeds the foundation for the augmentation of resilience that will largely
be determined by the structural integrity, cohesion, and nuclear self as
well as the availability of adequately attuned, compensatory self-objects
that may operate by the act of healthy dissociations.
In normal dissociation, we can separate a particular group of usually
connected mental processes, such as our emotions and our understand-
ing, from the rest of our mind. This is sometimes a conscious decision
and other times a defence mechanism employed sub-consciously or
unconsciously to cope with certain experiences.
In contrast to healthy dissociation, an unhealthy dissociation is the
result of a traumatic experience and lack of mourning mainly driven by
the unconscious and lacks partial or total connection with reality, and
the inability to use a high level of psychic energy productively, which
results in the weakening of perception and therefore affects integrative
functioning. In this context, Janet’s (1892) reality functions—an ability
to utilise the senses and mind to connect with reality—is a more rel-
evant concept than Freud’s distortion of reality principle.
Healthy dissociation is the turning away from one’s unbearable
emotion; unhealthy dissociation is the cutting off from the reality—
denying and disavowing unbearable feelings and reality. I here present
two examples to demonstrate an unhealthy type of dissociation, which
is the result of vulnerability. The narratives of the first child, whom I
shall call Abdul, are similar to those of Nastaran in the second vignette.
Abdul
Abdul was eleven years old when he was referred to the Centre by
his support teacher, after being involved in several violent incidents
at school in which he was perceived to exhibit dangerous behaviour.
Abdul’s parents were both killed early in his childhood in the war in
his country, and his care was taken over by his older siblings who even-
tually came into exile in Britain. School staff had a range of different
views about Abdul. They reported that some students and teachers
found him frightening because of his fighting and because of his lack of
control to stop. Some staff were irritated with him because they had had
numerous discussions with him about his behaviour which seemed to
have made no difference. There was also some sympathy for him and
a sense that he really did want to do better. What struck us was that
his fights occurred in response to what he perceived as provocation,
either in classrooms or in corridors where a staff member was present.
When staff were absent he seemed to do much better at staying out of
trouble.
In our first meeting with Abdul and some of his siblings it became
clear that he was often left alone and, although he received some mate-
rial care, no one was available for his emotional needs. No one talked
with him about his past memories, or his confusion and fears at present.
His siblings wanted to study and advance their job prospects and to
forget their own painful memories. Abdul seemed to be desperate
for adult attention. After the initial assessment, we suggested that he
needed a key adult in school with whom he could slowly build a trust-
ing relationship and with whom he could talk through all his confu-
sion about life in school. It was also important that this particular adult
could be firm with him, setting clear boundaries and sticking to them
with regards to fighting and other challenging behaviour.
Our meetings with Abdul revealed that he was bewildered and anx-
ious about the fact that in Britain teachers allowed children to “mess
about” in class. His anxiety was compounded by his difficulties in
English and in understanding the work. He knew he was supposed
to be “good” but could not manage to control his behaviour, and felt
very confused. The feelings were extremely strong and he did not have
a vocabulary for all the related concepts such as “feeling different”,
“afraid”, “terrified”, “anxious”, “sad”, and feeling that he was unable
to be a “good-enough” student.
RESILIENCE 107
Abdul’s siblings initially did not want to change their behaviour

towards him or support his attendance at our Centre. They took the
view that he was simply the “victim of racism” from other children
and teachers which he would learn to deal with in time, and that his
behaviour had nothing to do with the losses they had all been through.
To move from this view would have raised too many difficult memories
for the whole family, who were all in a new country trying to work out
their future.
The situation was difficult for the school because they were unable to
successfully engage Abdul’s family in working together with them. The
family also turned down the possibility of family consultations with us.
After a year, we managed to engage Abdul’s older sister and following
a short period of working with her, we were able to arrange a family
consultation. Subsequently one of Abdul’s older brothers also joined
one of our men’s therapy groups. Once Abdul’s feelings were recog-
nised at home, he was able to grieve for his parents with his siblings;
he was able to ask questions about them, their personalities and their
relationships with him.
Abdul became much calmer at school and was very successful in his
studies. The school staff felt relieved about these changes, and Abdul
became quite active in extra-curricular activities and a very likeable stu-
dent who was ready to go on to secondary school. We saw him every
week for six months after he began secondary school, and then we saw
him monthly, and then bi-monthly, for a further year. After this, Abdul
felt ready to stop coming for therapy.
Through work with such traumatised children, I learned that trau-
matic memories can lack verbal narrative. They may on occasion be
encoded in the form of vivid sensations and images, but the thinking
is disrupted and patients are not able to verbalise this experience. The
symptoms many of my patients commonly exhibit are: isolation, loneli-
ness, unresolved anger, depression, and impairment of interpersonal
relationships. However, to move more deeply into understanding the
refugee type of trauma, it is necessary to focus on the primitive and
archaic sensations and images arising from the unconscious to gain
access to the heart of the trauma that is still imprinted within the indivi-
dual’s mind and that leads to unhealthy dissociation—which a powerful
psychic introjection may be born that may attack the inner psyche and
create an intrapsychic dynamic with the ego which serves as masochist
to an internal sadistic object that has gained an autonomous psychic
function in the person who does not have resilience and is therefore
not able to dissociate from this attack healthily and to protect their
self-cohesion and integrity, so the person becomes a victim of external
trauma. This is not the result of internal conflict. Trauma inflicted from
the external world which leads the person to a state of vulnerability can
dominate the internal and intrapsychic capacity for thinking, reflecting,
and processing. To reclaim this capacity requires resilience and a vast
effort of one’s resiliency, which may have been lost as the result of the
external trauma even in a resilient person. Breaking the cycle of this
psychic force is necessary to separate the pattern of repetition compul-
sion commonly seen in refugee patients who have experienced severe
trauma. This needs to be processed at a level that an individual refugee
can cope with.
I have come to an understanding that dissociation, specifically
healthy dissociation, which is, in my view, one of the major concepts in
working with refugees who are affected by enduring external trauma, is
the function of the mind that pushes certain experiences into some inac-
cessible corner with some level of consciousness, but has sub-conscious
and unconscious connotations which may later emerge into conscious-
ness when the mind is ready to deal with it.
Resilience is a variable capacity for the self-regulation of states or
organisation of experience from infancy onward. These phenomena
are aspects of a factor that influences the interaction with the (m)other
and experience and interaction throughout life. This variable capacity
for organising experience comes together with the responsiveness and
sensitivities to the environment to determine the quality of experience
and interactions. The notion of a biogenetic of the self-esteem and self-
righting capacity, or resilience is: first, continuous in the life span of the
organism, second, variable in strength among individuals, and third,
influenced by environmental forces although not essentially alterable.
It is helpful to acknowledge that the conditions that are traumatic or
disruptive for one individual child may not be so for another with supe-
rior self-righting capacity and resilience.
The functions and experiences related to the emerging self and to
resilience are infinitely more elusive and complex to observe and specify
than the trauma, especially in the case of children. The human species
has evolved with a capacity for mourning that reaches its most com-
plex expression in the adult. While replete with conscious experiences,
the need to mourn and the organisation of a sequence of mourning
RESILIENCE 109
processes seem to be unconscious aspects of both impulses and

defences. During the outcry phase of mourning, alarming and intense
emotion may occur as the mind reacts to the working models of the
new situation and enduring schemata. The deceased may be modelled
as harmed rather than dead. By the time of entry into a denial phase,
the person has reconstituted the operation of unconscious defensive
inhibitions. During this phase, dissociations are prominent, with opera-
tive schemata of the deceased as both dead and alive. With entry into
an intrusive phase, both usual and warded-off role relationship models
involving self and the deceased emerge, organising not only conscious
reviews, but unsolicited and spontaneous intrusive emotions.
In a working-through phase, the mourner may more easily contem-
plate more themes and to begin to be established as enduring schemata.
This work reduces alarm, emotion, and signal affects as it diminishes
the discrepancy, or mismatch, between working models and enduring
schemata. As the bereaved person slowly develops schemata that match
the reality of permanent separation, the work of grief would gradually
enter the completion phase.
It takes a long time to reach such a point of relative completion; the
work of schematic change is slow. While schemata enable people to per-
ceive, plan, and act rapidly, the schemata themselves cannot be quickly
altered. Like transference change and the developmental course of iden-
tification, the work of mourning cannot be rushed. Mourning should
not be considered as heartbreak; it is a process that actually prevents the
heart from being broken.
To better demonstrate the development of resilience, I now present a
vignette of a young girl, Nastaran, who gained a considerable resilience
in the therapeutic process:
Nastaran
Nastaran, an eleven-year-old young girl from the Middle-East, was
referred for assessment and possible therapy. The reason for the refer-
ral was her lack of concentration and not being able to engage with her
peers at school, as well as her extreme anger when she was asked ques-
tions, indeed, in the face of any emotional engagement or social inter-
action at school as well as with her foster parents or her social worker.
I was told that, when she was seven years old, Nastaran witnessed her
father, his uncle, and their few political friends who had a meeting in
their house get shot by the military guard in her country. Her mother
with the help of other friends and family immediately took her and her
younger brother, two years her junior, to another city. Their paternal
grandparents took Nastaran and her brother Sahand to live with them
and their mother left and joined the opposition party that Nastaran’s
deceased father was one of the leaders of, hoping for her own survival
and that of many others including her own children in her country.
It was a heart-breaking situation for a young girl. I immediately
offered Nastaran an assessment, although this was the only informa-
tion in the referral. I did not know whether more was known by the
referrer or not (later, however, it become apparent that there were much
more to Nastaran’s past story as well as her situation at the time of
referral, but the referrer was affected by this narrative and considered
it to be the important one for therapy. One of the major losses of infor-
mation in this referral, in my view, was due to the fact that, due to her
outbursts of anger and lack of engagement in any form, this child had
been moved to seven foster carers within two months prior to the refer-
rals to the Refugee Therapy Centre. Although I was alarmed by not
having much information, I decided not to wait to write back to the
referrer for more, and invited the child for an initial meeting. I asked the
child to be accompanied by an adult for the first session, being a foster
carer, a teacher, or her social worker or other delegated professional).
This was arranged and Nastaran and her social worker attended for
assessment and I understood that they were an hour early, sitting in the
waiting room. I went and greeted her and her social worker, and asked
if she would come with me alone or if she preferred to be accompanied
by her social worker—she looked at her and nodded as if confirming
that she wanted her to come, so I invited them both to my room. After
a brief introduction explaining why she has been invited here, what we
do at the Refugee Therapy Centre, and the purpose of the day’s meet-
ing, I asked Nastaran to tell me a little about herself but she remained
silent. Her social worker started telling me about Nastaran’s anger
and the difficulties that they were facing in placing her in appropri-
ate care and school due to the constant change of foster carers who are
sometimes not just in a different area, but in a different city. Nastaran,
throughout this part of the session, was completely silent and unmoved
as if nothing were being said about her. I stopped the social worker
and said “Nastaran, have you heard your social worker’s concern about
you?” She only responded yes. Indeed, she only responded “yes” and
RESILIENCE 111
“no” with a smile to any other questions I asked. I asked her social
worker if she could wait outside, as I wanted to spend some time with
Nastaran. I asked Nastaran whether this was ok with her. She nodded
without looking at her social worker. The social worker insisted that
she would like to stay as she had to provide a report. I explained that I
needed to have my assessment with Nastaran and asked her firmly to
leave the room.
After the assessment and after Nastaran confirmed that she would
like us to work together, looking into how we may find a way to deal
with her anger without making her more angry and disappointed,
I talked to the social worker and we agreed to start the work immedi-
ately. Four months into therapy Nastaran was able to tell me that her
mother was a good teacher and strong, and taught her that she should
be pleasant and polite and that she should not complain about what
life threw at her. Another rule was that she should never share the fam-
ily business and what happens in the family with people outside it.
I very gently said: yes, of course in the ordinary situation back home
and within mum’s culture these rules must be very important, but your
mum is not here and I wonder whether she would actually like you to
talk if she were here, seeing how not talking is affecting you. I also said
that she did not need to force herself to talk to me, but only if she were
ready, but that it was ok to cry if she felt sad. She burst to tears. I said:
I wonder if you feel you are letting your mum down by not being able
to be polite and pleasant to people around you always? She was silently
in tears for most of this session, nodding and looking down at the car-
pet, though occasionally making eye contact with me. In later sessions
she was able to say that she saw her mother being raped, beaten, and
killed and she could not do anything—just scream.
Although Nastaran was coming to therapy, I accepted that she was
extremely depressed as a result of what had happened to her and was
gradually becoming able to show more tears in the sessions than frus-
tration. Although outside the consulting room she continued to not
relate to people in a meaningful way. When I raised this with her (I now
think the timing was not right and it might have been a mistake) she
regressed back to her frustrated way of talking in therapy and would
not talk about her past or current experience for a while, though she
would still respond briefly to me if I asked her something. By doing
this, I could see that she started gaining some resilience while she was
upset with me, thinking I was colluding with all these others who did
not understand or care for her, she managed to hold her politeness
with me, which was her mother’s desire. I gently interpreted this and
she responded positively. She then developed a capacity to talk about
school, her teachers, and fellow students, and social services, express-
ing her wish to be nice and polite to everybody around her as she liked
to have a good manner. She said she did not like to upset her foster
mum for not being able to wake up in the morning. It was not her fault;
she just could not get up in the morning; she could not study, could not
pay attention to her teacher and made them angry with her. But she did
not want this.
This was such a massive progress in which, in her way, Nastaran
was saying that there was too much pressure and too much expectation
on her beyond her current capacity to deal with it, and it was for that
reason she constantly felt angry and frustrated and thought people who
were supposed to care for her did not, and did not understand her situ-
ation at all. I interpreted this and she agreed. To my surprise she sud-
denly became quite excited and in a bubbly way, and with a real happy
smile asked me: “How can you understand so well and other adults
don’t?” This was a great shift from her deep depression. I said: “well, it
is my job; I studied a long time and worked in this field for a long time,
also perhaps because you can talk to me now, but are not yet able to tell
others about what you feel, so, they have no idea.” I asked whether she
would like me to arrange a meeting with her foster carer, social worker,
her psychiatrist, her teacher (a case conference) to discuss this with the
hope of changing the relationship to bring some peace and happiness in
her life. She said: “Ok, but they are going to tell you repeatedly that I am
‘bad’.” In listening to her, and the perception she had of other people,
I often felt that I wanted to tell her: “You are wrong, people care about
you and it is for this reason you are coming here.” But I knew it would
not be beneficial at this stage and it could alienate her from me as well.
One session, eight months into therapy, she broke down and said that
she did not want to come to therapy anymore. When I asked her what
had happened and whether I had said something to upset her, she said
no. With further encouragement she said: “I love you so much and I
love you more every day and I want to see you every day, but I cannot
and if I don’t come anymore I can still love you and think about you the
way I love and think about my mum.”
It was difficult for me to hear this and I didn’t know how to digest
it. I was frozen for a moment. I did not expect this. I gathered myself
RESILIENCE 113
and said: “Thank you for being honest with me, Nastaran. We can talk
about this and whatever decision you make we will follow for now and
of course you can resume therapy after a while if you decide to stop
now. But, tell me more about your thinking.” With further explorations
it become apparent that she had developed a very strong attachment in
transference and she had been becoming preoccupied with the thought
of my mortality and this terrified her. So, to stop this psychic pain and
to calm down, she had started to cut herself. We explored this for a few
sessions and agreed that I would talk to her social worker, proposing to
meet her twice a week, rather than once, for a period—once again she
gave me a real smile which was relief for me.
We agreed to meet twice a week after the summer break and this
was containing for Nastaran. In a session she asked if I could not go
on a summer break. Light heartedly, I said: “That is not a fair request
Nastaran—don’t you think? You have over six weeks summer break
from school and you do not want to give me even two weeks?” She,
for the first time, laughed loudly and said: “I am not your boss”; I said:
“Yes, you are.” We had a very happy session full of good energy from
Nastaran which was beautiful to witness.
We started our twice weekly sessions and Nastaran opened up for
the first time and talked about the losses that she had experienced, the
feelings of loneliness, of being strange and different, and of how much
she was missing her mother. She was able to say that her memories
created difficulties for her and she could not cut off from them. In this
process we started focusing more closely and systematically on her
memory and her dreams, although “nightmares” might be more accu-
rate. On many occasions Nastaran would say with embarrassment that
she was unable to describe the contents of a bad dream and what she
was seeing during the day (her flashbacks). She once again started feel-
ing that no one understood her or knew what she had endured, and she
started to wonder what the point of talking about all this was.
Transference–countertransference
In countertransference, my response to Nastaran’s emotional state
at any given moment, and my controlled empathic sorrow about her
experience of trauma, was my greatest asset and obligation. However,
it had the potential lead to disadvantage and disaster by getting me
too involved and so unable to remain as her therapist and her listening
other in a containing and objective manner and unable to facilitate

an environment of safety for her explorations of the trauma she had
endured, for her self-discovery and development of her resiliency.
I needed to constantly work to protect both myself and Nastaran by
imparting an understanding the impact of the trauma she had endured
and by recognising and addressing the effects upon us both by using
transference–countertransference interpretations. In the isolation of
the consulting room, I constantly found myself between numerous
boundaries—between body and mind, past and present, conscious
awareness and unconscious processes, self and other, material and
intra-psychic, phantasy and reality, fact and fiction, desire and fear of
fulfilment, conflict and deficit, separateness and oneness. The list can
be expanded to include all types of psychological and philosophical
boundaries, in particular, ethical ones which were potentially involved,
despite my intention of objectivity as her therapist. More often than I
have wished for, I have found myself drifting over dilemmas of what
to do and what might be a reasonable intervention in each particular
situation. At so many junctures I have found myself infuriated about
what Nastaran had endured and that a little girl had had to go through
what she had experienced, and at such a young age. So many times I
wished I could just embrace her and hold her, wanting to protect her
from further suffering.
I was pleased that I did, with great difficulty, manage to control
myself as I was aware that, to be useful to Nastaran, I had to be ready to
give space to her and to listen to her pain, her confusions, her destruc-
tive mind, and, although she was mostly idealising me and stuck in
positive transference, at times through interpretations she could allow
herself to project some of her feelings to me, or attack and destroy what
I had to offer. I am not just referring to open attacks, but much deeper
and unconscious destructive attacks. In these situations I usually, and
in my clinical work in general, remind myself of Freud’s (1939) sugges-
tion that patients are impelled to such behaviour because they cannot
accept and internalise another person’s idea unless the other person
is tested to destruction. The process of internalising an idea involves
attack, sometimes an overt attack, which is always dangerously chal-
lenging. In order to be experienced as real, and be related to as exist-
ing in Nastaran’s own right, and not as just her phantasy. Reminding
myself of the foundational theories of psychoanalysis helped me
to survive my empathic countertransference as well as Nastaran’s
RESILIENCE 115
occasional violence in transference. As a result, the process would

consistently open-up possibilities, seeding for further resilient quali-
ties in Nastaran. As a survival tactic of such transferencial attacks, as a
routine in my practice, I laid down the foundation for development of
a new relationship, enabling Nastaran to learn to relate again, to man-
age to live through such empathic countertransference. Indeed, at times
Nastaran’s destructive attacks required me to know who I was and my
exact responsibility in the consulting room, not just what I politically or
morally stood for—and that was one of the great assets that I acquired
from my psychoanalytic training. Working with such a traumatised
child requires a constantly renewed effort to stay in touch with one’s
own feelings and those of theirs. By and large I do manage to do so by
using the concepts of Winnicott’s (1971) “use of the object” and Bion’s
(1962) “psychic containment”, and with my resilience and ability to
dissociate healthily.
In one of the sessions, in which Nastaran was quite frustrated and
fidgety, I made an interpretation; she immediately started crying with
despair. Not wanting to lose this moment, I encouraged her to talk fur-
ther. She said that she could not talk as she did not know what to say.
This was not uncommon. Children often cannot find a way to express
their feelings in words. So, I said, as I usually do, if she wanted to tell
me what was going on in her mind she could do so by drawing and
together we could think to find the best words for her experiences and
she agreed with a sweet smile, saying: “You are very clever mum, I wish
you could be my mum.” I smiled back and said: “I am sure my children
will not agree with you” and we laughed together before the session
ended.
As our therapeutic work progressed further and Nastaran gained
the ability to put her experience into words, her anger subsided very
quickly, becoming almost non-existent. She started to talk to people
around her about her thoughts and feelings. In one session she reported
that she had talked to her foster mother and told her that she didn’t
want to be bad, but she felt that that she did not care about her and that
she was just doing her job—but she could not share her thought about
this with her foster carer. In another session she told me that she had a
meeting with her social worker and told her that she did not wish to see
her because every few months her social worker changes and she did
not like that—it is a bad system. She started talking and playing with
her peers in school.
In transference, sometimes Nastaran was able to express her

