From The Carlat Child Psychiatry Report, March 2019, Trauma in Children and Adolescents

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Topics: Family Separation | Free Articles | Registered Articles | Trauma

We hear of many children and adolescents who are refugees, most seeking asylum. There are calls for professionals to meet the needs of these people. How hard is it to do this—to take time off from regular practice to work in a different setting? It’s easier than you might think. However, is this kind of work as rewarding as people say? Can it be a remedy for burnout? What are the liability issues? We interviewed Suzan Song, MD, PhD, who is a humanitarian protection advisor for the United Nations.

CCPR: Can you tell us a little bit about your work with refugee and displaced persons abroad and locally?
Dr. Song: Globally, I’ve worked with former child soldiers in Sierra Leone, Liberia, and Burundi; worked in Haiti post-earthquake; taught child psychiatry in Ethiopia; and consulted on a parent-infant intervention in the Democratic Republic of Congo. When the Syrian crisis broke, I was a humanitarian protection advisor from 2013 to 2015 for displaced Syrian adolescents in Jordanian refugee camps. Since the 2016 U.S. election, most of my work has been domestic, specifically related to unaccompanied and separated youth and families; torture survivors and asylum seekers; survivors and victims of human trafficking (both sex and labor); and families, including hostage families.

CCPR: Many of us feel overextended in our daily work, and yet doctors working in pro-bono settings often report that volunteering is a stress reliever. Can you speak to this?
Dr. Song: The benefits of volunteer work are many, chief among them the satisfaction of helping people in need of care who would otherwise go without. The gratitude of many families is reward enough for many doctors doing pro-bono work. But I also am paid for most of my work. I have a small pro-bono clinic, but otherwise am paid. I think it’s important for agencies to prioritize the emotional lives of survivors, in part through hiring people who are well-trained and able to give excellent care.

CCPR: Do you have an example of a particularly poignant moment?
Dr. Song: Sure. Every first encounter I have with a survivor—whether a victim of torture, a separated youth, or a victim of human trafficking—is poignant. For most, it’s their first time seeing a psychiatrist, talking about their past or present struggles. It truly is a gift to be on the receiving end and to feel empowered to help in some meaningful way. The traumatic experiences are of course harrowing, but because I’ve heard just about everything now, I’m more fascinated by what aspects of the human spirit help the person not only tolerate, but actually engage with life.

CCPR: Can you give us a specific example?
Dr. Song: Just the other day, someone high up in the government asked me to see someone urgently. So I saw this surgeon from West Africa in my pro-bono clinic. He was from a very poor, rural part of his country where none of his siblings attended school. His uncle supported and inspired his interest in learning, and he ended up not only becoming a surgeon, but earning a fellowship to get specialized training in eastern Europe. He returned to his home country to practice at a time when there was a political uprising. A high-ranked government official was shot during a protest, and my patient was called to do the emergency surgery. The official ended up dying, despite my patient’s best efforts, and my patient was put in jail and tortured, awaiting execution for being a political dissident. He was able to escape with the help of a captor whose mother he was a surgeon for. This is a common type of person seeking asylum. It’s common for such people to have experienced torture. But the ability of this man to forgive, restore hope, and find personal agency (after only 2 sessions) was very striking. I learned a lot from him and think of him often.

CCPR: Paint us a picture of a typical day. Do you work in a regular office? Do you have regular appointments? Do you have a translator? Are you talking with parents, kids, or both? Are you prescribing medications or doing therapy?
Dr. Song: In my pro-bono clinic, I have 1 day every 2 weeks scheduled specifically for these kinds of patients. I have very good relationships with community organizations and often go there to see patients if they can’t come to my downtown office. Most patients are referred by about 5 or 6 different community agencies and government agencies (Department of Health & Human Services, Department of Homeland Security, etc), so they know me and my work, and I tend to take on the most difficult cases. If they aren’t too difficult, I provide free consultation to the community agency’s therapists and counselors to help them build confidence and skills. I give trainings to one torture-survivor program in the community and have loved watching the counselors grow and feel more comfortable taking on hard cases. Even with “just med management,” I always incorporate therapy (and do so in my general practice as well), so I do talk therapy and meds if needed. I speak with parents and kids, and do family sessions if needed.

