Australian Occupational Therapy Journal (2014) 61, 13–19
doi: 10.1111/1440-1630.12094
Feature Article
Experiences in occupational therapy with Afghan clients in Australia Pamela Maroney, Marianne Potter and Vinod Rai Thacore Adult Mental Health Program, Doveton Community Care Unit, Monash Health, Doveton, Victoria, Australia
Background/aim: With a steady increase of refugees arriving in Australia from Afghanistan coupled with reports that prevalence of mental illness amongst Afghan refugees in South-East Melbourne is particularly high, mental health providers will need to acquire cultural competence to provide effective treatment. There is a dearth of literature on the subject of rehabilitation of Afghan psychiatric clients in the Australian context, providing the impetus for this article. To illustrate the impact of Afghan socio-cultural beliefs and attitudes on the implementation of occupational therapy and rehabilitation programmes in a mental health facility and adaptations to accommodate the needs of the clients and their families. Method: Two case vignettes of Afghan clients are presented to illustrate the variance in goals and expectations of the clients and their families to that of the occupational therapy and rehabilitation programmes offered. Conclusion: Family expectations and involvement, culturespecific factors and religion play significant roles in the presentation and treatment of clients from the Muslim culture and require modification in implementation of rehabilitation programmes. A need for developing family or community-based services is proposed coupled with culturally responsive practices. Culture sensitive models of occupational therapy will need to be developed as younger generations of refugee families acculturate and need psychological help to deal with conflicts with parents and elders who hold values different from those adopted by their children born and brought up in the Australian socio-cultural environment. These and other issues
Pamela Maroney BAppSc (OT); Occupational Therapist. Marianne Potter BSW; Social Worker. Vinod Rai Thacore FRANZCP; Consultant Psychiatrist. Correspondence: Pamela Maroney, Adult Mental Health Program, Doveton Community Care Unit, Monash Health, 20 Matipo Street, Doveton, Vic. 3177, Australia. Email: [email protected] Accepted for publication 7 October 2013. © 2014 Occupational Therapy Australia
mentioned above provide fertile fields for research in this evolving area of occupational therapy. KEY WORDS conceptual foundations, culture, mental health, populations/conditions, refugee.
Introduction Recently, globalisation has seen an unprecedented movement of people from one country and culture to another. While most people by choice immigrate in search of better opportunities and lifestyle (Richerson & Boyd, 2008), political refugees (United Nations, 2010), on the other hand have been forced to leave their homeland in a bid to escape life threatening situations to settle in socio-cultural environments quite alien to them. In the process, refugees may find themselves marginalised, subjected to racism and discrimination within the society they finally settle (Leamy, Bird, Le Boutillier, Williams & Slade, 2011). These factors put the refugees at risk of suffering from symptoms of anxiety, depression, post-traumatic stress disorder; and psychotic illnesses and psychological disorders among their children (Fazel & Stein, 2002; McGorry, 1995), with a potential for retraumatisation (Porter & Haslam, 2005; Silone, McIntosh & Becker, 1993) in the course of therapy and rehabilitation. A high prevalence of depression and anxiety has been reported by Afghan community members and health workers amongst the Afghan population in South-East Melbourne (Rintoul, 2010). Sulaiman-Hill and Thompson (2012) identified main sources of stress contributing to psychological ill-health among predominantly Muslim Afghan and Kurdish refugees in Australia as ‘spending too much time reflecting on past experiences and current international events, separation from family and feeling overwhelmed by resettlement challenges’. A high level of psychological distress and morbidity were observed in some individuals for several years after arrival. However, little literature is available on the mental health status of Afghanistan-born Australians and Afghan refugees in Australia (Queensland Health Multicultural Services, 2011).