anger and frustration, telling me that I didn’t care about her enough,
otherwise I would see her every day at least, or take her to my home.
In one session she would say: “You are also like all other people here
in London: doing your job.” During this period she found it difficult to
leave the sessions and always had something to say when I would tell
her our time had finished for the day. She could either be clinging and
idealising of me, telling me how much she wanted me to be her mother
or at least her foster mother, or would say: “See? I know you don’t care
about me and what happens to me after I leave here.”
In further exploration, Nastaran was gradually able to look at the
positive side of our relationship rather than its limitations. This was
accepted by Nastaran and provided her with the opportunity to explore
her current living environment and focus on people she now had in her
life and how she could build a better relationship with them. With this
type of realisation Nastaran started to recognise the foundation of her
anger was mostly related to what she experienced in the past; she there-
fore stopped projecting onto people around her in the here and now.
Gradually, she became interested in school, got involved with sport
activities, and developed a reasonable attachment with her foster carer
and two other foster children in the house, as she was developing her
resiliency and her ability to relate in her new environment.
The process of having me as her “listening other” helped Nastaran to
understand and accept her past and present, without too many challeng-
ing feelings. Although the process was challenging on occasion, where
my intervention was appropriate, great progress and sublimation was
made, especially where transference provided the idyllic therapeutic
room to work on Nastaran’s object world, which was characterised by a
massive emotional impact, and which was subject to inclusive distinc-
tion and oscillation and marked by a continuous diffusion of her trau-
matic experience, including that related to her primitive part-object.
Her withdrawal from her new cultural environment, in an attempt to
find sanctuary against destruction by her persecutory objects, formed
her defence mechanism. In the first few months of therapy, when she
came close to an object in transference, whether in love or hate, she
would become extremely terrified. This fear would lead her to introjec-
tive identification in catastrophic fear of persecution.
Nastaran’s level of depression combined with her severe anxiety
was evidence from the beginning that her sense of self was exiled from
RESILIENCE 117
her self and needed to be recreated. My main aim for the therapeutic
outcome was to facilitate a therapeutic alliance in which Nastaran could
build resilience by having me as her listening other as resiliency can be
achieved and enhanced by being listened to. Cases such as Nastaran’s
make it possible to replicate Werner’s (1992) conclusions on resilience
from a psychoanalytical perspective. Although Werner (1992, 1994) used
data of a different kind, it touches on a similar question, and, though
she does not use the concept of the listening other I am discussing, all of
her patients who managed to bounce back indicated in their feedback
that they had had a good experience with someone, whether neigh-
bours, a social worker, or somebody else, which is within the realm of
the object relations theory and of being listened to. So, Nastaran’s case,
as well as some other cases I discuss in this book, can be compared with
cases in Werner’s (1995) work, where a high-risk group of people who
survived despite severe atrocities had had protective factors by having
had a significant other they could internalise as a good object. I there-
fore hypothesise that one of the main factors in dealing with the effects
of traumas, the creation of psychic space, the development of resilience
and the ability to dissociate healthily for any child, or indeed adult, is
the existence of a listening other.
By presenting Nastaran’s case, I am once again illustrating an inter-
cultural psychoanalytical investigation into the origins, modes, and
treatment of trauma of the children of refugees as well as psychical
suffering in general. The vignettes I present in this book by and large
provide an account of the way a traumatised mind works; it denotes
with the analytic understanding of psychopathology and reconceptu-
alisation of the therapeutic process, and implications for working with
traumatised children of refugees within the intercultural psychoana-
lytic technique. These cases over and over again confirm a perspective
on Bion’s (1962) container on inadequacy and violent emotions; on
the waking dream (flashback) and narrations; and on persuasion of
functioning of the therapist in countertransference. Nastaran’s factual
encounter with her agonising and horrendous past experience’s tak-
ing place in a contained therapeutic environment, using transference–
countertransference interpretation when I considered it to be safe and
appropriate, provided the possibility to stumble upon what was so dif-
ficult for her.
Nastaran’s case and her narratives are greatly similar to Abdul’s that
I presented above. But I would like to discuss it here too to demonstrate
a defensive form of dissociation. To recap, Abdul, a young boy of eleven

years old from Central Africa had:
• Suffered from a lack of concentration and was withdrawn
• Seen his father and brothers shot by officials in his home country
• Been told by his Mother: “Always smile and don’t complain”
• Endured the trauma of his Mother being raped, tortured, and killed.
This child’s defence strategy was typical of autistic withdrawal, and he
did not talk in therapy for a few months, although at times he became
tearful in the sessions. The intensification of sharing his pain was
too great for this patient and became challenging in countertransfer-
ence. There was a need to help him to foster some resilience and work
towards strengthening his ego, for both of us. I communicated with
him verbally, but I have always doubted whether I was able to con-
vey to him a clearly defined meaning related to his experience. Having
said this, I was aware that I did not know much about him, and that I
should be very careful not give him the impression that I was intending
to explain his truth. His continued silence in tears, but no words, was
very regular. He never missed a session and consistently came early.
So, with gentle communication, I intended to contain an unsaturated
meaning schematic with projectuality that required his contribution in
order to become actual.
My intention was to establish a meaning, and not merely to con-
firm, reject or add something. Although he was silent for a long time,
I kept talking to him and about him, as I was aware I could be helpful
to this young person, to find words that had meaningful connotations
to his experience. He could then express his feelings about them, which
would be the beginning of building some level of resilience. This relates
to my theory of the listening other. Abdul’s regular attendance was con-
firming that he started gaining some level of resilience. I assumed that
having me as a listening other in his on-going silence was helpful to
him as his lack of eye contact started to disappear. He was looking at me
when I was talking to him about him and our relationship and feasibly
could observe his affects. I was thinking his lack of response demon-
strated his fear of relating and being let down, hence, the foundation of
his unhealthy dissociation. His unconscious processes which prevented
him from relating and developing healthy dissociation, amongst other
factors, links to his traumatic losses from early childhood and his inabil-
ity to mourn.
CHAPTER SEVEN
Working with unaccompanied minors,

trafficked children, and child soldiers
I
n this chapter I discuss working with unaccompanied minors,
trafficked children, child soldiers, and children of refugees and their
families. Here, I aim to give an idea of what is faced by children of
refugees, the necessary and frivolousness need for therapy by outlining
the stories of four such children as illustrative examples of the varied
and extreme experiences endured by an individual child.
Unaccompanied minors
A large number of children of refugees are unaccompanied minors
who are left facing the struggles of building a future alone. These brief
vignettes illustrate the importance and necessity of their access to
therapy.
Aran
Aran was seven-year-old boy during initial stages of ethnic cleansing
in his country. The police in his village (from the majority ethnic group)
had a station next to the village football pitch. Shooting the ball while
119
the children were playing became a favourite pastime, followed by

beatings of any child who protested.
When Aran was about ten years old he and other children from their
ethnic group were forbidden to go to school. His elder brother (intel-
ligent and politically aware) had been warned not to attend any meet-
ings. It was when walking to a meeting in defiance of this that he was
shot dead. His body was kept in the street—under guard in the mid-
summer heat for four days, after which the family were finally allowed
to bring the body home. The stench was terrible, making the wake very
difficult. Meanwhile life was made increasingly difficult for the minor-
ity population: a curfew was imposed; young men were forced to fight
in the army, many of whom would be killed; telephones were cut off;
snipers fired in the streets making it impossible to stand near windows
or bring in supplies safely. One day the army arrived at the door of the
family home.
Aran witnessed his sister and aunt being raped by at least fifteen
soldiers. His older brother was rifle-butted in the face when he pro-
tested. The family had to leave the house; men and women were sepa-
rated and the younger men removed, to be killed, it was assumed. The
rest of the family escaped to a refugee camp in a neighbouring country,
but conditions were very bad with little food and extreme cold. Aran’s
uncle was very ill and could not help the family. Meanwhile Aran
met other youngsters and decided to return with them to his village
to dig up some valuable items the family had buried. The house was
an unrecognisable burnt shell. And although he found some money,
fighting prevented his return to the camp. Aged fourteen, he joined
the militia where he witnessed many further atrocities. At fifteen,
he arrived, after an arduous journey, to the UK in the back of a lorry.
When we first saw him at the Refugee Therapy Centre he was unable
to sleep at night, was suffering frequent flashbacks and having suicidal
thoughts. Other aspects of his behaviour had also come to the attention
of the Youth Offending Team. Like many young people who have expe-
rienced violence, he would be very quick to act out aggressively, with
little empathy for the person receiving it.
During the two years he was in therapy here, he felt contained
enough to talk about the events he had experienced, frequently grip-
ping the sides of the chair with white knuckles. As therapy progressed,
his nightmares and flashbacks diminished and his sleeping improved;
U N A C C O M PA N I E D M I N O R S , T R A F F I C K E D C H I L D R E N , C H I L D S O L D I E R S 121
he stopped behaving aggressively and did well at college. He was also

able to contemplate the fact that he might never see his family again.
Aran eventually felt well enough to say that he could manage on his
own, though, of course, he was assured that he would be welcomed
back at any time if he felt he needed support.
Ivan
Ivan started attending the Refugee Therapy Centre at the age of four-
teen, with a history of aggression and violence, and an already length-
ening criminal record of assaults and attacks in the UK.
Ivan suffered from severe sleep disturbances and flashbacks. His
level of communication was extremely poor.
Through therapy it became clear that he had arrived from a war zone
and during his journey here he experienced difficulties. He also had
been deeply traumatised by his family, and by his brutal father in par-
ticular. From an early age, he had virtually lived as a feral child, with
food left out in the yard for him, and slept in the barn with animals or
in a van.
Ivan had never attended school and had to be educated alone in this
country due to continual conflicts with other children. Eighteen months
after starting at the Refugee Therapy Centre he was able to attend col-
lege successfully, had a part-time job, had developed empathy with oth-
ers, and had begun to realise that no child should be treated as he had
been. He had also learned to handle difficult situations without resort-
ing to violence, and has not been in trouble with the police again since.
He has continued to do well and became an articulate and thoughtful
young man with well-developed ability for insight.
As in all the vignettes presented, having a listening other is impor-
tant to deal with child depression and anxiety and for opening “psy-
chic space” for developing resiliency. These vignettes are important
from a psychoanalytic perspective since they can be taken to mean that
resilience could be a part of specific character traits, which would be
relational, and whether those traits are developed from interpersonal
relations, or are interpersonally supported. The existing psychological
and psychoanalytic perspectives on resilience are not satisfactory in rela-
tion to character formations. A question that then arises is: if resilience
and vulnerabilities are not things that lie in the objective external event,
what is it about the personality that enables—or disables—the capacity

to cope and deal with atrocities without psychological collapse?
Rose
Rose, a fifteen-year-old of Central African origin, was referred to the
Centre for assessment and possible therapy to help her with anger
issues. Rose was an unaccompanied minor and living with a foster
carer. Rose’s social worker referred her to the Centre, in liaison with
her school. The school was concerned by her behaviour, reporting that,
although she was obviously intelligent, she would frequently provoke
shouting matches with other children and ignore the teacher when she
tried to intervene. The school reported as an example how, on one occa-
sion, she had taken one of her peers’ MP3 player from her desk with-
out asking. When the girl and her friends confronted Rose, she insisted
that she had only “borrowed” it. She became angry at being accused of
stealing and quite aggressive towards the girl. When the teacher tried to
intervene, Rose called her a “bitch” and said the other girls were pick-
ing on her and telling lies.
In her first session at the Centre, Rose seemed to become attached
very quickly and welcomed the opportunity to talk. She said that she
had wished to have someone to talk to for a long time because she
could not sleep, could not concentrate at school, and found herself get-
ting bored. After initial assessment, we suggested that Rose receive
weekly therapy at the Centre to support her with the challenges she
was facing.
At first, Rose didn’t attend her sessions regularly and found it dif-
ficult to understand why she couldn’t see her therapist only when she
wished to. When she missed a session she would say that she had for-
gotten to come. It seemed that Rose did not trust anyone, especially
adults in positions of authority like her class teacher or her social
worker. We had some difficulty communicating with the foster carer
about Rose’s non-attendance; however, the support teacher at Rose’s
school was able to help us to engage with her. We notified her of Rose’s
appointments and Rose seemed to like the support teacher, who made
an effort to remind her about her appointments and encouraged her to
attend.
It took Rose a while to trust her therapist and speak about her
experiences. However, over time we gathered that Rose’s parents had
been politically active in her country and were shot in front of her at
a political rally. She started caring for her three younger siblings, but,
later, soldiers arrived at the house demanding money, and then they
commandeered the house and evicted them all. Rose was forced to live
in the local market begging for scraps of food until she was picked up
by the militia and forced to fight. She was relieved when, following
an injury, she was taken to hospital where a doctor, recognising that
she was still a child, allowed her to stay at his house. Worried for his
own safety, he put her in touch with a European man who was initially
helpful but was, in fact, recruiting for prostitution. She was forced to
have sex with a number of African and European men before the same
group flew her to London. On arriving in London she was “rescued” by
a woman from a church who was very concerned by how anxious she
seemed. Her complaint, in addition to the anger she often felt, was of
feeling anxious and having disturbed sleep. After a while she was able
to discuss what had happened to her and acknowledge the difficulty of
coping with the trauma she had been through.
Rose attended therapy for a year and progressed well. The outbursts
of anger stopped. She started showing interest in her lessons and gained
respect for her teacher. We provided her with one-to-one mentoring on
top of her therapy to help her with her schoolwork. After that year,
Rose had to stop coming because she had to move to another part of the
country. In her feedback, Rose told us:
I did not know what to expect, but therapy has helped me to

express my feelings. It makes me less angry and more confident.
I feel relaxed. It is nice to talk to my therapist; even if she is a
stranger you can tell your feelings openly without fearing. When
I am sad and come to the Refugee Therapy Centre, my therapist
helps me understand a situation; it helps me to find a way to pass
the problem. It makes me able to talk about things that I’ve never
spoken about before. At first, I was uncomfortable speaking, but I
trust my therapist very much. Now I can talk about anything.
Trafficked children and rape as a weapon

Sexual violence against adults and children is, in many regions, a par-
ticularly common instrument of terror and intimidation in civil or
political conflict. In countries ravaged by recent wars, in Afghanistan,
Rwanda, or the Balkans especially, more girls suffer the added trauma
of sexual abuse and rape, and have to enter adult life with the psy-
chological consequences of war that include memory of extreme per-
sonal violation. In the Balkan Wars involving Bosnia and Herzegovina,
and Croatia, as well as during the Rwandan Genocide, raping teenage
girls repeatedly was exercised as a deliberate practice to force them to
bear “the enemy’s” child. Moreover, in the Rwandan context, rape was
systematically used as a weapon of ethnic cleansing with the aim of
destroying community ties. Although there is little to no data or pre-
cise documented evidence in some invasions and intrusions, to a great
extent it is thought that every adolescent girl who survived military
attack by the militia was raped. Their own families and community
then ostracise many of those adolescents who became pregnant; some
abandoned their babies; some committed suicide; and some kept their
enemy’s child, at the expense of losing their relationships with all other
family members.
Many children of refugees suffer appalling violence and have been
tortured either as part of collective punishment of whole communities
or as a means of extracting information from parents. Too frequently,
often with no intervention, children throughout the world are exposed
to physical, mental, and emotional abuse and torture and suffer immeas-
urable pain. In some cases, children report to us that they were tortured
as a form of punishment for their parents, whilst some children report
having been taken, imprisoned, and raped as if they were adults. The
imprisonment of children is becoming an increasing concern in and of
itself; however, that children are kept in the same conditions as adults
is even more alarming and demands our attention. In some Asian, Latin
American, and African countries, children are, for the first time in his-
tory, being imprisoned and facing trial for genocide. Accountability for
grave crimes should certainly be a priority; however, to hold a child
accountable by means of imprisonment and further torture breaches
any attempt at justice, with long-term social consequences for the com-
munity involved.
Here, I present a vignette of a young girl, Marjane, who was raped.
Marjane
Marjane came to the UK at the age of sixteen. She was a victim of “state
rape”, a torture strategy used as a weapon to demoralise and terrorise
women, and to destroy their families’ “honour” in the community.

Marjane had been raped by a gang of soldiers while she was still a
virgin and had become pregnant as a result. In her community, rape is
a taboo subject and a great source of shame that was not to be talked
about, so Marjane had suffered in silence. Eventually, her mother and
grandmother arranged for her to leave the country. She appeared to
adjust to life in the UK and was attending English, maths, and compu-
ter classes at college. She met a young English man whom she began a
relationship with. However, the relationship did not last for long and,
when she had the baby, problems surfaced and Marjane started having
flashbacks about her experience of gang rape.
Marjane was referred to the Centre by her personal tutor from col-
lege, who could see that Marjane had changed after her baby was born.
She knew that Marjane had come to the UK alone and had no family or
friends here. The tutor was concerned that Marjane was unable to cope
with being a single mother at such a young age. In discussion with her,
Marjane showed interest in being referred for therapeutic help.
During the assessment, Marjane became quite tearful. She said that
she missed her mother and nothing else was wrong with her. She was
insistent that she was trying to be a good mother to her son and would
never hurt him, no matter what. It was apparent to the assessor that
Marjane needed help to deal with her psychological issues and that we
also needed to be aware of possible child protection issues.
Marjane’s English was quite basic so she was referred to a psycho-
therapist who was able to speak to her in her own language. She very
quickly began to engage with and trust her psychotherapist, who saw
her on a weekly basis, so that she was able to be honest about her feel-
ings. She disclosed to her therapist that she had developed an urge to
abuse her baby and also had nightmares in which she had mutilated her
baby. She told the therapist that she was terrified that her baby would
be taken away from her if she disclosed this to her social worker. With
her therapist’s intervention, Marjane was able to see that social services’
interventions are designed to protect her and her baby, rather than to
punish her or separate her from her child. Gradually, Marjane’s flash-
backs and nightmares decreased as her trust in the professionals help-
ing her increased. She was able to build a healthy attachment and bond
with her little boy, whom she had not been able to relate to previously.
She also brought her baby for some individual infant psychotherapy
(via play) because he was having great problems separating from his
mother and his nursery reported that he could be very aggressive

towards other children.
When Marjane reached the age of eighteen, she was no longer under
the care of social services and had to move to live independently. She
became quite anxious and fearful about her future. She was worried
about her immigration status as well as her housing situation and wel-
fare benefits. In addition to her therapy, we provided her with a weekly
session with a support worker to help her with these issues during this
very anxious time. Marjane also began attending one-to-one English
language mentoring at the Centre to help with her college work.
After eighteen months of attending weekly therapy sessions, Marjane
was well enough to stop attending. In her feedback she told us:
The therapy helps a lot. I feel good now, because I am talking in

my original language, many thanks to Refugee Therapy Centre. My
bad dreams stop completely. I am not scared to hurt my baby and
I learn to love him very much. I learn that it is not his fault what
happened to me. I am very good now, but I know, talking to my
therapist, I need to think what I tell my child about his father. I have
a long time to get there, however. I now have to focus on now.
Child Soldiers and the military use of children