CCPR: What about secondary trauma?
Dr. Song: Absolutely. It’s hard to hear horrific stories. One reason why I have a pro-bono clinic and am a humanitarian advisor is because it’s hard to sit with these stories. I can only hear a story about something if I’m in a role to help, if I have agency. Right now with the border crisis, lawyers are taking the brunt of the trauma. They’re doing amazing work but don’t have any training on trauma or resiliency. I was shocked when first doing training for the State Department/Department of Defense on human trafficking—most of them had never undergone formal training in trauma. Reporters also need a lot of support; they’re asking the critical questions and are listening to ongoing human rights abuses, then have to leave. Reporters appreciate our help.

CCPR: What type of training would a child psychiatrist need to do ahead of time, and how would the psychiatrist obtain that training?
Dr. Song: It depends on what you’re interested in doing. If you want to work locally with survivors of forced displacement (refugees, asylum seekers, survivors of torture, separated youth, etc), then having training in trauma-informed care and cultural sensitivity is critical. The National Child Traumatic Stress Network (https://www.nctsn.org) has free online training and is a great resource in general. I’ve always learned the most from supervisors, though, and have stayed in touch with many supervisors from training, as well as hired my own clinical supervision.

CCPR: What about cultural considerations?
Dr. Song: Understanding culture and context is critical to all of our work with patients. There have been two main approaches to understanding the role of culture on mental health. One approach, termed “etic,” is to look at the differences across cultures in terms of a general standard. An etic approach might look at overall rates of depression or anxiety across a variety of regions where refugees experience family separation.

CCPR: And what’s the second approach?
Dr. Song: The other approach, termed “emic,” describes distress in one’s own cultural terms. For instance, the separation of families may be experienced even more acutely in cultures where family units are emphasized over individual achievements, often the case in Middle Eastern cultures; this perhaps results in different rates of depression or anxiety for people from those places facing such stressors. An entire field of cultural and transcultural psychiatry has discussed this at length, but for the general practitioner, it helps to be curious, to ask questions when unsure, and to understand the unique role of culture and context on a person. Clinicians performing the evaluations should attempt to educate themselves about the history and cultural beliefs of the refugee populations they serve. The CDC’s website has some cultural sensitivity tips for clinicians who will be performing evaluations (https://tinyurl.com/yxrdj7r4). The DSM-5 also has a cultural formulation interview and supplementary modules that can be good resources to start with. For cultures where information is limited, we learn as we go.

CCPR: Do you have an example of cultural sensitivity that you picked up on?
Dr. Song: Sure. One example was in the refugee camps on the Syrian border; I knew it was inappropriate to wear shorts and thought pants would be fine. However, my ankles were showing, and that was thought inappropriate. Interpreters and your local partners should be critical in keeping you in check to make sure you’re aware of cultural nuances.

CCPR: What about malpractice coverage? Is that part complicated?
Dr. Song: Liability issues are relatively straightforward. My pro-bono work is covered by my institution’s malpractice. It’s always good to check, but volunteering is often in the scope of your job description. Check to be sure that the organization offers malpractice coverage, including tail coverage. In the US, you will likely need to become licensed in the state you are working. Overseas work typically does not require licensure in the country you’ll be working in, but you do need to check which laws apply to your situation in your destination country (https://sites.tufts.edu/jha/archives/2111). You may need to be working under the auspices of a university, a hospital, or an international organization like a non-governmental organization (NGO).