14 There has been a rising trend in asylum applications worldwide, with 2012 recording the highest number of refugees this century. Afghanistan remains the main country of origin of asylum-seekers (United Nations’ High Commission for Refugees, 2013). Over the past five years refugees from Afghanistan have steadily topped the list of those arriving in Australia from the Middle East and African countries (DIAC Database, 2012). With the influx of Afghan immigrants and refugees into Australia, mental health care providers are being called upon to treat and care for clients from diverse cultures. This can present therapeutic challenges, stemming from the traditional Afghan beliefs in the causation of illnesses and remedial procedures (MoriokaDouglas, Sacks & Yeo, 2004) and their non-familiarity with the Australian health care system (Queensland Health Multicultural Services, 2011). It is therefore imperative that mental health professionals acquaint themselves with the cultural and historical background of clients and their families, such as, their experience of emotional trauma, persecution, loss of family, uprooting from their country and community, post migration stress of resettling in a new country, adjusting to new social and cultural environment, and loss of identity and sense of belonging (Lipson, 1993). It will require health care professionals to develop trusting relationships with clients and their families if they are to provide culturally responsive and appropriate care (Bhui, Warfa, Edonya, McKenzie & Bhugra, 2007; Lu, Lim & Mezzich, 1995) and achieve desirable outcomes. It becomes necessary then for models of rehabilitation practiced in the western socio-cultural construct to be modified to ensure a culturally appropriate plan to treat clients from diverse cultures (Stedman & Thomas, 2011). In the Australian context, occupational therapists have supported the need for modifying their practices to provide client-centered interventions in treating indigenous clients (Stedman & Thomas, 2011) and the need to embrace and integrate ‘cultural awareness, complexity and connectedness’ into their practices (Humbert, Burket, Deveney & Kennedy, 2011; Iwama, Thomson & Macdonald, 2009). This article is confined to Afghan psychiatric clients referred to Monash Health services for psychosocial rehabilitation at the Doveton Community Care Unit, since they served to draw attention to the very specific issues requiring flexibility in the programme being offered. These include their vulnerability (Lipson, 1993), social and religious beliefs and expectations of clients and their families, which were at variance with the goals and aims of the western orientated concept of rehabilitation.
Doveton Community Care Unit (CCU) Doveton CCU is a 20-bed residential rehabilitation facility housed in a cluster style development, located in the © 2014 Occupational Therapy Australia
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residential area of Doveton, a suburb of Melbourne. Its mission is to assist individuals with psychiatric disabilities by providing access to a range of treatment modalities aimed at increasing their functioning and enabling them to live successfully in the community. The rehabilitation programme is targeted at improving clients’ independent living skills to their optimal levels and engaging them in more meaningful and purposeful activities, with an emphasis on their specific needs. The programme includes group and individual sessions focusing on psycho-education, coping skills based training, pre-vocational support, leisure and healthy lifestyle activities.
Aim The aim of this article is to illustrate (a) the impact of socio-cultural beliefs and attitudes of Afghan clients on the implementation of occupational therapy and rehabilitation programme at the CCU and (b) the adjustments made to accommodate the needs of clients and their families; with the aid of case vignettes of two clients with different clinical presentations. These issues provided the impetus for this qualitative presentation. Approval was gained from the Director of Research Services, Research Directorate, Monash Health to report the information relating to the case studies. Names and identifying information have been changed to ensure anonymity and confidentiality. Suggestions for further research in this area are offered.
Method Clients are admitted to the CCU with a brief record of their psychiatric history provided by the referring agency. Individual clients are allocated primary and secondary case managers. A detailed assessment is undertaken by a multidisciplinary team and progress charted and monitored during their admission. Parents and family members are interviewed periodically to gain their perception of the client’s illness and progress and to clarify any concerns they may have regarding the programme. The team managers collate information thus obtained and a plan for rehabilitation formulated in consultation with the multidisciplinary team. The client’s progress is discussed at regular ‘case reviews’. The information and progress recorded during their stay at the CCU formed the basis of the case vignettes presented below.