Here is a vignette of a young boy called Misha who suffered at the
hands of the militia.
Misha
Misha started attending the Refugee Therapy Centre when he was ten
years old, following a referral from his primary school teacher. He pre-
sented as being deeply depressed and hard to engage. Through draw-
ings, we managed to get a picture of a pleasant early life in a lakeside
African town, suddenly interrupted by the arrival of militias at his
school. Some of the older boys were randomly selected and made to
lie down in front of the others, after which their limbs were hacked off
with machetes. As the violence worsened, his family fled, but Misha and
his mother were captured by the militia. Whilst in captivity Misha was
forced to shoot older children and his mother was also killed. Following
a courageous rescue by his father, the remaining family eventually

sought sanctuary in the United Kingdom.
As Misha engaged with on-going therapy, he began to talk more.
He began to learn to cope with aggression at school—which he found
deeply traumatising—by being more pro-active in searching out help
from staff. Young people, who have been traumatised by aggression and
violence, though initially numb and unable to defend themselves, can
frequently start acting aggressively at a later time. As he was engaged,
I hoped that, through therapy, discussing his past events and associ-
ated feelings, and working on strategies for his present-day difficulties,
Misha will be able to control his unacceptable behaviour and take con-
trol of his feelings and action.
The mental health of refugee children can be affected by experiences
of loss, separation, and stress and the varied psychological impact of
the uncertainties brought about by the refugee experience, including
attempts to integrate into a new society and culture. The psychologi-
cal impact of life in the host country, the UK for example, is often both
positive and negative. The relief associated with new-found safety
and access to food, shelter, education, and other opportunities not pre-
viously available is of course significant; at first glance, many social
workers, politicians, and other relevant professionals overlook or fail
to ascertain the extreme challenges that are also entailed in starting a
new life here.
Within the host country, the previous dangers from which a refugee
child has fled, either with family or unaccompanied, may no longer
be present; however, the stress and potential traumatisation incurred
through the asylum-seeking process—as well as the social isolation
brought about by language barriers and other consequences of social
rejection (including prejudice, racism, xenophobia, inaccessible services
and care, and cultural bewilderment)—often exact extreme costs for
refugee children. Moreover, the additional anxiety produced by inad-
equate or unstable social and caring structures (foster homes, state cus-
tody, poor housing, and poverty) can leave lasting psychological and
emotional effects without proper attention and intervention.
Children of Refugees and asylum-seekers, indeed Unaccompanied
Minors endure a range of post-migratory traumas related to resettle-
ment challenges, social isolation, economic deprivation, and restric-
tive asylum legislation. Restrictive asylum policies prevent asylum
seekers from being able to negotiate these new challenges in their new
environment. There is a need for empirical research specifically focus-
ing on relationships between past and post-migratory traumas. The
high levels of exposure to traumatic events prior to seeking asylum
combined with vulnerability are the strongest predictors of psychologi-
cal problems in refugees.
Problems such as immigration and welfare issues contribute to the
poor psychological health of these vulnerable adolescents.
The following vignettes of Abel, Farhad, and Hassan demonstrate
the extent of the damage caused to young children caught in the transi-
tion to adulthood in the host country.
Abel
Abel, from North Africa, arrived alone in the UK when he was thirteen
years old. Prior to being helped and sent to the UK, Abel was picked
up by a rebel group, imprisoned, and tortured in his country of origin.
Upon his arrival to the UK, as an unaccompanied minor he was under
the care of the local authority, through which he found a foster care home.
In the assessment, Abel reported that he built a respectful relation-
ship with his foster carers and the other two foster children in the house.
He began to feel part of a new family and content in the process of reset-
tlement, until he reached seventeen years of age when he was told that
he had to move into an independent living accommodation. Abel man-
aged this transition with great difficulty, although he was developing
the skills to live independently while staying in regular contact with his
foster care family, including joining the family for Sunday lunch. When
Abel turned eighteen years old, he was told his asylum application was
rejected and that therefore, since he was an adult, the local authority
would no longer be able to support him.
The impact of this news hit hard, resulting not only in acute stress
but also in overnight destitution and dissolution of all he had been
building since his arrival in the UK. Fortunately, Abel’s foster mother,
who had been his carer since his arrival as an unaccompanied minor,
found him and decided to take matters into her own hands. Although
saved temporarily from the immediate effects of destitution, Abel had
to sleep on the floor as there were no extra beds in the house. His foster
mother was also unable to provide him any financial support and nor
did he have any other source of income.
Over time, the foster mother was able to find a voluntary place for
him in the local farm to assuage his demoralising feelings. Despite this
attempt at support, however, Abel was becoming more and more anx-
ious and depressed, developing outbursts of anger. Seeking additional
support, his foster carer contacted the RTC, expressing her concern
about Abel. Although legally he was considered an adult, and, in gen-
eral, we recommend that the person contact us themselves or ask their
GP to refer them, hearing the narratives from his foster carer, I made
an arrangement to meet him for a one-off assessment to see how if at
all we might be helpful at this stage. I expressed to her that some of his
immediate needs included finding a solicitor for his immigration issues
as well as accessing education, both of which were beyond our remit.
The foster carer explained that she had managed to convince his college
to allow Abel to continue his study until the end of the academic year
as he had already registered before his asylum application was rejected.
Despite this allowance, he was still in need of financial assistance to
support his transport to college, books, and food.
His GP was seeing him as necessary, although the surgery staff had
initially refused him. He also needed to access a dentist as he was grind-
ing his teeth in his sleep as well as when he felt really frustrated and
angry or when he found himself in a sudden stressful situation. One
cause of stress for him was the fact that he was struggling to keep his
situation hidden from his friends at college. The first question Abel
asked me when we met was: “Why I cannot be normal and live like
normal people?” I asked him to tell me what he meant by this and what,
in particular, was abnormal for him. He said:
When people ask you “What are you doing? Where are you work-
ing? Where are you staying?”—I don’t have a life; I can’t tell my
friends. When I’m at college I’m OK. But I can’t go home. So I go
home with friends to their house. Or I just walk around. Sometimes
I stay in the street all night. But I don’t sleep there. I don’t feel safe
if I’m out on the street. I am scared of drunken people—I usually
sleep in the night bus.
The experience of a young person in Abel’s situation, unfortunately,

is not so infrequent. Although, due to a variety of reasons, the mate-
rial and political dimensions of such circumstance may take a while to
relieve, there is an immediate possibility for psychological intervention
to contain and support a young person facing such challenges. While

the material and political realities of any situation cannot be overlooked,
supporting a young person to gain the skills necessary to find and rely
upon their own resilience during such turmoil can have life-altering
impact.
Farhad
Farhad, a young man from Afghanistan, endured extreme and sadistic
torture. He came to the UK from Afghanistan via Iran when he was fif-
teen years old. He was referred to the RTC when he was aged eighteen
after his asylum application was refused and he needed support for
appeal but could not find a solicitor who was willing to support him.
He said his asylum application was rejected in the first instance as he
was not familiar with what he had to do and he went to court without
any representation. His first appeal was also rejected as, by then, the
children’s services had stopped supporting him, causing his homeless-
ness for one year. He said:
Before that, I was seeing a counsellor that was organised by chil-
dren’s services but, once I reached to the age that the children’s
service support stopped, my counselling was cut off and stopped
as well. They said: “Don’t worry; you are OK now and you don’t
need any counselling anymore.” This made me feel very bad. My
counsellor was the only person I didn’t need to be anxious to go to
see. When you don’t have power or money you can’t do anything
important for yourself; you just have to manage yourself. I hate
asking people for help. For ages I was feeding myself from the bins
in the back of restaurants. I was told by my social worker where
I could go to eat, but I didn’t go to charities to get food because I
didn’t have money for bus ticket.
Homelessness effected Farhad’s health and he said he couldn’t sleep at

night and his hair began falling out. The violence he experienced while
sleeping on the streets caused him to feel desperate and further dam-
aged his health. He started looking for work or anything to do in order
to rescue himself. He said:
I was not feeling well; I felt very weak and had chest pain and
was coughing all the time—but I was not entitled to go to the
GP. I managed to work for the place owned by a Pakistani—nice

man—who I become friendly with and I would work in his shop in
exchange of food and accommodation. You know young people my
age: they spend nice time with other people; they go to parties they
have a good weekend. My situation is different.
Farhad was very keen to stay in the UK because he feared for his life if he
had to return to Afghanistan. As therapy progressed, Farhad appeared
to cope reasonably well by learning to stay active and keep busy: going
to college, finding new friends, and building a strong support network.
He said, “Now I have here and so many people helping me, I feel like I
am a good family again. I don’t feel alone and it helps me to cope with
so much painful things.”
Hassan
Hassan, a fifteen-year-old Kurd from Iraq, came to the UK alone to seek
protection after his parents both were killed. He was referred to us not
long after his arrival and came to therapy on a regular basis.
The focuses in his therapy were his outbursts of anger and his
withdrawal. He was progressing well and was just at the stage at
which he had learned to control his anger by verbalising his feel-
ings without losing his temper. He was managing to make friends
and, for the first time, stayed with the same foster family for over
eight months. Sadly, and unacceptably, the Home Office rejected his
asylum claim just before his eighteenth birthday. His social worker
told him that in four months the social services support would stop.
His social worker explored the possibility of his going back to his
country, which upset him greatly, prompting him to lose his temper.
The police were called as he presented an extreme anger toward his
social worker. He left the social service building, but later found out
that the police officers had gone to his house, broken down his room
door suspecting he might have been in his room. He was called to
go to the police station, which he did, where he was told that he
couldn’t go back to his house anymore—he was only given enough
time to pack-up and leave. So, instantaneously, he became homeless
that night. This of course made it difficult for him to attend therapy
regularly, but he kept coming as much as practically possible for him
and asked to continue. During this time he slept on buses, stayed
with friends and sometimes in a mosque or church. He wasn’t able to

eat every day. Sometimes he would come much earlier than his ses-
sion and would make tea and eat biscuits as a meal and would rest in
the sofa in the waiting room.
How should we be working with children of refugees?

Here, I focus on the mental health issues faced by children of refugees.
As a result of their experiences, the inner worlds of some child refugees
may be populated by memories of abuse and horror that often bear
little or no resemblance to their situation here in the UK. The life of
children of refugees is beyond an ordinary child’s life. Their life is often
dominated by the memory of the abuse and trauma they have endured
in the past, while they also have to deal with the difficulties of migra-
tion to the UK. If these difficulties are left unattended, they can lead to
serious mental health problems in later life. Children of refugees are
subjected to various forms and levels of stress. Whatever experiences
they have been through, whether more or less terrifying, they will all
have had to deal with:
1. Displacement from their home and familiar environment

2. The severe disruption of their normal routines of life.
The stressors which impact children of refugees happen at any time, or

continuously, through four stages:
1. In their country of origin

2. During their flight to safety
3. During their asylum application
4. In the process of integration.
As well as the risks that all children and adolescents face, many refugee
young people have added stress of having to leave their homes without:
1. Warning
2. Any basic necessities
3. Personal belongings
4. Any knowledge of the new cultural environment.
If children of refugees, young people, and their families are helped

early enough, much needless emotional suffering and intellectual
underperformance and involvement with crime can be prevented.
Although children of refugees’ experiences are varied, they share a
common theme of having lost their home, friends, community, and
familiar way of life. This experience often embodies feelings of fear,
uncertainty, and alienation at all stages until integration is able to take
place in a meaningful way. Often, the way to safety from whatever the
cause of persecution is fraught with uncertainty and confusion about
the future and their survival.
There are two types of children of refugees:
1. Those who came to the UK with parents or guardians

2. Unaccompanied children.
A common factor present in the first experience of those who have come
with their parents or guardian is that they experience their parents and
carers’ being uncertain and frightened during the journey. After arrival,
parents are no longer the people they used to be with a job, a place in the
community, or an understanding of how society works. They may feel
they have become second-class citizens—unable to speak the language,
relegated to poor housing, stuck under conditions of poverty, insecure
about asylum applications, and restricted from working. Parents may
be so distressed by what has happened to them—perhaps unable to
remember clearly—that they may be unable to talk coherently with
their children about what has happened. As children become aware of
this, they may do their best to act as their parents do or as their parents
wish them to, which often means not discussing the past in order to
cope with the present.
At times when children are most distressed and confused, the adults
they normally rely on are in need of support themselves and unable
to attend to their needs. When children are finding their own feelings
overwhelming, they can discover that their parents are even more over-
whelmed. Children can therefore become protective of their parents
by avoiding raising topics which they know can distress them. In this
way, children become accustomed to oppressing their own feelings and
thoughts about their own experience. Children usually follow their
parents’ attitude or the way they think their parents expect of them
(e.g., not talk about their bad experiences and try to carry on as though
nothing has happened).
The second experience of children of refugees is represented by those
unaccompanied—whose parents have been killed or disappeared, or
who, for a variety of other reasons, have had to make the journey to
safety alone. These children or young people are likely to have been
traumatised by the shock of separation and even the journey itself.
Often struggling to find a place of safety, which may take extremely
long periods of time and comprise psychologically and physically
demanding experiences, they do not have the opportunity to mourn
their losses. Some may have lost their parents without knowing what
has happened to them; consequently, they may be full of unthinkable
and inexpressible fears and anxieties about what might have occurred.
Often, they have no one they can turn to for emotional support to voice
their feelings.
Even in cases where the child may be aware of the whereabouts of
their family, there is often a feeling of abandonment accompanying the
experience of resettlement anyway. The parents may have felt forced to
send their child away for their own safety or that of the family. At other
times, the child may have left in their own sense of desperation. In cases
where a child comes to be looked after by siblings, distant relatives, or
foster parents there may be additional complications, and greater feel-
ings of isolation. If siblings take the role of primary carer, there may
be a deficiency in attention and care simply due to their focus on their
own needs as young people generally, and on their own struggles in
the process of resettlement specifically. Foster carers may not know the
child well, or may not be fully aware of the child’s prior experiences, nor
want to know or have any idea of how they can be truly supportive. The
complexity of the situation for unaccompanied minors can be extreme
and issues of care, supervision, and containment—or lack thereof—can
potentially reinforce feelings of loneliness and isolation for the child.
To create the best possible intervention for a refugee child identifying
with either of these kinds of experiences is a challenging and delicate
process. There are no easy answers—each child has different needs so
it is not possible to simply list a series of actions to take in every case. It
is most important to remember that attempting to understand a child’s
situation is itself a positive act. Understanding can guide and inform
our actions.
Trauma
Trauma is a complex combination of biological, psychological, and social
phenomena that can create lasting emotional difficulties. One way to
determine whether an emotional or psychological trauma has occurred,
perhaps even early in life before language or conscious awareness are in
place, is to look at the kinds of recurring problems the person might be
experiencing. Observing these in adults can serve as clues to an earlier
situation that caused a deregulation in the structure or function of the
personality.
Traumatising events can have an acute emotional effect on indi-
viduals, even if the event did not cause physical injury or immediate
psychological problems. The definition of what is psychologically trau-
matic, therefore, is fairly broad, and includes responses to power of
occurrences and its aftermaths. Consequently, it is difficult to determine
in general whether a particular event is traumatic. Perhaps a reasonable
way to identify trauma and its adaptive symptoms is to ask the person
what has happened, rather than what is wrong. One central theme in
this approach that is quite an important aspect from a psychoanalytic
view is the intrusion of the past experience into the present and conse-
quent regression and fixation, confronting the person who has endured
trauma (Alayarian, 2011).
Objective and subjective views of trauma

There are, in general, two components to a traumatic experience: the
subjective and the objective. Usually the subjective experience of the
objective events constitutes the trauma. The more we feel and believe
we are endangered, the more traumatised we can become. It is our sub-
jective experience and the level of resilience we have that determines
whether an event is traumatic or not, and if it is, to what degree. In
this sense, psychological trauma may be any type of event or encounter
which causes an overwhelming emotion and a feeling of helplessness.
Whether there is physical harm or psychological problems, both could
result in physiological disturbances that can create confusion between
mind and body. This plays a most important role in the long-term effects
and presentation of psychological trauma. Therefore, trauma is distinct
according to how one is experiencing it; the specific aspects of an event
that are traumatic can vary from one individual to another (Alayarian,
2004, 2011).
Before World War I, attention was not given to the illness known as
“traumatic war neurosis”. Freud initially wrote little about war neuro-
ses, yet the subject had a profound impact on psychoanalytical theory
which resulted in his publication of “Psycho-analysis and war neuro-
ses” (1919d). He attempts to reconcile the existence of what he calls
“danger-neuroses” with his view that neuroses are caused by a conflict
between repressed libidinal impulses and the “ego instincts” of self-
preservation. He (1919d) suggests that:
In traumatic and war neuroses the human ego is defending itself

from a danger which threatens it from without or which is embod-
ied in a shape assumed by the ego itself. In the transference neu-
roses of peace the enemy from which the ego is defending itself is
actually the libido, whose demands seem to it to be menacing. In
both cases the ego is afraid of being damaged—in the latter case by
the libido and in the former by external violence. It might, indeed,
be said that in the case of the war neuroses, in contrast to the pure
traumatic neuroses and in approximation to the transference neu-
roses, what is feared is nevertheless an internal enemy. The theo-
retical difficulties standing in the way of a unifying hypothesis of
this kind do not seem insuperable: after all, we have a perfect right
to describe repression, which lies at the basis of every neurosis,
as a reaction to a trauma—as an elementary traumatic neurosis.
(p. 210)
Types of trauma children of refugees experience

Experiences of war or political violence for children of refugees are
enormous in scale; they are brutal, repeated, extended, and volatile.
Moreover, they are often compounded by witnessing life-threatening
events, and, in some cases, being forced to be violent to others by the
aggressor or the internalising their aggressors behaviour by means
of embracing the identity of an executioner. Other situations, such
as kidnapping, imprisonment, torture, and domestic violence are, on
the whole, associated with the child helplessness and a fear of injury
or death. Children of refugees, who have been exposed to violence
and torture, or visited their parent/s in prison, without any support
or community engagement, are indirectly tortured—and may further

be traumatised as a consequence of possible disclosure of violence
towards others that they have committed by force. For children, wit-
nessing someone close to them being tortured (this tool of torture is
commonly used in the case of political prisoners) can be extremely
traumatic—and the greater the attachment to the person, the greater
the stress would be. Coercive power used in prisons, detention centres,
concentration camps, some refugee camps, and in the community as a
whole, such as in Rwanda, that refugees and children of refugees come
from is overwhelming.
Coping with one’s own feelings

Although children of refugees may try very hard to forget their painful
past experiences, they often find that they are unable to do so because
this would mean denying their own history and, often, denying the
existence of other family members who have been killed in war, lost,
persecuted, imprisoned, tortured, or executed. So, when we are work-
ing with such a child, we are not just clinicians; we are hearing and
bearing witness to the traumas that many children of refugees have
endured. We hear of unbearable human rights violations. We are fac-
ing a complete human wrong. We may indeed feel extremely angry,
frustrated, powerless, and unskilled and desperate to do something to
help. However, as much as we may want to help, it is important to stop
doing anything before thinking and reflecting on our feelings, seeking
supervision and consultation. We need to remember it is not about us,
despite how our hearts may break at the circumstances of the child in
front of us; we are there to serve this child as a professional, and also as
a campaigner for human rights.
It will take children some time to mourn their losses and come
to terms with what has happened. For some children, this process
may seem to occur rather quickly compared to others who struggle
deeply to deal with their sense of grief and guilt accompanying their
traumatic memory. However long this process may take, it is our job
to tolerate it at every stage in order to be truly helpful. What chil-
dren of refugees principally need is to feel they can be listened to in
a containing manner—to be understood and respected as children
who have suffered human rights violations, but who are children
nevertheless.
Although children coming from war zones or environments where

they were exposed to tremendous human grievance have in a certain
way seen more than their peers from other contexts, they are not in any
less need of engagement in typical childhood activities and experiences
(e.g., school life, socialising, community clubs, and extra-curricular
activities). Despite their different experiences, it is critical that profes-
sionals and teachers involved do not treat these children as fragile or
incapable. Instead, children of refugees have experienced abnormal cir-
cumstances and they need to reclaim their normality—and, with the
right therapeutic intervention, many will.
To feel contained children of refugees need:
• To have their own behaviour and that of others satisfactorily

managed.
• To be protected from bullying and undue provocation.
• To be firmly controlled from hurting their fellows or disrupting their
work.
• To experience justice and fairness in school and have a sense that
they are neither disadvantaged nor specially privileged with regard
to what behaviour is considered acceptable. When their behaviour
is not acceptable, they need to be told in unambiguous terms so
that they understand the severity of the situation. When others do
wrong against them, they need to see that the standards are similarly
enforced.
• To experience dependability and consistency. Seeing and being spo-
ken to by the same teacher every day can provide a reassuring sense
of stability; so can being in the same classroom or the same part of the
school building; whereas frequently encountering different staff and
moving from one location in the school to another can psychologi-
cally resonate with the chaos, disruption, dislocation, displacement,
and fear that they have already experienced in their lives.
It is possible to offer children and their family’s specialist counselling