CCPR: That’s kind of a relief. How do you prepare your current patients for these forays? How do your preparations change depending on the length of time you’re away?
Dr. Song: For my medication management patients that I see once a month, I just schedule around the time. But for the therapy patients, I just tell them, “Next week, I have to be out of town.” If it’s longer than that, I have someone who covers my patients while I’m away. So most people are actually fine. Some of the work, especially in active humanitarian conflicts or my work with the UN, can be a bit harder with scheduling. They may call you and say, “We need you in 2 weeks or within 3 weeks to go abroad.” It’s very short notice, so then I say, “Yes, I can do this now,” or I say, “No, I can’t do it.” There are options.

CCPR: What about the issue of boundaries? How much do your patients know about the work you do when you are away?
Dr. Song: A lot of people find me because of my work. Many of our patients Google us before coming and they see the kind of work that I do. They (and I) don’t talk about it except that they’ll say, “I’ve seen the work. I think you’ll understand me because of this work.” Or they might say, “My life isn’t like the stuff you see in Burundi, but…” or, “I respect the work you do abroad.” All of those statements are very useful in therapy. But I never initiate the topic about my global work with patients, nor do I find it necessary to talk about current events or my experiences with patients.

CCPR: What is it like coming back from these trips? They sound intense.
Dr. Song: Working in areas of armed conflict or humanitarian emergency can be emotionally draining, though not noticed in-country. I tend to feel it much more deeply after returning home; the emotional weight settles in within about a week. For many years, I was gone for a week every month to a post-conflict country. Leaving the US was fine, but the return was difficult. There was always this cultural dissonance returning home, so after a few years I developed some rituals to help.

CCPR: Tell us about those.
Dr. Song: Sure. I would tell my team a day early that I was leaving, then have a full day to myself. I would try to make sure I had enough power in my laptop to watch a Julia Roberts movie, because to me she’s so American. I would watch the movie to get my emotional state back to the US. I also had Luna bars that I would eat to get me back into the American picture, and that’s actually helped me quite a bit. What’s harder is dealing with the emotional valence of the trips on return. I’ve had security issues abroad where my life was targeted, and at the time, it seemed reasonable—that human life is expendable in areas of armed conflict. But when I return home, I realize how close I was to actual harm, and it takes some recalibration. It was harder doing the humanitarian protection work because colleagues were not indigenous locals from the area, but were humanitarian workers and still in-country, too familiar with that lifestyle and without the uprooting back and forth between lives.

CCPR: How does a person learn about these opportunities? What organizations does one approach? Is it easy or hard?
Dr. Song: Find mentors. My work domestically began during residency training; I did asylum evaluations with a mentor, who has now become like family after 10+ years. If you’re interested in doing one-time evaluations, Physicians for Human Rights (https://phr.org) is always looking for psychiatrists to do psychological evaluations, and they provide trainings throughout the year. And honestly, many residents and early-career CAPs have more experience with global work than senior CAPs—there’s a lot for both to offer, and pairing up could be a great avenue for bidirectional learning. If you want to work globally, I would highly recommend going with an organization. I only work in countries where invited. But after 15 years and multiple security issues, I’ve decided to mainly work with humanitarian organizations like the UN. That’s a bit harder, since most of these organizations require at least 8, but sometimes 13 years of experience. But if you’re willing to go abroad for a year or more, Doctors Without Borders (https://www.doctorswithoutborders.org) and Partners in Health (https://www.pih.org) have good programs set up.

CCPR: Thank you for your time, Dr. Song.

Editor’s note: Volunteer work in underserved areas can add welcome variety and enrichment to your practice. The American Academy of Child and Adolescent Psychiatry has a new Resource Group for Children at the Border; contact me at ­jfeder@­thecarlatreport.com if you are interested in getting involved. Also, for those wanting to help in the aftermath of the recent deadly wildfires in California, contact Caring Choices located in Chico, CA, which is organizing volunteer work (http://www.­caring-choices.org). There are many organizations that take volunteer psychiatrists worldwide, including IsrAID, Partners in Health, and the International Committee for the Red Cross.