Case 1: Ahmed A 30-year-old single Muslim male, with a history of Bipolar Affective Disorder and several admissions for inpatient treatment, was referred to the CCU for psycho-education and with the aim of developing independent living skills. When unwell, Ahmed exhibited religious delusions and resorted to aggressive and violent behaviour
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towards his family and others in response to his perception that they did not worship Allah respectfully. Ahmed was born in Afghanistan. He was eight when he left with his family, due to war, finally arriving in Australia at the age of sixteen. Well behaved and studious as a child, he related well with family members. At the age of 15, he developed strong views about his religion and described himself becoming an ‘outcast’ as a result. At school, he was bullied with racist taunts by his peers and, being a quiet and shy person, became increasingly withdrawn. He then made a ‘deal with God’ that if he were spared certain problems, which he declined to disclose, he would devote his time to spreading the message of his religion. He later took to wearing traditional Muslim clothing and grooming. He did not do well at university as he found the curriculum overwhelming and dropped out after repeated failures. Thereafter, he worked for 3–4 years but did not continue as he was subjected to racial taunts and bullying. He then had no desire to return to work unless it was compatible with his religious beliefs. During his stay at the CCU it was difficult to secure appointment times with Ahmed as he was off-site on day leave to attend his Mosque to pray five times a day, or overnight leave with his family. He would attempt to postpone scheduled appointments or fail to attend. He did not associate with fellow co-residents. His social circle constituted his immediate family and a few friends from the local Mosque. His desire was to marry a Muslim woman who would worship at the Mosque and wear a traditional dress. He had poor insight into his illness. He reported fleeting suicidal thoughts, which he related to depressed mood but added that suicide was forbidden in his religion and feared going to hell if he harmed himself. He was ambivalent about medication and said that he was taking it only because he was on a community treatment order (CTO) and had no choice. His goal was eventually to be able to ‘see God’ and enter the ‘after life’ known in his faith as ‘paradise’. His ambition was to become an Imam (Leader of a Mosque) and spread the message; ‘there is no God but Allah and Mohammed is the messenger of Allah’, and convert others to Islam. His goal to obtain a job was in line with his Muslim belief in earning his own keep rather than depend on others. The activities of daily living and conventional adult lifestyle were relatively unimportant in the face of achieving his passage to ‘paradise’. Ahmed’s family wanted him to continue living at the CCU, given his past history of aggressive behaviour at home. His family brought in food for him and his mother cleaned his unit. His mother took him on a month’s leave to Afghanistan, and got him married. Having kept mentally stable he was eventually discharged home, under the care of the continuing care team, although his family requested that he stay at the
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CCU until his wife was able to migrate to Australia and become his carer. The family had concealed his mental illness from the Afghan Muslim community for fear of stigma.
Case 2: Salim A 23-year-old single male with a history of Depression with Psychotic features and Post Traumatic Stress Disorder was referred to the CCU with the aim to learn daily living skills and manage independently. He had several admissions to hospital in the context of depressive episodes and suicidal attempts, in response to command hallucinations. Issues within the family were contributing to deterioration in his mental state. Salim was born in Afghanistan in a family of ethnic minority group. ‘Very strong and healthy’ as a child, he prayed daily with his family and took part in festivals but did not attend a Mosque. The family had experienced significant war and trauma events, with several close members killed by extremists. Salim’s father fled the country, leaving his family. Salim was aged eight and revealed that this is when he first felt depressed. Father finally arrived in Australia eight years later and sponsored his family to join him. Salim felt safe in Australia but struggled academically in senior school and could not continue with his studies. He experienced some bullying and dated his depression from that period. He did not return to school. His ambition was to become a doctor. During his stay at the CCU, Salim resisted engaging in psychotherapy. He said he ‘hated answering questions’ and declined to undertake guided assessment questionnaires. He came across as downcast and withdrawn while talking about his illness as if engrossed in his own thinking. He was distressed at experiencing command hallucinations, which he reported hearing only after a doctor questioned him about them. He said that his parents believed that the voices belonged to ‘shaitan’ (satan) and he believed so too. He felt that medication was not working because the voices continued. Seeing doctors made him feel worse. Salim’s father was the head of the family and main decision maker. Salim’s mother did not speak English and his father declined an interpreter, choosing instead to translate for her. It was therefore not possible to obtain mother’s perspective of Salim’s illness directly. The family felt Salim was ‘dangerous’ to himself; ‘like a baby’, and so monitored him very closely. His mother indicated that he could not live without someone to look after him, to give him medication, do his washing and cleaning and expressed concern that he would be tempted to resort to alcohol and drug abuse if he ventured out. Salim’s parents indicated that they were distressed and burdened with his illness. His father lamented over what he himself had done wrong to deserve this situation and expressed his anger and disappointment at Salim for not listening to their advice. © 2014 Occupational Therapy Australia