and psychotherapy in agencies such as the local Child and Family Con-
sultation Service, or organisations which specialise in working with
refugees and asylum-seekers, like the Refugee Therapy Centre. How-
ever, whatever helps the child and family may receive, it is unlikely
to immediately alleviate the situation. Counselling, psychotherapy,
and family therapy can all provide opportunities for children to come
to terms with their memories and express their distress. But they can
provide no quick route to recovery, nor can they simply take away the
distress. Many may come with scars both physical and psychological
that run deep, and these wounds of the recent past may re-stimulate the
wounds from long past.
This is not to say the child will be incapable of play and laughter and
having fun; indeed, these things often occur and need to be encour-
aged. There needs to be recognition that a laugh, a joke, and a good
game of football do not restore what has been lost; they just make the
pain a little more bearable for a child who cannot yet put her or his
experiences into words.
When working with children who have endured severe trauma,
we need to cope with our own sense of helplessness that this type of
situation may bring. It is difficult to feel so helpless, but we need to
realise and accept, as clinicians, that this is our obligation to serving
these vulnerable children: if we are indeed to help encourage a posi-
tive change in their lives, it is through consistency in our approach
and an ability to listen without judging or becoming too emotionally
engaged. The experiences children of refugees have gone through can-
not be changed. But, with appropriate containing therapeutic interven-
tion, they may accept those horrific memories as their past experience
and develop hope for the future. Here, I present a vignette of a young
girl whom I shall call Florence. Doing so, I have to note that this has
been one of the most painful narratives I have heard from a child, but
also I consider one of my most successful works with a brilliant out-
come that I never could imagine or hypothesise at the beginning of our
therapeutic encounter.
Florence
Florence, aged fourteen from Central Africa, was referred for assess-
ment and possible therapeutic support by her psychologist in the local
Child and Adolescence Mental Health Service (CAMHS). From the age
of ten, Florence was raped, beaten, and forced to perform sexual acts
with her rapist. Her mother killed herself as it was the only way she
saw to escape the trap set for her and her daughter, whom she had to
see abused repeatedly, without any hope of reaching freedom. Indeed,
she saw no hope of her child’s rapist’s being prosecuted for raping a
minor. It is any child’s worst nightmare to lose their mother to suicide
and especially in such a situation. For Florence, this nightmare was

reality.
In the country where Florence came from, there is no societal
pressure or legislation to protect the rights of women or children. So
Florence was pleasantly surprised when, in the UK, she was taken
under social care, having been allocated a social worker that she built
a good relationship with. She was happy with her foster family and
was very excited that she could see the local MP, Jeremy Corbyn, at the
Refugee Therapy Centre. She told me that she felt like a very important
person now. She asked about the system in Britain and how come a
Member of Parliament would come to the RTC and allocate his valuable
time to see her or other refugees. I referred her to one of our Mentors at
the RTC to help her with her study. Again, she was pleasantly surprised
and said: “If anything I wish or want comes true I could wish something
else.” I asked her what her other wishes would be. She said to have
her mum here to enjoy life with her (She became tearful in silence and
all her excitement disappeared). I felt her pain and became speechless.
What could I possibly say to that? At that moment, I wished the same
for her. I held my tears, gathered my thoughts and told her: “It would
be wonderful, but we know that is not possible as your mother made
a decision to end her life; but I am sure she would be happy for you
enjoying your life and looking to your bright future if she were alive,
whether she were here with you or not.” In tears, she said: “You are
right; my mum loved me and I know she is happy for me. I know she
is happy that I have you here to help me with everything.” Her voice
become stronger again and she said: “I want to read and understand
everything and when I grow up, properly stand with other activists
to protect other children and represent children from my country and
other African countries and to get a massive group together to rescue
all children in the world.” I said I wondered if it were difficult for her
to stay with the thought of her mother not being there for her and if she
felt angry that her mum felt so vulnerable watching her daughter’s suf-
fering that she decided to end her life and I wonder if this is confusing
for Florence. She said: “Let’s honour my mum’s memory by ensuring
her tragedy is never repeated.” That made me happy.
When Florence was brutally raped, she had no family or carer to
report it to; there were no officials to prosecute her torturer and rapist.
After her mother’s suicide, Florence said that she was heartbroken and
lost her voice, unable to scream in pain when she was raped and beaten
by her torturers. She said: “I did not feel the pain anymore; I was just
watching them and waiting for them to finish every time.”
Florence and I worked for two years on a weekly basis with a long
break in summers and around Christmas each year for her to enjoy
her holiday with her foster family. We reached the stage when finally
everything was moving in the right direction for Florence. Bit by bit we
struck down the most problematic part of her traumatic memory and
passed them as a past painful memory, and reached the stage at which
she could also focus on the loving relationship that she had felt with
her parents and the rest of her family before the traumatic events took
place. We also focused on her experiences here and now and the great
hopes and aspirations that she had developed for her future. Parting
was difficult for both of us and I had to be strong for both of us too.
She asked me if she could come and visit when she really, really missed
me or needed to talk about something. I could see that she was not yet
ready to say goodbye and for separation from me as her listening other.
She was doing well in school and at home and would soon start study-
ing for her A-levels. So, after careful consideration, I proposed to have
a regular meeting every two months. She was so pleased, she jumped
from her chair and, to my surprise, came towards me, held me very
tight and kissed me saying: “Thank you”. We met regularly without fail
until she went to university. The last session we had, she came to my
room and shortly afterwards asked me if she could introduce her boy-
friend to me who was with her and sitting in the waiting room. I agreed.
She called her boyfriend in, introduced him to me, introduced me to
him as her “British Mum”, and with, fun and deep laughter told him
“Now you know if you ever want to have my hand in marriage that you
have to ask for permission.” This, as we arranged before, was our last
session and, although I was surprised by her boyfriend becoming a part
of it, on reflection, I could see that Florence wanted to show me that she
was OK. At least twice a year, however, she calls me still and we have a
little chat about her life. She sends me Christmas cards also.
The impact of trauma on perception of the self and the world

Here I would like to come back to the sense of self again. The endur-
ing effects of an event, such as torture, sexual assault, and violation
in the community as a weapon of torture, can lead to a change in the
perception of self, others, and of the child’s world. In these kinds of
circumstances a child may not yet have the capacity to cope, or may
build the capacity for altering beliefs about self and the world to the
extreme in order to feel in control. As a result, a child of refugees may
believe that all officials could be potential perpetrators or rapists and
that the world is not a safe place and that no one can be trusted. Some
children may come to believe that a bad thing happened to “me”,
and “I” must be getting punished for something terrible that “I” did,
because bad things only happen to bad people; they believe that life is
dangerous and that “I” should always fear what could potentially hap-
pen to me at the hands of other adults. Such negative beliefs certainly
increase the stressors in a child who has endured traumatic atrocity due
to environmental factors.
For a traumatised young patient who has lost trust completely as
the result of these environmental factors and believes the world is not
always a just and fair place, the therapeutic goal is to incorporate and
assimilate the experience of the trauma into the past experience, with
hope of altering the child’s beliefs to incorporate the new. With this
change in perception, a child with such a negative belief can change
and form the view: I am not a bad person for being persecuted or for
having to leave as a result of war; and sometimes bad things happen to
good people, and, although I had bad experiences, the world is not an
unsafe and insecure place altogether. This change may be temporary
initially and its revocation is reasonable and understandable if the per-
son has a reappearance of symptoms in the form of fear or intrusive
thoughts, which may then be projected onto such issues as their asylum
application being rejected, mandating a possible return to the danger-
ous situation they have fled. Although these fears and intrusions might
be rational and justified, the progression of adjustment to the unpre-
dictable might be challenging; this is a normal reaction to an abnor-
mal situation and it is the result of existential anxiety, which of course
accompanied by an unconscious element of trauma and recovery. I pre-
sent a vignette of a boy I call Bearish below.
Bearish
Bearish was referred by his support teacher from school with confirma-
tion from social services. In our initial meeting, his mind was flooded
with confusing and broken-up memories of the trauma he had experi-
enced which he was unable to make sense of or to manage. His mind
was populated by violent images and thoughts as though it were

happening just now. He could not cope or relate to what was happening
to him internally, and this mirrored the violence that was felt to have
happened, and, indeed, had actually happened in the external violent
world he had lived in.
It was challenging to engage with him in any coherent way and in
trying to make contact with Bearish I was mindful of what he may have
been exposed to, and to what extent his mind may have been flooded
by his experiences, resulting in him, left with no psychic space and no
clear sense of himself, unable to relate to anyone else.
Bearish was fifteen years old when he was referred to us. He was
from Afghanistan and lived with his parents and siblings there before
the Taliban attacked their home.
The referrer indicated that Bearish requested a referral to the
RTC after failing to engage with his local CAMHS and his frequent
requests to see his GP, asking about sleeping tablets since he was
suffering from severe depression and insomnia. In London he and a
friend were violently attacked by a gang in the street when walking
as neither could sleep. The attack had taken place only four months
after his arrival in the UK. I asked him, hoping that, as it had taken
place here and he had had to talk to police and other professionals
involved, he therefore might be able to give a coherent narrative of
his situations. This was a success and he was able to give me a clear
narrative of the attack, his feelings, what happened after, and what
sort of support he was provided with. He also said that, since this par-
ticular attack, he had been experiencing a great desire to cut himself
with a knife and to watch himself bleeding. He said that he had been
referred to a child psychiatrist that he liked and the psychiatrist told
him that he needed to be referred for psychotherapy, but he could not
talk to the doctor at CAMHS. He continued saying that he was ask-
ing to be referred to the RTC to see me. This was surprising. To my
knowledge, I had never heard of a child or a young person his age
and with such disturbed psyche asking to be referred to us or who
even knew what the RTC was. So I asked him how he knew about us.
He told me that one of his uncles was treated by me in the 1990s in a
different organisation and it changed his life and recommended me
to him. With further information, I could recall his uncle who was an
extremely disturbed young person referred by the juvenile court for
assessment and treatment.
With this knowledge about his uncle, I thought that Bearish’s

difficulties must stretch beyond the impact of the street attack in
London, indeed, to the incident in Afghanistan. This would explain
why he presented a confusing combination of events and he felt psy-
chological numbness and was concerned about his state of mind and
his desire to cut himself to stop the confusing pain that he was not able
to cope with.
Bearish’s facial expression remained too serious throughout the ses-
sion for his age—the way he sat and held himself and the way he spoke
gently with a mild lisp expressed little emotional variation. This was
despite the referral letter which indicated that he was very angry and
had violent outbursts if he was asked questions He spoke in a com-
posed manner and thanked me for seeing him politely at the end of the
session, asking if I were going to see him myself, while there was some-
thing I could see in his eyes which suggested he was, in fact, vulnerable
and very frightened. I felt that what he was telling me was of consid-
erable concern to him; despite the fact he tried hard to hold himself
together physically and control his voice, not conveying the strength
of his vulnerability. I desperately wanted to offer him some interpreta-
tions, but had to hold myself back to keep the boundary and to keep to
the time constraints. So, I said that our time was finished for the day
and that I would like us to meet next week to catch up and discuss this.
His eyes shone and I was pleased that we could end the session on a
positive note.
In the following meeting, which I still considered part of the assess-
ment, I told him the interpretation I had wanted to tell him previously
but was unable to due to time. He immediately burst to tears and began
by telling me about the attack in London and continued by telling me
of what happened to him and his family back home in a great rush.
Bearish described how he and his friend were surrounded by a group
of young people, had been punched, kicked, and stamped on their
faces and heads and all over their bodies. He was in hospital for five
days and his friend for over a month as he had had serious bone frac-
ture and a dislocated shoulder. The gang members told them before
leaving that if they told the police and gave identification, they would
be cut into pieces with a knife next time and bleed to death. His account
of the attack was coherent yet it lacked any feelings attached to it, and
my impression was that Bearish was guarding himself from a psycho-
logical breakdown. I told him that it seemed to be that he was fearful
of feeling what had happened to him. He said that since the attack he
had been fearful of going out at night and even felt scared of walking
anywhere during the day time. He felt fearful of being attacked again,
particularly in the areas in which he lived and where his attackers were
also from. He was becoming increasingly isolated, spending a lot of
time alone in his bedroom after school.
Bearish then described in detail what happened when the Taliban
attacked their house.
He was struggling and I said, very gently, that I could see and under-
stand that it was a difficult memory he was trying to tell me about and
that I was listening and I could see how he had been so deeply affected.
This helped him to express himself better. He then started telling me
about his relationship with his parents and his sister who was two
years his senior and how close they were but how, since she reached
her teens, they had grown apart. Bearish seemed to link the distance
between him and his sister to adolescence, as though there were some-
thing about puberty which was responsible for the distance between
them. Bearish described how as kids he and his sister would spend all
of their time together, and he always felt protected by her. He told me
that he was the younger one and said people often asked him why he is
not as communicative as his sister, as he was usually quiet and only felt
comfortable enough to talk freely to her. He reflected that he felt con-
fused about their very different characters, and said that if they weren’t
siblings, no one would think they were related—she was beautiful,
kind, outgoing, respectful of others, intelligent and best in school, and
so helpful and protective of him, he said. He said they had an argument
for the first time which had culminated in Bearish threatening to kill
her. Bearish said he couldn’t recall what had been said or even what
the argument was about, just that it was the worst thing in his life up
to that point. He continued: “Of course, I wouldn’t really have wanted
to hurt her, I loved her. To calm the situation, my father asked me to go
and get a book from my uncle in my grandparents’ house which was
five minutes away. My grandmother wanted me to stay for lunch. I got
the book from my uncle and I think it was around three o’clock in the
afternoon when I said goodbye and I promised my grandmother that
the first thing I would do would be to apologise to my Zara.” At this
point Bearish was in silent tears.
From his scarce descriptions of his life I was left imagining some-
thing chaotic, to be endured, and within which there was the risk of a
violent attack on him at any moment. I was struck by his voice and his
facial expression remaining composed and affectless throughout our
first assessment meeting and the level of the information and detailed
narrative that he had provided me with in this second one. Despite not
having any understanding of why I had a feeling of estrangement, of
being unsafe, isolated, and sad, I made an interpretation of my counter-
transference feelings and Bearish said that that was exactly how he felt
and said: “You now can imagine what I feel and why I get angry.” “Yes
I can Bearish.” He continued:
I am very sad and angry because I saw my father killed, lying in

blood outside my house; my sister was raped and laid in her blood
in the hallway and my mother’s head was cut off in the kitchen
and no one did anything about it. I was only away for two hours—
I managed to put my mother’s head next to her body in the kitchen
and ran to tell my grandparents what had happened. When I got
there, I became unable to say anything. I was opening my mouth
to scream but no noise was coming. I then fainted, I don’t know
for how long. When I woke up my grandfather and my uncle were
sitting on both my sides and holding my hand; I opened my eyes,
looked at them and remembered—the three of us started crying.
I then knew that they knew. I still could not say anything and never
said it to any soul until today.
The way in which Bearish presented himself and the words with which
he chose to articulate his most traumatic experience to me provided
me a glimpse into how it had been difficult for other professionals to
reach Bearish. I began to consider whether his idea of not having had
an opportunity to apologise to his sister was linked to his fear of his
own possible aggression and of becoming so out of control that his
anger may kill another person. I thought about his having to undergo
yet more guilt and confusion, losing her and his parents in such a vio-
lent way, before he had the opportunity to process this first argument
and anger. I made a light interpretation on this and asked him what he
was feeling right then now that he was able to tell me what had hap-
pened. By this point he had stopped crying; he reflected on what I had
said and in his monotone voice he said that he was still struggling to
recall what he had felt at the time and why, and that he could not tell
how he felt.
I said that that was ok, that we could work on things and I hoped
I could help him to feel safer, but it also suggested that he existed in
what I called a state of dissociation. Bearish agreed and said that he had
spoken about avoiding going out, especially at night, as he felt unsafe
and feared being attacked by the gang again. I considered the possibil-
ity that my feeling of being unsafe in countertransference was related
to the uncertainty regarding what might happen if Bearish heightens
awareness and if the intensity of Bearish’s memories increased and he
felt more keenly their emotional impact the memory of the events that
he had witnessed in one of our sessions. I feared that, if that happened,
neither of us would survive them and I could not remain in the role
of his therapist and his listening other, the process of therapy would
become uncontaining for him.
I hypothesised that we had already formed a therapeutic dyad and
developed a good transference–countertransference interaction with a
sense of care and protection for each other. In the final few minutes
of this assessment session we focused on exploring Bearish’s anxiety
about going out as it seemed that we could both cope with this with-
out too much pain. We then arranged regular weekly sessions and a
time that would not interfere with his school and was not too close to
dark. He was pleased. When I wondered what he thought about this
arrangement, he replied quietly that I might be able to see him and refer
him to someone else. I was unsure what he was asking or wondering
about here. Whether he was asking to work with someone other than
me? Or perhaps worrying that that might happen without his wishing
it? There was no time to explore or think about this, and my experi-
ence was of being left with unsettling thoughts about the possibilities of
what might erupt in an unpredictable and potentially frightening way,
combined with some hope around Bearish’s having been able to articu-
late his anxiety concerning his experiences to both me and to himself.
I said that our time had finished for now, and that we would start think-
ing about his experiences together as and when he was able. Otherwise,
I said, we would focus on his life in the here and now and how we could
think together to make it easier. He thanked me again and the session
ended on a good note.
For Bearish, his attempt to acquire a sense of connection to others
and to establish an identity appeared to be complicated by the way he
perceived his attack, which had led him to an emotional crisis. Liveli-
ness and the capacity to have and express feelings appeared to have
been forgotten by him. The normal adolescent work of separating from

one’s parents was combined with negotiating a separate identity from
his sister, and, since they were not there, this appeared to have led to
a kind of confusion, rendering Bearish in retreat and locked up his
healthy defences. As weekly sessions began I remained heavily reliant
on transference and countertransference to understand Bearish’s trau-
mas without jumping to an assumption. I was mindful of the extent
to which my own struggle to build a picture depended upon the way
in which he presented his world in his unimaginative although dis-
torted, muddled, and undefined way. When he spoke like this it felt
as if he were completely deprived or robbed of his life and witness-
ing how he would wander out in the room without any connection to
me. I observed and identified the frightening flash of the memory of
the argument with his sister and the intensity of that memory. I had to
remind myself of how his memories were full of fundamental compo-
nents in different sections with different dissections and quantities that
touched his nerves and caused great pain and confusion as they had
not been reflected upon yet, and therefore could be stored and instead
reappeared as flashbacks until now. So, I constantly had to be mindful
of what Bearish may have witnessed or been exposed to, and which he
was yet to share with me.
After seven months in therapy Bearish, on his arrival for his ses-
sion, appeared quite anxious and unsettled and seemed agitated as we
approached my room. He paused outside the door and said that he
needed to go to toilet and he wondered whether someone were in my
room. Despite rationally feeling that this wasn’t the case I suddenly had
a powerful and momentarily paralysing experience of him and me as
two children who weren’t able to assert ourselves and open the door to
establish whether there were someone in my room or not. He went to
the toilet and, feeling strange, I entered my room and faced my PA on
my desk doing something. I was terrified, asked her to leave the room,
and sat feeling empty but stressed, waiting for Bearish. He entered and
began to speak in an agitated manner.
There were about five minutes remaining when Bearish said that
there was something he wanted to talk about, something to do with
his sister, and he’d be annoyed with himself if he didn’t say anything
today. He added that he knew that there wasn’t much time left, but it
had really been on his mind. I felt aware of a powerful and growing
sense of dread concerning what I was about to hear. Bearish said that
the argument with his sister was because he had opened the door to
his sister’s bedroom and had seen her sat in front of a mirror touching
herself and Bearish was terrified. There was a silence and claustro-
phobic feeling in the room and I felt unable to process this or to say
anything, so I decided to stay silent. He was looking out of the window
for a while, and then he looked at me and began to speak about school.
I said to Bearish that my impression was that he wanted to be able to
share this troubling experience with me and to then get away from
it; he may feel it would be just too difficult for us to talk about this
together right then and that, for this reason, he’d shifted to talk about
school here in London instead, though of course this was OK. I added
that I thought it was important for him that I realise how he had taken
a leap of trust in our relationship by telling me about this experience,
and how unpleasant it must have been for him to have had to carry
the weight of these very disturbing images and thoughts in his mind
for so long. He nodded and said he never could have imagined that he
could have talked about it with anyone as long as he lived. I suggested
that maybe it felt difficult to feel free to talk about it further, and that
he worried that he and I wouldn’t be able to handle this, but that I
thought he also felt he couldn’t continue to not talk about the thoughts
and feelings that were stirred up. He nodded in agreement without
saying a word.
It was becoming more and more clear to me how Bearish’s mind had
been populated with trauma and how he was overexposed to experi-
ences that were disturbing and intrusive for him prior to the trauma of
his family being killed, and how there was no time between his disturb-
ing feeling around his sister that he loved so much and losing her.
In a number of sessions following on from this disclosure I was aware
of a counter reaction to Bearish’s having shared this information with
me. I thought about whether I had responded in a respectful and con-
taining manner or not, as Bearish missed two sessions after this without
phoning to inform me. This was the first time he had missed sessions,
so I thought that I must have said or showed something to make it dif-
ficult for him to continue. I became concerned that he might never come
back and felt that I had failed him. Thankfully he rescued me from my
dreadful feelings and attended the next session. I was very pleased to
see him. I spoke to him about the anger he seemed to feel, which was
not only linked to his choosing to share the feelings attached to his per-
sonal experiences with me, but was also a reaction against a part of him
wanting to trust and depend more on me and the process of therapy. By
not coming to the sessions, he was punishing himself for this trust and
showing me that I should not be trusted. I also spoke about the worries
he might have about the impact of sharing these troubling experiences
and also of the fear of losing me or of my leaving him in an array of hor-
rible feelings. It was the first time he showed anger. He said he didn’t
know what I was talking about. In that session and a few sessions after,
whatever I would say to reconnect with Bearish, he appeared to have
a problem understanding. If I tried to make contact with the part of
Bearish that needed help with processing these experiences, he would
say that I wanted to force him into uncomfortable and distressing ter-
ritories and was driving him mad. Whereas my experience of time
passing without further exploration of these thoughts left me feeling as
though I was becoming a neglectful mother, colluding with his denial
and avoidance. At this stage, Bearish remained guarded and said very
little. I felt that for the time being he had closed the door on talking and
thinking about his further experiences, whatever they were, and that I
should respect that and not push him. Having little expectation of mak-
ing contact, I shared this with Bearish. He immediately agreed and said:
“Thank you, yes; I do not feel able to think further about what I had told
you and other things I still have not.” So we resumed our therapeutic
relationship on the promise that we would continue as long as it took
and that he would tell me if he felt I was pushing him, the moment he
felt it. The work continued.
Disturbances in multiple value processing

subsystems due to trauma
Some traumatic events can affect children’s value-processing subsys-
tem. For instance, incest can disturb a healthy relationship, resiliency,
and autonomy, and genocide can disturb collective identity, interde-
pendence, and community subsystems, which may demobilise one’s
psychological resources to respond, superseding other sub-systems.
These types of experience can fragment the schemas, principles view-
points, assumptions, representations, and judgments about the self, the
other and the view of the world, and about the efficacy of the exist-
ing value-processing mechanisms that a child might possess. Children
of refugees, like others, interrelate within a set of connections that
provide emotional, social, and material support as well as a sense of
being socially entrenched, of belonging and of meaning in life. There
is also development of a system of accustomed social contingencies
that are rooted psychologically and emotionally as the basis of feelings

of safety, security, and belonging. Events that many of the children of
refugees endure may threaten these connected networks and thinking
and remembering well-established connections can be a cause of the
traumatic events which shattered such connections, therefore creating
involuntarily confused, vulnerable and negative feelings due to the loss
of connectedness by suspension.
The formation of having a sense of identity, agency, and self-efficacy
is a developmental milestone to adulthood with affirmative conse-
quences on individual well-being and for psychological resiliency.
From a psychoanalytic point of view it is important to assess what is
specifically traumatic in a child’s life at the particular time of thera-
peutic encounter, rather than focusing just on the past narratives: is
it, for example, the fear of castration or anything that could resemble
or remind of castration and a narcissistic wounding to the sense of
self and identity? Self-sufficiency or development of positive identity
builds emotional independence which leads to feelings of being com-
petent, adequate, and in control over the self and in relation to others.
Trauma, therefore, can disturb psychological connectedness and cause
feelings of loss of self and helplessness, and can disturb the develop-
ment of resiliency, a healthy object relation, autonomy, and identity
formation.
Early disturbances prior to the refugee-related event can also impact
the shared affective exchange in relating as a child, and with compan-
ionship for an adult. It affects the lack of feeling of warmth and con-
nections to an adult and creates insecurity and mistrust for a child.
Early childhood trauma affects formation of personality by the whole
sequence of emotional development that can gather avoidant or puz-
zled and confused object relations and also the therapeutic relationship.
This of course can generate personality difficulties, set off assumptions
and beliefs about self and objects, and impact on emotional as well as
cognitive functioning. Psychological traumas such as abandonment,
imprisonment or death of a parent, parental neglect or divorce, the loss
of significant others, such as a long-term child minder or care giver can
also disturb the relevance of object relations. Object relations as the rela-
tional model, which accounts for the distortion of objects by pointing
to the inherent difficulty of the search for relatedness, is the most use-
ful theory in working with refugees. One of the important concepts is
not only what others have been for us, but also what we wanted them
to be. The object relations theory, in my view, is the most appropriate

way of working with children who endured trauma. As Greenberg and
Mitchell suggested:
Although cognitive development is not independent of affective
factors and psychodynamic struggles, early primitive forms of
cognition are unavoidable and universal […]. Early forms of per-
ception and cognition, lacking a sense of time, space, and object
constancy, contribute to the painful intensity of the struggles within
early object relations. For the relational model theories one need
not fall back on drives to account for distortions of interpersonal
reality. (Greenberg & Mitchell, 1983, p. 406)
I will return to object relation theory in more depth in later chapters.
Disturbances of automatic schemas due to trauma

Traumatic events for a child can disturb the automatic functions that
effect the automatic activation of schema. They may be beyond the
existing repertoire of schemata that direct the adaptive response to such
occurrences which may put a demand for originality toward new value
processing structures. Additionally, as a result of the trauma, children
of refugees may present behaviours that do not match their personal-
ity and value system prior to enduring trauma and may be unfamiliar,
indeed unacceptable for their carer and other professionals involved
in their case in the host country. Paradoxical morality—committing
immoral acts, or getting involved in petty crime such as shoplifting,
or on occasion wishing to join the extreme political, social or peers
activities—is a higher order of moral goal in the phantasy of the adoles-
cent who feels lost and is searching for identity. It represents one of the
potential behavioural schemes of trauma response, and many children
of refugees who are referred to us at the Refugee Therapy Centre who
have suffered multiple traumas can find this pattern of paradoxical
morality unmanageable.
What are other possible effects of trauma?

Some of the common patterns of emotional trauma may result in com-
pulsive behaviour patterns, self-destruction, uncontrollable reactive
thoughts, splitting off parts of the self, inability to make choices, the
inability to maintain close relationships, and unhealthy dissociations

from the past and present.
It is important to mention that, over time, for some children of refugees,
especially those within a caring family and support system, symptoms of
an emotional trauma without professional support or treatment can be
subsided at the conscious level and normal daily functioning can slowly
return. However, looking at this process from a psychoanalytic point of
view, there is an active process of the unconscious that remains and which
may need some psychological work later. Therefore, although symptoms
do appear to be gone, they may surface again in different forms, espe-
cially in another stressful situation. Sometimes these responses can be
delayed for months or even years, and often children and people around
them do not associate the symptoms with the precipitating trauma, but
the child’s daily functioning in life or life choices continue to be affected
mainly by unhealthy rather than healthy dissociations.
The severity of children’s experiences before coming to the UK or
another host country with or without parents, and problems related
to adapting to the new cultural environment, indeed when they reach
eighteen years old, immigration matters are influential on each child
and young person’s states of mind, and determines the impact of their
on-going stressors. This may have differing emotional impacts, par-
ticularly just after arrival. An important component sometimes is the
avoidance of thinking or remembering the past trauma, which actually
may, for a time, be helpful if one can indeed dissociate healthily from
these intrusive thoughts. In this way children consciously or uncon-
sciously want to manage their process of resettlement and integration
without psychological collapse. Therefore, those who successfully
avoid having intrusive and stressful memories and emotions related
to trauma they have endured already have some level of resilience and
have the capacity for healthy dissociation.
Differentiating between stress and trauma

There is difference between experiencing emotional trauma and expe-
riencing stress. Stress can deregulate nervous systems for a relatively
short period of time, and it may take a few days or weeks before the
nervous system calms down and reverts to a normal state of equilib-
rium. This return to normality often does not occur when one has been
affected by traumatic events. One way to determine the difference
between ordinary stress and the emotional effect of trauma is to look

at the degree to which an upsetting event continues to affect a person’s
life, relationships, and overall functioning. If the reason for distress can
be communicated and be responded to adequately, and can be returned
to a state of equilibrium, one is in the realm of stress. But if one turns
out to be distant, in a state of active emotional intensity, the person is
experiencing an emotional trauma, though sometimes one might not
be consciously aware of this intensity. This emotional intensity may
instead be manifested in a defence mechanism that an individual devel-
ops against the memory of trauma which can, in turn, cause them to
dissociate unhealthily from relating to the experience of trauma.
Single traumatic event and repeated or on-going trauma

There is a distinction between single and repeated traumas. Single
shocking events, such as earthquakes, hurricanes, floods, volcanoes,
plane crashes, robbery, rape, and homicide, can produce trauma reac-
tions. But the traumatic experiences that result in the most serious men-
tal health problems are usually prolonged and repeated, and at times
can continue over years of a person’s life.
A single unexpected direct traumatic event may cause typical symp-
toms of relentless flashbacks, persistent avoidance, and increased
arousal. This does not appear to strain the massive denials, psychic
numbing, self-anaesthesia, or a personality disorder characterised in
the PTSD symptoms and diagnosis, though this type of trauma can
impair some areas of psychological functioning.
The complex traumatic events, which are continuous and repetitive
ordeals that gain prolonged and appalling anticipation in one area of
human functioning, produce the most severe effects on mental health.
Such experience may create enormous defence mechanisms of repres-
sion, denial, dissociation, somatisation, self-anaesthesia, depersonali-
sation, self-hypnosis, identification with the aggressor and aggression
against the self. The impairment in emotional processing includes a
sense of constant anger and frustration, and deep sadness and fear,
which is all quite common in refugees’ experiences. Toleration of pro-
tracted stressors, inflicted with intent by persons, is much more com-
plex than the toleration of accidents or natural disasters. If harm was
inflicted deliberately in the context of a social relationship, as in the
case of torture, the predicament is greater than that of an accident. In
situations where the injury was caused deliberately in a relationship by

a person whom the injured party exposed their vulnerability and may
become helpless by the tortured, or by a parent or caregiver in relation
to the child, the effect of trauma can be horrendous. Sadistic abuses
on the subject of interpersonal violence by a person or persons as an
eruption of passion in the severest forms are those inflicted deliberately.
Premeditated cruelty such as torture can be more terrifying in the long
term and more injurious than impulsive violence.
One of the important effects on trauma on the child is the possibility
of regeneration of neurons which can lead to recovered brain function.
It is important to understand how the nervous system works and how
to repair it, but as a society we must first learn how we can contribute to
the eradication of torture in any form and especially that on children.
Of all the tissues and organs in the human body the nervous system
is the most intricate and complex, consisting of more than a thousand
neurons. These neurons make precise connections with each other to
form functional networks that can transmit information. By identifying
the genes that specify the characteristic behaviours of each of the differ-
ent neurons in the nervous system, it might be possible to manipulate
them to induce stem cells to become neurons or to induce neurons to
regenerate.
How is it possible that something that happened in childhood could
affect someone’s health many years later? Deregulation of the body’s
stress response systems is one of the reasons, as it is one of the main
systems that respond to a stressor. These systems are the hypothalamic–
pituitary–adrenal axis (HPA axis), and the autonomic nervous system
(ANS). Early life stress can lead to a deregulated HPA stress response
and children with early life adverse experiences can develop different
HPA responses to acute stress. For example, women who were sexu-
ally abused as children exhibited increased pituitary–adrenal and auto-
nomic responses to the social stress and adversity stronger than that
of women with reasonably healthy development as a child. Studies of
early life stress and HPA deregulation have reported similar findings
(e.g., Bremner et al., 2003; Heim et al., 1998; Rao et al., 2008).
Most of the costs associated with “problem kids” or “children with
challenging behaviour” are associated with unforeseen consequences
that children and adolescence of refugees, indeed other children all
experience, and as the result for some in the short term it may affect
their educational needs and leads to making uninformed choices. Due
to a lack of appropriate intercultural therapeutic intervention, matters

can get worse from the grouping children of refugees together in a
special home or special education classes, which has been shown time
and time again to achieve little else apart from making them feel alien-
ated and segregated from society. This had the effect of making things
worse and damaging the future of these children, as well as having tre-
mendous cost to society as a whole. I’m not suggesting we should stop
trying to help children of refugees to learn and understand their new
environment—and to learn what can seriously affect their lives in nega-
tive and life-threatening ways. I have, however, learned, and this is a
known fact in intervention design, that trying to stop behaviour is an
almost impossible task, while guiding children towards more desirable
behaviours is more effective. Most importantly, focusing on developing
children’s resiliency should allow us as clinicians to focus our efforts
on guiding children of refugees, as well as other children at risk, away
from trouble that can influence their lives negatively. Being judgmental,
prejudicial, dishonest, hypocritical, and dogmatic about these issues is
only going to keep us on the road to nowhere that we have been on for
so long.
There are other factors which may have effects on children of refugees
prior to the specific refugee-type trauma (e.g., torture, persecutions,
witnessing atrocities in family and community, displacement, loss, and
separation). Embryology has had a major influence on the leading sys-
tematisers in the field of developmental psychology (Fishbein, 1976;
Sameroff, 1983; Waddington, 1957; Weiss, 1961, 1969). The majority of
the theories of development that were prominent throughout much
of the twentieth century accorded little attention to neurobiologi-
cal processes (Cicchetti, 2002; Goldman-Rakic, 1987; Johnson, 1998;
Nelson, Thomas, & de Haan, 2006; Segalowitz, 1994). Basic research
in neuroscience in the last few decades has begun to elucidate the
events that mediate the relation between experience and development
of behaviour. Researchers in the field of developmental psychopathol-
ogy are searching for further knowledge to inform their investigations
and to be able to develop further knowledge of the neural mechanisms
that might underlie the dynamic, multiple-level interactions that exist
among genes, brain, behaviour, and experience (e.g., Gottlieb, 2002;
Gottlieb & Willoughby, 2006).
Neurobiological development is a complex process originating at
conception and extends throughout the lifespan (Casey, Tottenham,
Liston, & Durston, 2005; Cicchetti & Cannon, 1999; Thompson &
Nelson, 2001). Brain development can therefore be altered by various
factors. For example, genetics, physiological, psychological and social
stressors, and psychological factors can result in pertaining aetiologic
factors that modify the normal progression of brain development.
Trepidations and any sort of disruptions causing stresses that
take place in the developing brain can trigger a stream of movement
of growth and function changes that lead the neural system down a
pathway that deviates from normal neurobiological development
(Cicchetti & Tucker, 1994). Accordingly, abnormal trepidations and
stress at one stage of brain development will likely impede the crea-
tion of new structures and functions, distorting the form of structures
and functions not manifested which can limit the embellishment and
usage of ones that had appeared earlier (Cicchetti, 2002). Subsequently,
abnormal neural network configurations and operations are likely
to develop, which can cause atypical and irregular connections to be
retained or created. These types of developmental abnormalities may
eventuate in the development of irregular uncharacteristic neurocir-
cuitry and often compound themselves into enduring forms of psycho-
pathology (Cicchetti & Cannon, 1999).
Neuroscience focuses on neurobiological development, and
researchers (e.g., Gottlieb, 2002; Gottlieb & Willoughby, 2006, Cicchetti &
Tucker, 1994; Eisenberg, 1995; Greenough, Black, & Wallace, 1987;
Kandel, 1998) in the field of developmental psychopathology have
begun to use this knowledge base to inform their investigations
aimed at uncovering the neural mechanisms that might sub serve the
dynamic, multiple-level interactions that exist among genes, brain,
behaviour, and experiences that may become part of the pathology
induced in the brain structure and may distort the child’s experience,
with subsequent alterations in cognition and social function. Black et al.,
(1998) indicated that experience-expectant and experience-dependent
processes may continue to operate during psychopathological states;
children who incorporate pathological experience during these pro-
cesses may add neuropathological connections into their developing
brains instead of functional neuronal connections.
Although present knowledge on the nature of the relations between
neurobiology and behaviour in development across the lifespan is far
from complete, in recent decades a number of studies have emerged
that enhanced the ability of neuroscientists and psychopathologists
to discover pathological processes in the brain (Amso & Casey,

2006; Casey, Giedd, & Thomas, 2000; Casey, Tottenham, Liston, &
Durston, 2005; Durston et al., 2006; Johnson, Halit, Grice, & Karmiloff-
Smith, 2002; Ozonoff, Heung, Byrd, Hansen, & Hertz-Picciotto,
2008; Schumann, Barnes, Lord, Courchesne, 2009; Schumann, Bloss,
Barnes, Wideman, Carper, et al., 2010; Hazlett, Poe, Gerig, Styner,
Chappell, et al., 2011; Pierce, & Eyler, 2011). This rapid growth in the
development of sophisticated techniques permit the anatomical and
physiological imaging of the nervous system and provides new oppor-
tunities for researchers to find out varied information about the brain
and brain metabolic processes, glucose metabolic rate, the ability to
distinguish between cerebrospinal fluid and the capacity to detect bio-
chemical changes within brain cells, such as changes in neurotransmit-
ter receptors, and the examination of brain connectivity through tracing
white matter tracts and detecting brain functional connectivity (Hunt &
Thomas, 2008).
As developmental psychopathology and neuroscience share some
principles, the connection between neuroscience and developmental
psychopathology can provide better understanding and perhaps even a
good framework to support the study of neurobiological developmen-
tal scientists. Scientists in these disciplines have long asserted that one
can gain valuable information about an organism’s normal functioning
by investigating its abnormal condition and believe that a firm knowl-
edge base of normative developmental processes is essential for under-
standing both psychopathology and resilient functioning (Sroufe, 1990;
Cicchetti & Cannon, 1999; Goldman-Rakic, 1987; Johnson, 1998; Nelson,
Thomas, & de Haan, 2006, Cacioppo et al., 2007; Cicchetti & Posner,
2005; Gottlieb, Wahlsten, & Lickliter, 2006; Masten, 2007; Pellmar &
Eisenberg, 2000). The incorporation of neuroimaging into the research
armamentarium of developmental psychopathologists may contribute
to an increased comprehension of the mechanisms underlying vulner-
ability and resilient qualities and characteristics. Psychopathology and
resilience of course cannot be understood fully unless all levels of anal-
ysis are examined and a multi-level empirical research is developed
that can be investigated within neuroscience and developmental psy-
chology and psychoanalysis.
The development of such scientific and inclusive research will
provide the possibility for a deeper understanding, better diagnos-
tic approaches, indeed the development of intercultural therapeutic
strategies that can advance the treatment, as well as provision for the
prevention of behavioural and emotional symptoms, as well as pre-
vention coping strategies that may have been adaptive in their initial
context, but proved to be ultimately maladaptive due to the trauma
suffered.
Investigation of brain structure and function developmentally can
discover aetiological pathways and necessary precursors for the devel-
opment of symptoms associated with various mental health problems.
The differences in structural brain development and brain activity can
provide an endophenotype (Gottesman & Gould, 2003), and bring an
alternative for identifying those individuals who are more likely to
respond positively to various treatments, those whose symptoms may
be more obstinate and intractable to intervention, or even those at risk
of developing severe psychological problems. Additionally, investigat-
ing the activity of brain systems associated with disrupted behaviours
and emotion dysregulation can aid in understanding typical individual
variability in brain function and organisation, and in understanding
processes of risk to vulnerability and of development of resilience.
Here I bring a clinical vignette as an example to illustrates some of
the dynamics I have discussed in relation to developmental factors.
Yamur
Yamur was a very bright and talented but deeply troubled eight-year-
old girl whom I saw two times weekly for psychoanalysis for four-and-
a-half years, until she successfully entered secondary school and settled
very well.
She was referred to us for a psychological assessment and an IQ test
to establish whether she had a learning disability. A year prior to this
referral, she was assessed by an educational psychologist who reported
that Yamur was an intellectually challenged child and needed a com-
prehensive assessment to identify her needs. The educational psycholo-
gist’s report indicated concerns about Yamur’s depression as well as
concerns about her increasing inability to learn, or to respond to her
teacher and that she was unable to function effectively. Her ability to
mix with her peers and make friends was considered non-existent; she
had been unable to achieve educational success, despite high levels of
support provided by the school. While she found little meaning and
satisfaction in these activities, she was driven to drawing and gained a
keen recognition by her teacher, and she therefore developed a strong