16 He described having lost trust in Salim and felt angry at the impact that his illness was having on the family. Parents hoped that he would recover and return to his studies. That Salim had won first prize in a painting competition was of no interest to the father. Father declined to attend a carer support group due to concerns that the Afghan community would become aware of Salim’s condition and source of ‘entertainment’ within the community. However, the family accepted a few sessions of family therapy. Salim said that he found comfort in his religion and praying three times a day, which helped cope with his problems. He said that he would never give up trying to deal with his difficulties (Islam considers giving up hope as a sign of lack of faith in God and a sin). He indicated that depression was not recognised in his country. He felt that seeking help and advice from his parents would improve his situation. Salim’s parents were initially extremely resistive of him coming to the CCU, as they feared for his safety, but finally agreed. Salim seemed ambivalent about coming to CCU. On the one hand he said that he wanted to make his parents happy and be at home, on the other, he was keen come to the CCU to gain ‘freedom and independence’ and to be able to do more things by himself. During his stay at CCU, Salim did not relate much with other residents and spent most of his time in his room drawing and painting, his hobby. He did not show much interest in developing self-sufficiency as he felt that he did not need it. Parents brought in his meals. Salim’s father visited regularly to see if he was coping. Salim tended to spend more time at home with his family than at CCU but continued to attend social activities and maintain contact with his previous community case manager. Ultimately, despite strong advice from the treating team to let Salim continue with his rehabilitation at the CCU, his parents decided to take him home due to their ongoing concerns that since he could not be under constant supervision of the staff, he would be at risk of self harm. Receiving no encouragement from his family Salim felt quite stressed at the thought of staying on at CCU to attain his goals and decided to go home to be followed up by the community treating team.
Issues encountered in rehabilitation of Afghan clients Some issues arising during rehabilitation of Afghan clients at Doveton CCU are highlighted as follows: ● Reluctance to engage in mental health services for fear of social stigma and ridicule and religious or traditional beliefs concerning causes of mental illness leading to problems of compliance with therapy or medication and accessing social supports. ● Obtaining comprehensive information about a client posed barriers due to language problems and reluctance to use interpreters for fear of information leak© 2014 Occupational Therapy Australia
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ing out into the community. Access to female members of the family was restricted due to cultural reasons and their perceptions regarding clients’ problems not readily attainable. Engaging male clients in the rehabilitation programme which has a strong focus on improving independent living skills, like cooking, cleaning and shopping, appeared of no interest as cultural norms for males tend to be in conflict with these tasks. Being a minority group within the CCU client population and therefore not having others to socialise with from their own cultural background or have common interests in activities, Afghan clients tended to isolate themselves. Being away from family environment, gaining independence from family and individuation, a primary aim of rehabilitation at CCU, does not often fit well with their cultural norms and traditions. Regular activities were difficult to implement in certain areas, requiring adjustments in staff expectations and incorporation of culturally compatible attitudes of clients and their families into the programme.
Modifications implemented Taking into account the needs and expectations of the Afghan clients and their families, a shift was made, to make the programme more flexible and culturally responsive. This necessitated moving away from focus on independent living and: ● focusing on male clients gaining access to support groups in the community, ● developing family relationships through psychoeducation since the client is ultimately to be discharged home to live. Offering ongoing family support and therapy, ● providing literature on mental health, illnesses and facilities available in printed Afghani language, ● considering use of tools for culturally appropriate assessment of goals, motivation to learn living skills, interests and areas to be improved, ● allowing access to family members to fulfil their cultural roles, e.g., allowing mother or other family members to attend to domestic chores like providing meals or cleaning, ● allowing time for prayers and structuring activities and appointments around those times.