attachment to her. She (her teacher) reported that Yamur sometimes felt
faint and panicky while sitting shivering in the classroom and often fell
from her chair. The teacher held her to get her up from the chair but she
was not able to walk; she felt that her feet were not touching the ground
and that she was about to fall over and over again, holding strongly to
her teacher for a while, then letting go of her teacher and coming back
to normality.
A few sessions after this report, when I felt I could, I asked Yamur
about her recurrent fainting incidents. At first she declined to respond;
I insisted that it was important to talk about it and to see whether there
is any way to stop them—she suddenly responded, “No, I don’t want
to stop it.” I asked why. She said: “I love my teacher and that is the only
time she hugs me and holds me and it feels so good” and she started
crying. I let her cry for a bit, and then asked her if she could tell me what
was upsetting her at that moment. She said: “I miss my mum. I miss
having hugs and kisses; I miss mum combing my hair—can you hug
me please? I know you can’t, you explained to me before, and I know
if I faint here you know it is not real—please let me hug you and kiss
you.” She said that she was unable to concentrate on her school work.
When Yamur was six years old, she witnessed her mother being
badly beaten in their house by soldiers while they were arresting her
father. Her mother was taken to hospital by neighbours and family, but
no one explained to Yamur what was happening to her parents. At one
point she found an opportunity to ask her aunt, but was told to shut up
and that it was not the time for silly questions. She never asked after
that. When I asked her what she herself remembered she responded
readily and said: “I remember my mother was lying on the floor in our
house back home, screaming and calling my father. I was very worried;
I was scared. I called her but she did not say anything and did not look
at me. There was blood on the floor and on the blanket.” This was one
of Yamur’s earliest childhood experiences with her mother, her father,
and the adults around her.
At the time Yamur commenced psychoanalysis she was in care and
living with a good foster family. Shortly after I started seeing Yamur her
mother came to London and informed her and other family members
that her husband (Yamur’s father) had been killed by the authorities in
their country of origin (In the initial assessment Yamur’s foster carer
had said that Yamur’s father was still in prison and was not allowed any
visitors, and her whole family had pleaded for Yamur to be taken away
from the country, before the authorities arrested her too or took Yamur
to prison and tortured her in front of her father in order to extract a
political confession from him). The father was one of the distinguished
leaders of the opposition party in their country.
Yamur was kept in care for another four months before being moved
into a place with her mother. At this point I realised, that Yamur had
become withdrawn, regressing as well as becoming more acutely
depressed. This also coincided with the time that I proposed to see
her for weekly psychotherapy sessions, but, in consultation with her
mother and also Yamur herself, we together decided to postpone this
decision to a later stage and to try to provide space for Yamur to deal
with the grief of her father’s death, which took her several months. It is
important to mention that the process was very difficult for me.
During the three years of therapeutic work, Yamur become able
to connect with her memories, to deal with them as past events and
gained tremendous resiliency. There were four phases in this process.
In the first phase, she clearly wanted help to come out of her extreme
confusion and to know what was going on around her. We used draw-
ing in this process to help her to find words for what was in her mind
but could not be expressed verbally. Therefore, using this we managed
to unlock the confusions in her mind. In the second phase we focused
on her stabilisation in her day-to-day life by using play, and, on occa-
sion, when she felt she needed to, she would use drawing outside the
sessions to dissociate from the confusing and stressful things spring-
ing into her mind. This process provided the opportunity for Yamur to
gain the strength which became her asset, and to find sanctuary from
her psychotic state of mind. In the third phase we focused on Yamur’s
life in the here and now, to some level focusing on transference, while
also looking at some of her dreams which were not purely the anxiety
dreams she had been having at the start of therapy. In this process,
Yamur started feeling alive, and became excited at the thought of a
happy and potentially successful future and what we together were
working towards. And she felt it worth working towards; it was not
just that she was complying with her school’s view that she receives
therapy in order to stay there. Her mother’s anxiety (who was also
receiving therapy at the Centre) decreased in this process. Her thera-
pist reported that the mother’s attitude to life changed, and she was
becoming more sociable, going to college, starting voluntary work in
her community and was not so preoccupied with Yamur anymore. The
fourth phase, although successful towards the end and would achieve
great progress, was challenging at first as it was a struggle for Yamur
to deal with separation from me. But we began the difficult process
of this important change. I indeed felt this in my countertransference.
I knew it was best for Yamur to end, but I knew I would miss her and
miss working with her. I was thinking of the very timid girl from our
first sessions who was so unwell, confused, and shaky with typical
psychotic presentation of her mind which was somewhere else most
of the time most of the time; a girl who was sent to us to be diagnosed
with a severe learning disability, who now grew to this young girl,
would grow into a young woman soon, who was highly intelligent,
top of her class, and a pupil that all her teachers loved and cherished to
have. I used this interpretively in transference and this provided such
a relief for Yamur, who could think of me as really caring for her and
not just doing a job. Although this process of ending proved difficult
in a sense for both of us in balance we did very well, and we mostly
focused on her progressive integration during the period we worked
together and the resilience that she gained that no one can take away
from her. Yamur asked me if she could send me a Christmas card every
year. I said there was no need from my side, but, if she ever felt that she
needed to remind me to think of her and sending a card would provide
her that, to do so by all means. I said I would like to hear from her what
she would be doing and where she would be when she became twenty
years old and I would be pleased if she could drop a line or two to tell
me that. She smiled with such a satisfaction and said: “Ohhh I love you
so much and … ”.
In the first year of therapy, the time was devoted to dealing with
Yamur’s feelings of despair, anguish, guilt, and anger over the trauma
she and her family had endured and the tragedy of their lives. The
images of abuse and her feelings of being abandoned were the cause
of her constant panic attacks, her breathlessness and choking, as well
as her fainting episode around her teacher whom she felt very much
attached to. All these were referred to as serious concerns by her school
at the point of referral. She had intense feelings of guilt about what
she perceived as her responsibility for her mother’s unhappiness and
she felt that she had failed her mother by not being able to do any-
thing about the death of her father, or the beating of her mother during
the soldier’s intrusion. Much of this guilt was associated with Oedipal
struggling. She never verbalised that she felt that her mother was
neglecting her, but, in the beginning of our work, she was expressing
her feelings by saying that she was missing her mum and her hugging
her as if her mother had also been killed—this continued even when her
mother joined her in the UK. It seems with the killing of her father she
had lost her mother too and she felt totally lonely and isolated. She was
drawn to men who were about her father’s age when she saw him last
(in their late thirties), and she was particularly interested in older men
who needed help. She was also becoming excessively altruistic, unable
to say no for fear of hurting, rejecting, or offending someone, whether it
was her mother or her peers in school.
Throughout the process, Yamur spoke of something inside—vague
and unspecified—that had to come out if she were to feel happy again.
In the second year of treatment, she developed a habit in which, on
leaving each session, she automatically stated the time of the next
appointment. I interpreted that in a session, saying that she feared that
there would be no tomorrow and that I may not be here for the next
session. She nodded strongly with a very sad smile and tears in her
eyes. This confirmation from her developed a very strong countertrans-
ference in me that stayed with me for a while—by the end of each ses-
sion, I would be feeling her pain, wanting to embrace her, before she
reminded me of the time and the day of next session—but I managed
to contain my feelings as I was aware that I had to let her go. With
reflection and consultation with a colleague, I started saying: “We have
come to the end for today; I will see you on Thursday” or, “I will see
you on Tuesday, Yamur. Ok?” She responded. Her automatic statement
at the end of each session reminded me of the anxiety she suffered in
transference and my becoming able to be not too consumed in her pain
and just confirming the next session somehow helped Yamur to cope
with her intense feelings and trepidation in our relationship. Working
with transference–countertransference, and as our work was progress-
ing, this ritual helped to address her jumpy edginess and the thought of
hers that people in her life and people she cares for are always unpre-
dictable and may not live from one minute to another.
During the last year of our work, just after I proposed that we need
to begin with the possibility of her stopping therapy as she was doing
very well, she began having “bad dreams”, as she called them. She
dreamt that someone was following her. She would feel trapped, una-
ble to escape, unable to move and unable to scream for help and she
would wake up shaking and sweating, then she hears voices telling her
she should die, she is going to die anyway, but when she said: “Who
is this?”, she couldn’t hear anything anymore. In this process we spent
considerable time working on her intense depressive feelings, and her
wish to die and join her father so that she need never suffer the separa-
tion from her loved one, her negative introjective feelings that some-
how she was going to cause death to her mother as well as anyone else
she “loved”. When I asked, she said she was worried she’d cause the
death of her teacher and me too. In a session she offered apologies to
me and said that while I and others thought of her as making progress
and we made such an effort to make her happy, inside she felt very
sad, unhappy, angry, disturbed, dishonest, and wicked. While every-
one around her thought that she had made considerable progress in
her therapy and she herself believed this as her school work had been
progressing well.
Throughout the process she gained the strength to ask her mother
some information about her father and the circumstances of his death.
We arranged a meeting with her, her mother, her therapist, and me. We
would usually get together every three months or on occasions when
Yamur wanted to talk to her mother about specific issues in their life
and her memory and needed help to do so. This meeting was challeng-
ing and many tears were shared between mother and daughter and for
the first time they embraced each other and cried without inhibitions.
Yamur’s mother apologised to her for unintentional neglect when she
most needed her and said: “It is painful and embarrassing to say this,
but I want you to know that I had a psychological breakdown then,
but I was not aware of it at the time.” She promised that they would
go together to visit their town in which they had lived and where her
father was killed, and would try to find out where her father was bur-
ied and, if people didn’t know, she said, she would put an advert in the
local newspaper asking if anyone knew, find his grave and they would
visit it together. Yamur asked: “What if no one knows?” Her mother
became silent and was in tears. I felt we as their therapists should come
to their help, so I said: “We do not know if that would be the case; it is
very clever thought of you and I am wondering whether your thought
will become reality. You then together can think of some other ways
you can pay respect to your father’s memory and together say goodbye
to him symbolically.” Yamur’s mother eyes brightened and said with
excitement: “Yes, that is very good idea. I am quite sure we can find out
where he was buried as he has so many friends and he was a respectful

man in the community as well as one of the leaders of his party, but, if
no one knows where has been he buried, then I assume he would not
be the only one. We can get together with other people whose family
members were executed and do something together to commemorate
them.” She held Yamur’s hand and said: “I promise we will do some-
thing together and I promise to be there for you this time, my darling
little girl. We will make a location, a special one for his grave.”
On my colleague’s recommendation they also decided that here in
London on a nice afternoon they could go to the local cemetery and
think about him symbolically. Yamur reported this was done very
soon after our session and reported more visits to the cemetery with
her mother. Throughout this process Yamur was repeatedly telling me
how good therapy was and how she thought every child should have
some and developed and maintained a great interest in the subject and
shared her view with her mother. I heard from my colleague that her
mother started a psychology degree in university as she developed
an interest in the area of mental health and working with children of
refugees specifically. From a psychoanalytic point of view, one of the
major functions of this interest was the attempt to reconstruct more
reality-adequate representations of their recovery and keen desire to
know more fully how such a change and recovery became possible for
them. Searching to know about herself, Yamur’s mother later devel-
oped interests in psychology and psychoanalysis as a career choice.
Yamur showed interest as well while she was also working hard in
therapy to establish her own individuation and her differentiation
from her mother. She began to explore her feelings that her mother
might have decided to study psychology because she was jealous of
Yamur’s relationship with me as her therapist and she desired to be
like me so Yamur would love and respect her better. She wondered why
her mother was becoming jealous about our relationship although she
allowed Yamur to be seen by me.
After this process Yamur’s depression lifted completely and she
then began to express her anger towards both of her parents and, as
she began to elaborate aspects of her negative feelings toward them
openly for the first time, her identification with her severely depressed
mother become more apparent to her. She then began to develop some
confidence and ambition for her future. This was vividly expressed
by her and she said: “From now on I am going to be my own person.
No depression for me anymore, thank you very much, no feeling bad

because the bad things other people doing and whether my mother like
it or not, thanks to you for taking all the bad things inside me out.” As
we successfully worked through her grief, her ambivalent feelings, and
her anger towards her parents and about ending her therapy before she
started secondary school, she began to establish a more psychic space,
a better sense of self, a mature identification and resilience.
Yamur’s treatment illustrates the value of a psychoanalytic perspec-
tive on anxiety and depression, particularly for children who have
endured such atrocities and severe trauma. Understanding trauma of
children of refugees and making appropriate use of projection, intro-
jections, and projective identifications with gentle interpretations pro-
vide a possibility of opening up more psychic space for development
of a better sense of self, resiliency, and character building by using
healthy dissociation from unbearable memories. Psychoanalytic for-
mulations and clinical implications aid me as Yamur’s listening other
to be mindful of the limitations and strengths that Yamur brought to
the treatment process and in understanding some of the dynamic and
environmental factors that contributed to her difficulties. Yamur was
a seriously depressed child who struggled with profound feelings of
helplessness, hopelessness, and confused feelings of guilt, deriving
in part from harsh and punitive superego introjects and the nature
and severity of her experiences. It seemed to me unlikely that she, or
indeed her mother, would have been able to benefit from brief treat-
ment, with or without medication. Consistent with the psychoanalytic
formulations that were discussed earlier and throughout, Yamur was
quite responsive to psychoanalysis and gained substantially from the
experience.
A few years later after the termination of therapy I received a card
around Christmas time from Yamur in which she wrote:
I am pleased to tell you that I am studying medicine as I told you a

few years back, intending to go to paediatrics, although, I hear it is
very competitive in the UK. I am very happy and while good aca-
demically enjoying life as well. I have a nice boyfriend who treats
me well and I love him. Oh, you can’t believe it, mum has a partner
and is very happy and I am so happy for her. You may already
know she is a qualified counsellor and working with women
who’ve escaped domestic violence. I feel a little shy to say this, but
I miss you very much, almost every day and will always think of
you with affection, warmth, and compassion. Your courage, your
committed persistence, reliability, and dependable approach and,
I dare to say, your character and your refusal to abandon me at a
time when I almost had been rejected by everyone around me and
had no hope, no fantasy and no respect for myself. You were the
only one who had faith in my ability, even if I was not able to show
it at the time, helped me to gain some measure of self-confidence
and self-respect. Thank you for ever and I hope it would not be
too much to ask if I can come and see you in your convenient time.
I have no problems to discuss; I just want to see you. I miss you!
With my very deep love and admiration …
My clinical intervention, in each process of engagement with Yamur

indicates the value of viewing various forms of psychoanalysis from
intercultural perspectives and with paying specific attention to object
relation theory. Yamur’s presentation in our initial meetings was not
just a series of manifested symptoms, but of serious disturbances
deriving from disruptions of the normal dialectical interaction of two
fundamental developmental lines—the development of mutually sat-
isfying, reciprocal interpersonal relationships and the development of
a differentiated, integrated, essentially positive and realistic sense of
self. These two developmental lines are fundamental to personality
development and organisation in psychoanalytic theory and its impli-
cations (Balint, 1959; Freud, 1930a; Loewald, 1962; Shor & Sanville,
1978), indeed in a varied intercultural possibility which may by some
be perceived as non-psychoanalytic formulations.
Two primary configurations of Yamur’s presentations derive from
her difficulty in coping with vulnerability and with severe disruptions
of her normal dialectical developmental process. I considered this to
be due to the environmental trauma that she endured. To cope with
developmental disruptions, she had become excessively confused and
pre-occupied with her bewilderment with both these developmental
issues (relatedness and self-definition), defensively but unconsciously
avoiding both. The formulation of her psychopathology deriving from
distortions and disruptions of normal psychological development pro-
vides a paradigm that organises various forms of psychopathology in
an integrated and economical mode, in line with some of the personal-
ity disorder criteria described in Axis II of DSM-IV, which, for example,
cluster primarily around issues of either interpersonal relatedness or

self-definition.
Although my approach is mainly psychoanalytical, I think it is
important to acknowledge the use of non-psychoanalytic theories that
helped to understand the situation that Yamur had been in.
CHAPTER EIGHT
Working with family
O
ne of the common issues that we face working with children
and young people is that adults tell us that they don’t want the
child to talk about what happened in the past and if they do
we should tell them not to. Many parents, and some foster carers for
unaccompanied children, indeed sometimes the child’s contact person
from social services, desperately want the child or the young person to
change their behaviour, not to think about past and get on with life—
because they care. However, as therapists we must remember that they,
the carers, and we know less than the child about the traumatic events
that they have endured.
When children are having difficulties, establishing links with their
home can be crucial; however, working with the parents of trauma-
tised children of refugees is not always easy. They may find it hard to
acknowledge that their child may have a problem, especially of a psy-
chological nature. Parents may be eager for their children to forget the
past, look to the future and do well at school. They may really want to
believe that the horrific experiences the family has gone through have
not affected their children, so they convince themselves that the chil-
dren are OK and are reluctant to accept evidence to the contrary.
169
Parents may easily feel blamed and criticised when told by

professionals that their child is having difficulties. They may readily
believe that problems are the result of professionals’ not understand-
ing their child’s needs, other children picking on their child, issues of
racism and discrimination, etc. They may refuse to see that the child’s
reaction would be disproportionate for such things, and is symptomatic
of other sources of distress. Sometimes, of course, parents may have a
point, and organisations may be reluctant to admit there are problems
of racism or discrimination also.
Experiences of exile mean that many women who are refugees and
asylum seekers have lost their support networks and community of
extended family and friends. This is particularly an issue for moth-
ers with young children who reported feeling extremely isolated and
lonely and sometimes becoming verbally or physically abusive or vio-
lent to their children, which does increase their psychological prob-
lems as well as those of their children. Many young asylum seekers
and refugee families face multiple social problems including difficulties
making an asylum application, finding a proper solicitor, living in poor
housing, poverty and difficulties accessing and receiving benefits, and
lack of knowledge about services. Some parents we serve feel that their
social difficulties prevent them from being good parents. Depression
amongst mothers, caused by social distress and isolation, increases the
worry for their children as they are aware of their parents’ not being
emotionally there for them.
In some refugee ethnic groups, a disproportionate number of house-
holds are headed by women. There are many lone mothers in these
refugee communities because so many men have been killed in fight-
ing or have been imprisoned while mothers escaped with children. The
experience we have is that many asylum-seeking refugee families are
not aware of their social and legal rights or services available to them,
often due to insufficient access to information or perceived, or actual,
exclusion from services when attempting to find help. It is no surprise
that this experience causes great frustration for many refugees, leaving
many feeling their needs have not been met or identified.
Effects of trauma on the family as a unit

Effects of trauma on families can be destructive. Often there must
be an adjustment in the role division between refugee partners and
parent–child relations which can lead to a gap in communication.
W O R K I N G W I T H FA M I LY 171
Indeed, refugee parents may, more than a child, feel socially isolated
and distant from their familiar environments, which can have adverse
impact on the relationship with the child—creating risk of identity con-
fusion. This future can limit flexibility of a child’s ability to adjust to the
new environment.
Common effects of trauma on families include:
• Adjustment in the role division between partners