Discussion The role of occupational therapy in rehabilitation of psychiatric clients lies in providing customised interventions, enabling them to engage in activities of daily living that have personal meaning and value, develop skills necessary to function independently in the community of their choosing, consult with family members and care givers to help promote satisfying daily activities, evaluate
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outcomes to ensure goals are being met and to make changes to the intervention plans as required (World Federation of Occupational Therapists, 2012; Occupational Therapy Australia, 2013). There is a dearth of literature on the rehabilitation of psychiatric clients from the Afghan cultural background in the Australian context. This article describes issues which surfaced during occupational therapy and rehabilitation of Afghan clients and which called for flexibility and a culturally sensitive approach in their management. Both clients were well conversant in the English language. Their parents, however, were not, with the exception of Salim’s father. Culturally, female members of the family remain in the background and are not readily accessible for interviewing separately, as in the case of Salim, where the father acted as the mother’s spokesperson. The issues within the family reportedly causing deterioration in Salim’s depression could not be fully explored. Being a member of a small community and with the stigma associated with mental illness, Salim’s father declined to use an interpreter as there is a fear interpreters will not adhere to confidentiality requirements (South Eastern Region Migrant Resource Centre, 2010). For the same reason his parents rejected any attempts to become involved in support groups. Family ‘secrets’ are very tightly held within the family and not easily amenable to exploration. In Ahmed’s case, his family took him on leave to Afghanistan to get married. At no stage had the family discussed this plan with the staff. Traditional Afghan causes of illness include imbalance of hot and cold forces in the body; non-adherence to the principles of Islam and will of God; possession by evil spirits (jinn); given the evil eye; and witchcraft (Morioka-Douglas et al., 2004). Evil eye and witchcraft are mainly seen to cause mental illness. Depression may not be considered an illness (South Eastern Region Migrant Resource Centre, 2010). Mental disorders are highly stigmatised and as such there is extreme reluctance to attribute the symptoms to mental illness (Kirmayer et al., 2011). In the cases described above the mental disturbances were attributed to supernatural phenomenon and satan and improper adherence to religious practices. The cure was sought in regular prayer (Morioka-Douglas et al., 2004) with medication considered not of much use. Engaging in Islamic and traditional practices like prayer and use of amulets can have calming effects and clients may not feel the need to make their therapists aware of it. Such beliefs can lead to ambivalence towards and non-adherence to prescribed treatment. The occupational therapists need to be mindful of such cultural beliefs alongside negotiating the benefits of rehabilitation and continuation of medication. It has been suggested that employment of traditional healers (Hiegel, 1983) and cultural consultants (Budman, Lipson & Meleis, 1992), who can serve to bridge the gap between the medical model and the refugees’ world
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view, deserves consideration. Older Afghan Australians may prefer traditional treatments to medical treatments (South Eastern Region Migrant Resource Centre, 2010). Involvement of a senior family member or a trusted family friend who has a ‘balanced’ view on mental illness and who would, in confidence, accept and mediate in discussing different treatment modalities would assist in achieving mutually desired results. Consideration can also be given to enlisting willing members of the staff of the rehabilitation or allied health services with experience and awareness of the ethnic background and culture of the clients to mediate in achieving mutually desired outcomes. That a strong cultural stigma is attached to mental illness was evident in both the cases. Efforts to join support groups were therefore resisted by both parents. Yet, as Lipson (1993) has stated, traditional psychiatric approaches, such as, individual insight or supportive psychotherapy with psychoactive medication have had limited success with refugees while support groups composed of others from their background and experience appeared to have been helpful. Ahmed had established his own social group in the mosque where he spent considerable time. Salim continued to attend social activities, which he had been engaged in prior to coming to the CCU. This aspect of their rehabilitation was recognized and facilitated in both cases. Sulaiman-Hill and Thompson (2012) found that refugees employed certain coping strategies such as, getting outside in the fresh air and going for a walk or discussing concerns with family and friends rather than with people outside of the family, which were more useful in obtaining relief from psychological distress. As such, focus away from engagement in the group programme and more on culturally appropriate individual rehabilitation strategies may prove more effective. Studies indicate that family support can be most valuable in alleviating emotional distress in refugees and thus it is advisable to supplement their treatment by including their