• Parent–child relations and gap in communication
• Wider generation gap—role reversal
• Adolescents: reduced flexibility of adjustment; greater risk of iden-
tity confusion
• Parents’ social isolation
• Feeling of alienation in unfamiliar environment
• Miscommunication with children
• Confusion of personal and cultural identity
• Low educational attainment
• Intergenerational misunderstanding
• Lack of family cohesion, which may lead to delinquency, neglect,
abuse, and community strain.
Below, I will present the illustrative case study of Amirshah and some
short vignettes, Hammed and Fran.
Amirshah
Amirshah, aged eleven, was referred by a clinical psychologist within
a Child and Adolescent Mental Health Service (CAMHS). They hoped
the RTC as specialist organisation could provide appropriate services
to support his long-term well-being. Amirshah was born into a middle-
class family in Afghanistan in 1998. Both his parents were doctors,
working in the same hospital. Amirshah was the only child. His parents
and extended family raised him with tremendous attention and care.
His physical growth and mental development was normal. He was a
happy, healthy little boy with a loving and containing childhood prior
to the traumatic experiences that disturbed his childhood development.
In the first therapy session, Amirshah was withdrawn and shy, hardly
speaking to me. He looked much smaller than his age. Responding to
my question, he said that he had no idea why he was coming to see me
and what he was supposed to do. His mother had told him beforehand
that he had an appointment without further explanation. I explained

that part of my job was working with children who had gone through
traumatic experiences, and as the result may experience some problems
in their new environment—children like him. I said my job is to help
and to listen to people talk about their experiences if they want to or
about any other problems they may face. I said sometimes we only talk,
sometimes we may play some educational games, and sometimes play
with toys. He immediately responded to this by looking at the corner
of the room which contains various toys in a box, as well as craft and
drawing materials and said smiling: “Now I know why these are here
in your room.”
I thought he was such an intelligent and polite child, and told him so.
I asked if he had had to keep his question about the toys to himself, and
if this were the case, he could tell me the reason. Amirshah made his
small body comfortable in a chair which was too big for him and said
yes: “I didn’t think I could ask, but I was wondering”, and then he fell
silent. With my encouragement, he started to draw two trees and two
birds on the smaller tree. He began to provide supporting narratives
which were extremely sad. In his narratives, the two trees were mum
and dad, and the birds were he and his little sister staying with mum
separated from his dad. The birds were crying—missing dad—but, as
soon as mum came into the house, he said, crying will stop and they
must do something or say something for mum to think they are happy
so she will be happy.
In his fantasy world, Amirshah wanted to have a happy family,
but couldn’t feel happy without his father. I thought it was likely that
Amirshah saw himself and his sister as birds symbolising peace and
freedom, giving him the ability to fly away from conflict and pain. The
mother was also suffering, so there were streams of hope for our work
to have a positive outcome.
Amirshah’s father was politically active in the resistance movement
against the Taliban. His mother also had been an active member of a
women’s freedom fighter group. Due to their political involvement,
Amirshah’s parents were living in constant fear of being apprehended
by the Taliban forces and eventually, due to harassment and threats,
they had no choice but to flee from Afghanistan. It was 2003 when they
left. Amirshah was only three years old. Although he had suffered psy-
chologically due to the loss of his social environment, he had no under-
standing of the escape nor was he prepared for it.
The family’s journey took around twenty days, walking during

nights through mountains and deserts with a very small amount of
food and water. Throughout the journey they ran out of food, and the
few loaves of bread that remained were left for Amirshah. During their
escape the family experienced shelling bombardments, gunfire, and
rocket attacks. They finally arrived in a refugee camp in neighbouring
Pakistan, where they lived in gruelling, awkward, and unfamiliar con-
ditions. Seven months later, while still in the refugee camp, Amirshah’s
mother gave birth to a baby girl, whom they named Sohela.
Four months later, Amirshah’s father was murdered while he
watched—tied to a tree and bashed in the head and stomach by Taliban
members. Amirshah could vividly recall that he had been standing by
his father’s body and was scared to leave him. In his child’s mind, he
felt as if he would have been able to save him from the horrible men if
he had stayed with his father’s body. He remembered that his father
was vomiting red food (which he now understood to be blood) and one
of the men had strangled him with a black wire. He remembered that
he was screaming for help and was beaten by the men and told to shut
his mouth or he would be shut up by losing his head. He continued
screaming as he wished to untie his father.
After a while people from the camp told his mother what had hap-
pened and she came and fetched Amirshah, while shaking, trembling,
and crying. His mother, quite understandably, was devastated by the
death of her beloved husband and, of course, changed. Taliban mem-
bers sent her threatening messages, stating that if she continued with
her activity she would be killed with her children. Amirshah explained
to me that when the Taliban is after someone, especially a woman, there
is no way to seek justice. So Amirshah’s mother had to flee once again
with her children to a hiding place to save their lives. They could not
continue living in the refugee camp, as it was also considered inappro-
priate in the culture for a widow to live alone without male protection.
They could not stay with their close friends and relatives in Pakistan
as everyone was concerned about their own safety and security as well
as Amirshah’s family. Therefore, his mother, unable to find any alter-
native, was forced to go back to Afghanistan again, despite the dan-
ger there as well. As she explained to Amirshah, in Afghanistan, even
if those bad men killed her the way they killed his father, Amirshah
and Sohela would be able to stay with their loving family. Amirshah
recalled that staying in Afghanistan for a year was nice for him, but he
could sense that there was some tension at the time, although he did
not understand what it was. They were again able to escape to Pakistan,
where they remained for another year before coming to the UK, after
spending a year in Russia as well.
Up to this stage, we can see this very much loved child experienced
continuous losses and insecurity for over five years. When I asked him
how he was dealing with those traumatic experiences and constant
uncertainty, he said as he grew up, he gradually had had to learn how
to suppress his own feelings and take over some of the responsibilities
of his father to be there for his mother and his little sister. The traumatic
experience and problems were constantly discussed and repeated to
Amirshah, which made him feel more responsible and caring, particu-
larly towards his younger sister.
Amirshah, at the point of initial assessment, presented with sleep
disturbances where he would wake up several times during the night
with bad dreams and could not go back to sleep, on many occasions
feeling that he had to check to ensure his mother was well and alive. He
also had a fear of darkness and noise and was chewing his nails to the
point of bleeding. He felt extremely isolated and withdrawn and had
difficulties relating to and socialising with his peers. Amirshah’s mother,
quite rightly, became concerned about her son and contacted their GP
for Amirshah to be referred to the CAMHS. Amirshah had begun to
think excessively about his father and fantasised about how he would
redress or take revenge of his father’s death, becoming increasingly
interested in watching violent movies on television. He also started ask-
ing his mother why, if they cared, the UK government had not killed all
Taliban, and whether there were any group that he could join when he
grew up to free all Afghan people from Taliban. He had weakened his
concentration and, as a result, started experiencing learning problems
at school despite having been a brilliant student in the past. Amirshah
seemed to have lost interest in most of the relational or recreational
activities and play that a boy his age would normally enjoy.
So, at such a young age, Amirshah was suffering from:
• Sleep problems
• A fear of darkness
• Social withdrawal
• Feelings of anger
• A strong interest in and desire to join a fighting group
• A preoccupation with violent movies and games

• A lack of concentration and difficulties with remembering his school
work
• A lack of attention and therefore difficulties in learning new skills
• A loss of interest in peers, play activities, and enjoyable
engagement.
Family support
An assessment interview was arranged with Mrs. Sharifi, Amirshah’s
mother, to establish her needs as well as to get more information about
Amirshah’s past history and present problems. It was evident that
Amirshah had taken on responsibilities far beyond the expectation of
his years. He was aware of all the family’s problems, including finan-
cial details of bills and other expenses that had to be paid. Amirshah so
desperately wanted to take on his father’s role by caring for his mother
and little sister.
Amirshah and his family were familiar with psychotherapy, which is
uncommon among many non-Western cultures. Mrs. Sharifi was find-
ing the adjustment to the UK difficult, since in Afghanistan she could
talk to her mother or older family members for advice and direction
as well as receive support for her emotional and other needs. While
she came to her own appointments regularly, Amirshah’s appointments
were cancelled a few times. Gradually, as practical assistance was pro-
vided to the family along with educational mentoring support, and as
Mrs. Sharifi’s trust and confidence were built up, Amirshah’s attend-
ance in therapy improved and eventually became regular.
The therapy plan consisted of supportive intercultural psychoana-
lytical psychotherapy, mentoring to support Amirsha’s educational
achievement, and the storytelling group. Issues were precisely exam-
ined in the context of the transference–countertransference within and
out of sessions, home, and school.
Amirshah’s mother was diagnosed with severe PTSD, com-
bined with clinical depression and anxiety, and received on-and-off
psychiatric care and counselling for a period. In liaison with her psy-
chiatrist and her previous counsellor, we decided to offer her therapy
in our service including intercultural psychoanalytic psychotherapy,
support work, mentoring, and the women’s storytelling group, which
included supporting her psychologically as well as helping her to
deal with settlement needs, her tremendous concerns and debilitating

anxiety for her children’s future, and supporting her through a proper
process of bereavement. These interventions not only gradually
improved his mother’s mental health, but changed Amirshah’s family
life, providing a context in which Amirshah and his sister could grow
and change.
During the early sessions, Amirshah’s often drew on the theme of
war in his work, drawing houses and trees, but also dead bodies, jet air-
planes, rockets, guns, and soldiers. He described guns as a tool, which
could kill bad people, dead bodies as those killed by bad people, and
soldiers as good men who hold guns but cannot do anything to stop
dangerous bad people killing good people. His drawings changed as
therapy progressed from war- and gun-focused to softer presentations
of flowers, cars, and themes of computer games appropriate for his age.
The strong black pen he usually used changed to paints and coloured
pencils. This, I thought, was a great positive change, and I raised this
with him. Smiling, he confirmed that he did not remember when he
last had had nightmares. He also reported that he did not fear that his
mother would die if he were not looking after her during the night.
He said: “Mum is of course much happier now that I am doing well at
school.”
This was amazing progress for such a short time, less than six
months. However, despite these changes, during some sessions he
would become distracted and seemed tired, finding it difficult to finish
the sessions, begging to stay longer. When I would ask him if he’d like
to finish his drawing, he would perceive that as a way of making the
sessions shorter for him without telling him, which he did not like. l felt
this related to his underlying anxiety of loss and his mother’s depres-
sion. We worked through many of his traumatic experiences and his
desire for revenge expressed through his drawings; however, it was dif-
ficult for him to verbalise the trauma he had endured in his childhood,
including talking directly about his father’s murder.
In a session when he was drawing a gun and a man, he said that
the gun could kill bad people. I thought it was a good time to address
his father’s killing scene, and his unresolved and delayed mourning.
I asked: “You wish to have a gun to kill the Taliban who killed your
father?” He gazed at me as if he had seen a ghost, letting his mouth
hang open. I immediately apologised, saying that I did not mean to
scare him. He calmly asked how I knew about the Taliban and asked
me if I were from Afghanistan like his mother. I said: “no, I am not from
Afghanistan, but I know about the Taliban and the horrible things they
have done and are doing to people.” I dared to add that we were talking
about him and the loss of his father, not me. I continued and asked if it
were difficult for him to talk about it. He nodded, saying he wanted to
talk about it, but didn’t know how and pushed all toys in front of him
towards me.
I thought Amirshah was asking me to more actively participate in
his recovery and help him to do his grieving. I felt I was in an almost
impossible situation here and needed to take great care and was asked
by him to play the role of a fox and later a deer. Amirshah killed all
the animals and was the hero of the game. By doing so, in his mind,
he also wished to kill the part of me reminding him of his past. Dur-
ing this process I reserved any direct interpretation to prevent further
stress for Amirshah who, by now, was able to show the severely trau-
matised part of him with severe aggression and did not care to be the
sweet, vulnerable little boy whom I desired so many times to hug and
to say “Don’t worry; you will be ok” to. We were close to the end of the
session. I only said congratulations and well done for feeling safe to
communicate your anger with me. Thank you. I have to confess that, so
many times after our sessions, I closed my consulting room door and
cried on his behalf, and my own, for such human wrongs—the horrible
world that we are living in where children have to endure such atroci-
ties at such a young age.
I said to Amirshah that I knew he needed me to be strong for him; and
that I would be. Together we could find ways of talking about his pain
and would not let him be the victim of Taliban’s inhumane and horrific
action. He replied, agreeing, and then thanked me. This reflected that
his fixation with bringing retribution and punishment to his father’s
murderers, presented by his internal violent feelings in therapy, in part
represented his need for the opportunity to mourn his father without
the fear of killing me.
Following this breakthrough, I was able to observe in our sessions
that my presence in Amirshah’s life was becoming more positive. His
mother also reported to her therapists that her son was constantly talk-
ing about Aida; if he was not happy with her motherly manner of disci-
plining him, he would threaten to tell Aida about it. This indicated that,
in transference, I was becoming the father to Amirshah and therefore
controller and protector of the family.
Within this process, Amirshah started relating to his peers better

and was making friends; indeed, he participated in all school activities
very well, academic or not, working well in group exercises, acting, and
games, from which he had been totally withdrawn before. Amirshah’s
mother was loving and caring towards him, but usually relied on him
for support as this was a culturally acceptable expectation. So, after a
discussion between her therapist and me, we decided to organise a fam-
ily meeting to discuss this—to give Amirshah a chance to be a child and
enjoy his childhood. This was also to help Mrs. Sharifi recognise her
strength and capacity as a good mother who didn’t need her son to be
an adult for her. This meeting was arranged and both mother and son
used the space to communicate effectively, greatly helping Amirshah to
overcome some of his fears about noise, darkness, and the likelihood of
re-experiencing trauma. Amirshah began to feel positive and liberated
by the thought that his mum was the responsible adult in the house and
would ask for his help only when she needed it.
We then focused on his mourning which was painful and challeng-
ing, but passed this period quite quickly. As a result, Amirshah became
less preoccupied with his past and more focused on his present. Our
therapeutic goal had been achieved, but to support the family long term,
Amirshah continued to see me on a fortnightly basis as he had built
great trust in and attachment to me, seeing me as someone with whom
he could share his happiness and success and talk about his problems.
He enjoyed talking about his school, subjects that he liked or disliked,
his friends and his little sister, his mum and extended family. Often he
brought his school reports with him and talked about his progress. With
a cheeky smile, he would thank me for helping him to get to this, to
which I would reply: “Did your mum put you up to this?” He would
confirm this, but also confirm that he himself meant it, which we would
laugh about. One day he was very excited and told me: “I have news
for you; l have been chosen as the special student.” On another day,
he was able to express his feelings about his mother and said: “I don’t
like when she cries or gets upset. I feel sad and feel I have to do every-
thing she wants me to.” In another session, he told me how much he
loved London because it was beautiful and there was no fighting with
so many different people living in the city in peace.
Here we can see the process of mourning and its effect on this
young person. Mourning can be seen as the turning internalisa-
tion of the structure and function of the self-object or the organising
imaginations of the self in response to the death of a loved one. The

network of cognitive-affective schemata—that is, organising imagina-
tions of the self—can be sustained by and within the self-object which
might be tied in the traumatised, and be gradually transformed in such
a way as to uphold the veracity of the True Self and restore the sense
of self with more psychic space and resilience. Although mourning can
occur after any self-object loss, it is typically the loss of those self-objects
that have been relied upon to repair, sustain, and regulate aspects of the
nuclear-self that results in a full state of mourning. In such cases, the
self has not necessarily been dependent on the self-object in an archaic
sense; therefore, the loss, though painful, does not traumatise the core
self-structure. Successful resolution of mourning will therefore largely
be determined by the structural integrity, cohesion, and resilience of
the self as well as the availability of adequately attuned, compensatory
self-objects. Pathologic mourning will typically result when the self is
primarily organised around archaic self-objects, in which case the core
of the self, loses the strength and resiliency and becomes vulnerable to
disruption.
Dissociation, especially from a relational perspective, is a form of
psychical organisation in which psychical conflicts and threats to self-
preservation are regulated in the mind and can be considered as a
mechanism of defence employed when the mind cannot cope anymore.
Dissociative communication is not necessarily a characteristic of dispo-
sition, but it can be a warning sign that supplements disposition, which
may enhance the pseudo-integration of psychological being, rather
than true personality integration. So, unhealthy dissociation can be
considered as the foundation of the creation of a false self-observed in
some refugee patients who have lost a part or the whole of themselves
due to environmental impingements. If we consider object relation as
a formation of social bonds and of symbolisations, for a refugee who
lacks resilience, the external trauma and the cultural shock of the new
environment may break this bond and leave the person in a disarray of
violent and anxious feelings; this may take away the person’s capacity
to think, which is different from the innate tendency to repression. One
of the difficult tasks for refugees who are affected by trauma is the feel-
ing of loss, including the loss of the self, or at least a part of the self, and
the lack of mourning of the self which is lost or at least partly lost. This
is different from childhood mourning in the process of development
(Alayarian, 2011).
Freud (1917e) initially indicated that mourning comes to an

important and “spontaneous end” when the survivor has detached
emotional ties to the lost object and reattached the free libido to a new
object, thus forbearing comfort in the form of a substitute for what has
been lost. This assumes a view of subjectivity and object-love, and opti-
mism for post-war recovery that Freud articulated in “On narcissism”
(1914c). He defended against the cultural repression of loss by defin-
ing mourning as an essential process, theorising the psyche to be an
internal space for grief work, and bringing a discussion of bereavement
into the public domain. He later (1923b) redefined the identification
process previously associated with melancholia as an integral compo-
nent of mourning. By viewing the character of the ego as a melancholic
formation, he identified similarities between the two responses to loss,
suggesting that mourning and melancholia necessitate similar symp-
toms. Freud indicated that “profoundly painful dejection, cessation of
interest in the outside world, loss of the capacity to love, inhibition of
all activity” (1923b, p. 244) and “reaction to the loss of a loved person,
or to the loss of some abstraction which has taken the place of one, such
as one’s country, liberty, and ideal, and so on” (p. 243) can lead to mel-
ancholia. Losing a loved one therefore threatens to shatter one’s imagi-
nary psychic integrity. This threat explains why one clings to the lost
object—since acknowledging the loss would force the grieved one to
recognise the full extent of what has been lost, namely, an irrecoverable
attribute of the sense of the self that is necessary to having the sense of
coherent identity.
In response to the First World War, Freud returned to the subject of
mourning in “Thoughts for the times on war and death” (1915b) and
“On Transience” (1916a), in which he emphasised the cultural ideals
that were lost as a result of the war. He addressed the loss of “so much
that is precious in the common possessions of humanity” (p. 275) in
seeking to dissolve the “mortification” and “painful disillusionment”
(p. 285) with which wartime violence and brutality is regarded. In con-
trast to the predominant feelings of love that made the completion of
mourning possible, melancholic grief has ambivalent feelings of love
and hate for the other. This ambivalence stems from “a real slight or
disappointment coming from this loved person” (1917e, p. 249). Also
each single one of the memories and expectations in which the libido is
bound to the object is brought up and hyper-cathected, and the detach-
ment of the libido is accomplished in respect of it “when the work of
mourning is completed the ego becomes free and uninhibited again”

(p. 245).
In The Ego and the Id Freud (1923b) renounces the lost other, and
incorporates the loss through a consoling substitute. The self is restored
and the work of mourning brought to a decisive close when the free
libido has been reinvested in a new object. He formulated a perplexing
dilemma in the human psyche: the eternal conflict between the dual
instincts of Eros (the life instinct) and Thanatos (the death instinct). He
identified aspects of the death instinct with superego aggression, sug-
gesting that the superego was the agent of the death instinct in its cruel
and aggressive need for punishment and that its operative feeling was
frequently a punitive hatred—while other aspects of the superego were
protective.
Relating this to the trauma of refugees in war or political conflict,
it is possible for an individual to see the superego of the State as their
own idealised superego, rather than the parental one. Evidently, this
may be the explanation of how during wartime the social superego is
placed in the individual and how in turn the individual is positioned
in the social circumstances and acts on them. It can be said that Freud’s
(1915e) account of the unconscious and the structure of mind is simi-
lar to Plato’s account of the nature of mental health or psychological
well-being, Freud formulating his account with the establishment of a
harmonious relationship between the three structural elements which
stratify and constitute the mind: the id, the ego, and the superego.
• The id is the part of the mind in which the instinctual sexual drives
which require pleasure are situated. The id is the unconscious mind.
• The ego is conscious mind, self-created by the dynamic tensions and
interactions between the id and the superego, which has the task of
reconciling conflicting demands with the requirements of external
reality. All objects of consciousness reside in the ego.
• The superego contains the conscience, socially acceptable behaviour,
and morals, which are learned mainly from the parents’ attitudes
which have been internalised. The superego is an unconscious
screening-mechanism which seeks to limit the pleasure-seeking
drives of the id with the imposition of restrictive rules.
Amirshah’s mother was receiving regular therapy and as she pro-

gressed began going to college and started her career path in the
UK, which dramatically changed the situation for the whole family.
Amirshah and I started to discuss the process of ending therapy three
months in advance to give him adequate time to prepare. This was the
first experience of major change which Amirshah was able to prepare
for, which made the transition easier for him. Our last session, although
we prepared for a long time, had a significant impact on me and I could
sense was extremely hard for him. I was worried about his well-being
and had my own feelings of separation, sadness, and loss as therapy
came to an end. I felt sad in countertransference, and he in his trans-
ference. He asked with tears if he could talk to me if he had problems;
I told him that of course he was always welcome to come back when-
ever he felt he needed to, holding back my tears. He asked if he could
hug me, which I felt grateful for as I also needed to hug him. In tears,
he said that it was the softest and warmest hug he had ever received, to
which I responded by saying that was due to my layers of fat, causing
us to laugh as we parted. My job with this once vulnerable young man
was well done, but I still miss him and think of him with love.
Fran
Here I bring an example of a lone young asylum-seeking mother with
three young children who was referred to the RTC because she was
homeless, destitute, and pregnant at the time.
Fran said that she was sent to the UK as a child when she was ten
years old to stay with extended family due to the greater opportunities
for her here, following her father’s arrest and execution in her home
country. She was sexually abused by the son of the family she was
living with and, when she complained, she was kicked out of home at
the age of thirteen. She said:
I had nowhere to go, nothing to do and no one to stay with. I was

raped in parks on many occasions. I was hungry and scared and
I began prostituting myself in order to survive. I was constantly
abused by older men but stayed with them because I had no place
to go. Then I realised I became pregnant. I didn’t know anything
and I did not know what to do.
The first support Fran needed was from an organisation to help her
with her immigration matters and to put in an application for leave
to remain in the UK. She also needed support to challenge the social
services to provide her and her children with accommodation and
support. One of our Community Development Workers found a solici-
tor who confirmed that Fran was entitled to receive free legal advice.
With this solicitor’s help, the Home Office soon agreed to support her
and her children under section 4 while they considered her case. She
was granted leave to remain in a few months while she was receiving
therapy at the RTC, during which time she had her fourth child—she
was just eighteen years old.
In her feedback she said:
I wish I could’ve known the Refugee Therapy Centre earlier in my

life, maybe I would not have suffered so much abuse in hands of
all these older men for food and shelter and have so many chil-
dren without knowing who their father is. But, I now learned that I
can’t turn the clock back—but I learned that I can be good mother,
so my children can have a responsible mother. How would I do
this with my children? I know you help me and my children. Ref-
ugee Therapy Centre not just turn my life around from the most
frightening situation, it give me dignity and ability to be a proud
mother and take responsibility for my children which makes me
feel good—not mention I am helped to get my immigration sorted,
have nice house, benefit, go to school and everything that I never
could imagine. Thank you.
Looking at all the cases I have presented in this book, it is simple to

see how the external realities of these children and young people are
populated by violence and abuse, therefore not just preventing them
from developing their personalities towards a stable and emotionally
strong adulthood, but creating such vulnerabilities that cause them to
regress and reverse back and in some cases become like an infant. These
are evidence for annihilation as the result of traumas and the lack of any
continuing holding environments.
Winnicott (1965b) promoted the idea that, at the preliminary stages
of the development of mother–infant interaction, anxiety and the dread
of annihilation are closely connected to the notion of holding. It is hold-
ing that enables the baby to develop a sense of self and Winnicott refers
to this as the “continuity of being”: “The alternative to being is reacting,
and reacting interrupts being and annihilates” (1965b, p. 47).
Winnicott viewed the root of the tiny baby’s trepidation in terms of

being able just “to be” and considers aggression and destructiveness
not to be a function or projection of the death instinct, as the new-
born baby could not hate until it was able to comprehend the notion
of wholeness. This idea differs from Kleinian theory, as for Winnicott
the capacity of hate occurred after the holding stage. He (1965b) sug-
gests that in this phase the ego changes over from an unintegrated state
to a structured integration, and so the infant becomes able to experi-
ence anxiety associated with disintegration. In healthy development
the infant retains the capacity for re-experiencing unintegrated states at
this stage, but this depends on the continuation of reliable maternal care
or on the build-up in the infant of memories of maternal care beginning
to gradually be perceived as such. The result of healthy process in the
infant’s development during this stage is that he attains what might
be called “unit status” (p. 44). The holding environment of Winnicott
(1965b) therefore has as its main function the reduction to a minimum
of impingements to which the child must react with resultant annihila-
tion of personal being.
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INDEX
5-hydroxytryptamine 30–31 see also types of 23

serotonin archaeology 84
armed conflict 91, 102–103
Aberbach, David 96 asylum seekers xv, 2, 92, 127 see also
Abraham, Karl 18 children of refugees
adolescents 85, 88, 128–132, 171 attachment theory 15, 35, 60–62
adulthood, reaching 5 “Automatisme psychologique,
“aetiology of hysteria” (Sigmund L”: essai de psychologie
Freud) 53 expérimentale sur les
Afghanistan 123, 143, 172 forms inférieures de la vie
Africa 7, 104 mentale’ (Pierre Janet),
aggression 64, 72, 127, 181 45
American Psychiatric Association autonomy 16–17, 62, 67–68
40 awareness
anger 17, 109–111 case study 27
antidepressants 28 gradual awakening of 33
anxiety 19–27 post-traumatic dissociation
case studies 20–22, 24–27 and 71
existential causes of 19–20 repression of unconscious
Freud on 22–23 thoughts 50
symptoms 19 self and 78
197
198 INDEX
babies 183–184 children of refugees

Balkans 124 acceptance at school, importance
Barker, Pat 39 of 14
belief systems 104 aggression and 64
Benedict, Ruth 63 belief systems 104
Beyond the Pleasure Principle capacity for symbolic thinking 60
(Sigmund Freud) 39 case study 3
Bion, Wilfred 35, 115, 117 consistency welcomed 138
bipolar disorder 28–29 coping with feelings 137–139
Bosnia and Herzegovina 124 deficit approach to 47
Bowlby, John 32, 35, 61–62, 95 depression suffered by 28–29
brain, the 28, 155–159 development of sense of self
Breuer and Freud 34, 69 see also 63–64
Freud, Sigmund discrimination issues 102
dissociation 49, 104–105 see also
capacities, development of 62 dissociation
case studies emotional impact on 5
adolescents 128–132 examples of trauma suffered 7
anxiety 20–22, 24–27 fitting in 42
child soldiers 126–127 individual experiences 54–55
cognitive development 80–83 loss of culture and identity 33
concealed narratives 83–87 loss of environment 64
developing communication 11–14 loss of sense of self 64, 80, 179
developmental factors 159–168 loss of trust by 73, 90, 142
family situations 171–178, mental health issues 92–93, 127,
181–183 132–135
Freud’s 52, 66 models of care 41
rape 124–126 neurotic and anxious behaviour
transference 113–118 in 46
trauma 139–150 perception in 70
unaccompanied minors 119–123 physical health 4
unhealthy dissociation 106–118 psychic space of 55, 73
use of in psychoanalysis 74 stress for 2–3
witness to fatal shooting of therapists working with 89–92
sister 3 torture of 2
castration fear 151 trauma experience of 107–108,
Child and Adolescent Mental Health 136–137 see also trauma
Services (CAMHS) 80–81, two types of 133
139, 143 understanding of 74
Child and Family Consultation validation of feelings 79
Service 138 working with xiv
child soldiers 7–8, 126–127 children’s games 39
INDEX 199
Civilisation and its Discontents syndrome presentations 8–9

(Sigmund Freud) 14 two major forms 32
Cognitive Behavioural Therapy detachment 62
(CBT) 18, 75 developmental psychology 156
cognitive development 81, 152 developmental psychopathology 158
communication 13 disavowal 37
conflict 34 dissociation 39–54, 67–72 see also
connections 150–151 healthy dissociation
consciousness 27, 67, 70, 78 case study 25–27
consistency 138–139 defence mechanism, as 49, 52–53
“continuity of being” 183 Freud on 51
Cooley, Charles Morton 63 healthy and unhealthy 11, 42–45,
Cooper, Arnold M. 76 48, 51, 53–54, 104–105
cooperative peer play 15 highest incidence 44
coping strategies 56, 71 see also memory of trauma and 54
defence mechanisms misjudgement of symptoms 45
Corbyn, Jeremy 140 relational perspective, a 179
countertransference 50, 87, 146–147 repression and 51, 67
see also transference retreat into 78
Craig Lockhart Hospital 39 splitting and 68
Croatia 124 successful acts of 79
culture, loss of 33 types of 39 see also above healthy
and unhealthy
“danger-neuroses” 38 Dissociative Disorder Not Otherwise
Darwin, Charles 93 Specified (DDNOS) 40
data 77, 85–86 Dissociative Identity Disorder (DID)
death instinct 181 39–40
defence mechanisms 34–38 see also drive theory 59
coping strategies
dissociation as 49, 52–53, 55, 105 ego
ego and 23, 34, 38, 51 conflicts within 52
trauma for 79, 154 defence mechanisms 23, 34,
denial 37 38, 51
depression 27–33 defence of 51
biochemical causes 27–28, described 181
30–31 development and 14
Bowlby on 62 fragmentation of 27, 78
frequency of diagnosis 93 melancholia and 180
learned behaviour, as 29 reaction formations and 36
mothers 170 reality based 23
psychosocial factors 33 resilience and 79
severe 18, 28, 32 superego and 65
200 INDEX
war neuroses and 136 fetishism 94

Winnicott on 184 First World War writings 180
Ego and the Id, The (Sigmund Freud) forces that cause stress 56–57
181 fundamental contributions of 59
Ego and the Mechanisms of Defence, mourning 61, 180
The (Anna Freud) 36 patients, a view of 114
embryology 156 reality 105
emotion 23 repression 34, 51–52, 66–67
emotional well-being 5 sublimation 37–38
Erikson, Erik 14–16, 81 trauma and helplessness
Erziel, H. 84 60
Executive Council of the trauma’s economic perspective
International Society for 51, 65
the Study of Dissociation various writings 83–84
(ISSD) 40 war neuroses 38, 136
external events 10–11 From Anguish to Ecstasy (Pierre Janet)
eye contact 24–25 45
Faimberg, Haydée 94 genocide 150

Fairbairn, Ronald 68 Graves, Robert 39
families 169–184 Greenberg and Mitchell 152
case studies 171–178, 181–183 grieving 64, 180 see also mourning
effects of trauma on, listed 171 Grünbaum, Adolf 77
fathers, loss of 8 see also parents Guidelines for Treating Dissociative
fear 23 Identity Disorder in
Ferro, Antonino 94 Adults 40
fetishism 94 guilt 17, 48, 67, 73
First World War 84, 136, 180
Fonaghy and Target 60 hallucinations 41, 44
fragmentation 27, 51, 78, 104–105 healthy dissociation 70–71,
Franz and White 15 79–80, 108 see also under
Freud, Anna 34, 36, 51 dissociation
Freud, Sigmund helplessness 19, 22–23, 60, 139
anxiety 22–23 Home Office 19
archaeology and 84 homelessness, factors for
Beyond the Pleasure Principle 39 consideration 5–6
case histories 52, 66 hypnosis 46
defences, on 34 hypothalamic-pituitary-adrenal axis
defining psychoanalysis 76–77 (HPA) 155
dissociation 51, 69 hypotheses 77
Ego and the Id, The 181 hysteria
Erikson and 14 dissociation and 51, 69
INDEX 201
Freud on 53, 66, 69 “magnetic passion” 46

Janet on 46, 66 Major Depression Disorder (MDD)
27–28
id 23, 65, 181 Major Symptoms of Hysteria (Pierre
identity, loss of 4, 33 Janet) 45
imprisonment 124 maturity issues 12
Improving Access to Psychological meaning 103
Therapy (IAPT) 75 melancholia 180
incest 150 memories
incorporation 37 case study 26
individuality 16, 62 dissociation and 42–43, 47
infants 184 non-emergent 78
Inhibitions, Symptoms and Anxiety trauma, of 54
(Sigmund Freud) 60 mental functions 46
integration 53, 184 Meyer, Adolf 63
intellectualisation 37 Middle East 104
internal events 10–11 mothers see also parents
internalisation 36–37 babies and 183
interpersonal relations 15–16, Bion on 35
62–63, 65 Bowlby on 95
case studies 12–13, 81, 162–165
Jacobsen, Medvedev and Caron depression and isolation 170
31 Robertsons and 61
Janet, Pierre 45–46, 66–68, 105 social responsibility and 60
Journal of Trauma & Dissociation 40 splitting and 35
mourning
Kernberg, Otto 75–76 Aberbach on 96
Klein, Josephine 96 human capacity for 108–109
Klein, Melanie 34, 36, 59, 184 loss of self, for 178–180
Kleinman & Goods 32 psychoanalytic theory of 61, 72,
105
learned behaviour 29 self-objects and 179
legislation, changes in 6 “Mourning and melancholia”
libido 16, 38, 66, 136 (Sigmund Freud) 59
loss, feelings of
culture and identity 33 narcissism 35, 61, 180
environment 64 narratives 83, 107
mourning for 96 National Health Service (NHS)
sense of self 64, 80, 179 41, 75, 79
trust 73, 90, 142 nervous system 155, 157–158
unaccompanied minors, of neurobiological development
134 156–158
202 INDEX
neurons 155 American Psychiatric Association

neuroscience 75, 156–158 and 40
neurosis 38–39, 57, 66, 136 case study 175
neurotransmitters 28, 30 characteristic symptoms 56
dissociation and 71
object-libido 66 frequency of diagnosis 93
object relations theory 59, 61–62, pre-World War I 38
151–152 see also self-objects research into 8, 92
obsession 51 statistics 9–10
obsessive-compulsive disorder 45 variations of incidence 31–32
Oedipus complex 14–15 projective identification 34–36
“On narcissism” (Sigmund Freud) psyche,
180 dilemma of 181
Owen, Wilfred 39 dissociation and 53–54, 78
internal space for grief work 180
Pakistan, 173–174 vulnerability 11
parents psychic space
case study 12–13 calming effect of 11
changes in as refugees 133–134 case study 25–26
depression in 29 creation of 55, 73
fathers 8 memory and 42
mental health of 10 opening up 17
mothers see mothers personality development and 14
nature of relationship with 33 resilience and 48
role reversal 4 Psycho-Analysis and War Neuroses
support for 73 (Sigmund Freud) 38, 136
torture of children and 124 psychoanalysis
working with 169–170 constructivism in 50
Parkes, Colin 61 dissociation 48
patients (in therapy) 50, 84–88, 114 evidence for efficacy 18
perception 60, 64, 70 Freud on 76–77
personality change 63 goal of 49
personality development 14, hypotheses generated 77
65, 151 important contributions of 59
personality disorder 18 methodology 84
perversion 66 model for understanding trauma
phallic narcissism 17 72
physical health 4 mourning, theory of 61, 72, 105
Piaget, Jean 81 political factors 75
Pitchot et al 30 practice of 89
Plato 181 psychopathology and 32–33
post traumatic stress disorder 31–33 research 74–77
INDEX 203
trauma study 74–75 into trauma 8, 91, 96

psychopathology mental health of refugees 92–93
dissociation and 44–45 psychoanalysis and 75–76
neuroscience and 158 resilience 99–118
torture and 1–2 building up 73, 102
various configurations 16–18, controlling one’s environment
32–33, 56, 93 48
psychosocial development 14–15 ego strength and 79
psychosomatic problems 9 emphasis on 47
psychotherapeutic treatment, key external trauma and 108, 156
concepts of 1 focusing on 80
“Psychotherapy in the context of foundation of 34, 105
race and culture” (Lennox healthy dissociation and 11,
K. Thomas) 35 70–72, 78
punishment 181 literature on 100
memory of trauma and 54, 102
racism 35 need for study of 96
rape 124–125, 139–141 perspectives on 121
rationalisation 37 variable capacity for 108
reaction formations 36 vulnerability and 99–103
reality 105 Werner on 117
Refugee Therapy Centre risk factor approach 99
case studies from 9 Rivers, William 39
child seeking referral 143 Robertson, James 61, 96
detailed account of xv Robertson, Joyce 61, 96
group therapy at 96–97 Rosenfeld, Herbert 35
individual refugees’ attachment Russia 174
to and need for 22, 82, 123, Rwanda 124, 137
183
refugees see children of refugees Sapir, Edward 63
Regeneration (Pat Barker) 39 Sassoon, Siegfried 39
regression 8 schemata, 109, 152 179
relatedness 15–16 self 63–65
repression babies 183
denial, disavowal and 37 differing views of 104
Freud’s use of term 34, 51–52, false self 69
65–67 keeping in order during
psychoanalysis, in 48–49 trauma 67
William Rivers on 39 loss of familiar ground 78
research loss of sense of 64, 80, 179
further potential for 74 perception of 60
hypothesis and 77 self-definition 15, 17
204 INDEX
sense of 14, 72 psychopathology and 1–2

trauma and its effects on 141–142 punishment for parents, as 124
vulnerability 95 widespread nature of 9
self-objects 179 see also object transference
relations theory case studies 25, 113–118, 148, 163,
serotonin 28, 30–31 182
sexual abuse 44, 51 interpretations in therapy 86–87
Spencer, Herbert 93 Janet foreshadows 46
splitting mourning and 109
definition 35 unconscious reconceptualised 49
denial and 37 underlying rationale, as 91
healthy dissociation and 48 trauma, 135–168 see also torture
Melanie Klein on 34, 36 articulation of 66
trauma, sense of self and 67–69 attempting to define 135
Steiner, John 35, 85, 94–95 case studies 25–27, 139–141,
stress 153–154 142–150
Studies in Hysteria (Breuer and consequences of 5
Freud) 34 cumulative 105
sublimation 37–38 debriefing 91
suicide 30–31, 139–140 dissociation and 11, 43, 45, 49, 53,
Sullivan, Harry Stack 14, 62–63 69–72, 79–80, 104–105
superego effect of 56
conflict with ego 52, 66 endurance strategies 68
described 181 examples of 7
Freud invokes 65 families, effects on 171
pressure put on ego 23 feelings of loss 80
survivor’s guilt 17, 48 Freud on 39, 51, 56–57, 65
symbolisation 60, 80 helplessness and 23, 60, 139
identification with aggressor 34
Taliban 143, 145, 172–174, 176–177 internal and external events 10
Teasdale et al 28 mental health issues and 31
therapists 84–88, 89–92 psychoanalysis and 72, 74–75
processes for 50 psychotic-like symptoms and 41
rebuilding trust 73 refugees and 107–108 see also
risks associated with therapy 94 children of refugees
Thomas, Lennox K. 35 repression and 39, 48–49
time passing 42 research into 8, 91, 96
torture (of children) see also trauma resilience and 54, 102, 108, 156
case study 3, 24–25 sense of self during 67, 141–142
mental health problems and serotonin levels 28
32–33 single and repeated traumas
overview xiii–xiv 54, 154
INDEX 205
statistics of 9–10 vulnerability 99–103

stress and 153–154 events triggering 11
survivor’s guilt and 48 fragmentation and 51, 78
symptoms 153 sense of self and 95
therapeutic intervention 47 trapped in memory of trauma 43
victim perception 96 unhealthy dissociation and 104
trepidations (of brain) 157
trust, loss of 73, 90, 142 welfare entitlement 6
Werner, Emmy 117
UK Council for Psychotherapy Winnicott, Donald 115, 183–184
(UKCP) xi World Health Organization 96
unaccompanied minors xiv, 1–2, World Mental Health Report
119–123, 134 (1995) 31
unconscious, the 49, 57, 65–66 World War I 84, 136, 180
validation 85–86
victims 96

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HANDBOOK OF WORKING WITH

CHILDREN, TRAUMA, AND RESILIENCE

Copyright © 2015 by Aida Alayarian

All rights reserved. No part of this publication may be reproduced, stored in

British Library Cataloguing in Publication Data

A C.I.P. for this book is available from the British Library

Typeset by V Publishing Solutions Pvt Ltd., Chennai, India

Printed in Great Britain

ABOUT THE AUTHOR ix

UKCP SERIES PREFACE xi

Aida Alayarian, BSc, MSc, DocSc, PhD, is a consultant clinical

The UK Council for Psychotherapy (UKCP) holds the national register

When I want to understand what is happening today or try to decide what

—Omar Khayam (1099)

Torture is a strategic means of limiting, controlling, and repressing the

affect children’s psychological developments that vary depending on

Children of refugees and unaccompanied minors

could be extremely traumatic, impacting not only on an individuals’

The immediate reaction to the brutalities that Emely experienced at

are campaigning for human rights. We cannot continue to look at the

Physical health of children of refugees

Although there is a scarcity of research on the impact of multiple

• The experiences of children and young people

Reaching to adult age and homelessness

• What is considered as homelessness?

• Who is in priority need?

• The current UK legislation and court processes in child protection

It is important for clinicians to be aware of children and young people’s

Traumatic experiences of children

lack of confidence, survivor guilt (especially amongst older children),

Death or the threat of it, separation, loss of fundamental functions, and

Internal events are often triggered by an external event, but the

children, and of sharing the teacher with other children, or sharing in

expectations to be communicated clear to help him to interact in a more

initiation of cooperative peer play (usually around four to six years).

and self-definition. Relatedness and individuality (attachment and

such as withdrawal, denial, or repression, to cope with psychological

Abraham (1924) referred to associations between infantile and

Anxiety, depression, post-traumatic stress,

circumstances did not present anxiety. This type of anxiety is a normal

Four months into therapy, Titus’ depression and anxiety lessened. He

A number of people helped me to find myself after my parents

Offering some recognition of Titus’ complex feelings and allowing him

Here I will present a brief case study of a vulnerable young boy,

As a result, his whole existing psychic structure was shattered by

playing and making friends with his peers; he became academically

Biological factors of depression

per cent to a maximum of seventeen per cent (Weissman, Bruce, Leaf,

disorder in particular. In spite of this, it is important to know that most

A number of biochemical correlates of depression have been reported,

other patients that they categorised as “normal” matched for gender

Post-traumatic stress and post-traumatic growth

the United States. These wide-ranging differences can be attributed in

to understanding of the nature and aetiology of various types of

scarcely contained inside his or her sanctuaries; they preserve the

the mental mechanism underpinning the process, and the projective

Projection, identification, and projective identification

Reaction formation, identification with the aggressor

Internalisation and incorporation

by taking in and modifying the external world. Incorporation is the

Intellectualisation and rationalisation

Repression, denial, and disavowal

Mature mechanism of sublimation