families and social network (Kirmayer et al., 2011). Connectedness to the family was noted as an important element in both the cases. However, this aspect can also generate its own stresses as was evident in Salim’s case. It was quite apparent that Salim’s desire for independence and expectations of his parents were in conflict. His father did not value Salim’s skills and passion as a painter, which he seemed keen to pursue, but expected him to return to his studies. The extreme protectiveness of the family, following his self-harming incidents, hindered Salim’s goal of achieving ‘freedom and independence’ for fear of alienation from his family. Ongoing family and individual psychotherapy was organised to address these issues since family support and cohesion were identified as important factors in Salim’s recovery, but achieved limited success. Catering for family and religious issues emerged paramount in management and rehabilitation of these © 2014 Occupational Therapy Australia
18 Afghani clients. Prayer and faith in God to heal and not give up hope is traditionally seen as important in healing illness. Familiarisation of the cultural issues of these clients was facilitated during review of their progress with the treating team by one of the authors who has had experience in working with clients of Muslim background; their beliefs and attitudes towards medication and causes of mental illness. During these meetings self-examination of personal attitudes towards these issues was encouraged. Insights thus gained assisted in developing a degree of functional cultural competence among the team members and facilitated a more culturally responsive and client centred therapy. Other pertinent issues emerged from the experience of providing occupational therapy and rehabilitation services to the Afghan clients. One of the cardinal requirements in occupational therapy is motivation to learn new behaviour, which would enable clients to achieve more independence and self-confidence. These elements in personality development and learning daily living skills were not seen to be important by the clients and their families in both cases. The clients were well catered for in their physical needs by their families. Ahmed’s ultimate goal was to be a preacher in the Islamic faith and had made his own arrangements to achieve this. Salim, on the other hand, was looking for more freedom and independence to manage on his own and pursue his artistic leanings but met with resistance and indifference from the family to achieve this. The agenda of the clients and their families for admission to the CCU were at odds with what the rehabilitation programme was accustomed to offer and appeared more as a facility for placement and containment of the clients rather than rehabilitation. Panesar (2011) has questioned the justification of compulsory admission for psychiatric rehabilitation and expressed concern regarding the impact it may have on client recovery as the clients may regard the process as coercive. He advocates a voluntary admission of clients for rehabilitation to preserve their autonomy and facilitate their recovery with the focus of occupational therapy reflecting the preference of clients and their carers. Both cases discussed above were referred for occupational therapy and rehabilitation while on a CTO. This raises an important issue concerning their motivation and right and responsibility for self-determination and active involvement in the psychosocial rehabilitation programme. Research is needed to develop more culturally appropriate psychosocial models of occupational therapy with broad applicability within the background of Islamic culture but also leaving scope for modification to cater for individual needs of Afghan clients. Qualitative studies could provide more relevant information than quantitative studies in this respect. Residential rehabilitation programmes require clients to spend considerable time away from their families. © 2014 Occupational Therapy Australia
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This would not appeal to refugee clients given the importance of family support and involvement and has a potential to re-awaken traumatic experiences of family separation and loss during migration. Consideration therefore needs to be given to referring Afghan clients in particular for compulsory residential rehabilitation. Efforts will need to be directed at developing home based occupational therapy and rehabilitation services and include Islamic based supportive psychotherapy that fits within the client’s own cultural beliefs and traditions. Occupational therapy programmes, as in other areas of health services, will need to evolve over time in response to changing Afghan population in Australia. For instance, to cater for the younger Afghan generations seeking psychiatric help as they acculturate to the Australian way of life and seek independence and self realization, away from the traditional family environment (Awad, 2013), and as they come into conflict with parents and elders who hold values and ideals different from their own. These and other issues mentioned above provide fertile grounds for research in this evolving area of occupational therapy.
Conclusion The two case vignettes of Afghan clients presented in this article served to highlight the socio-cultural and religious beliefs, which impacted on occupational therapy and rehabilitation process. The conventional psychiatric rehabilitation programme required adapting to take into account the goals and aims of the families and clients as these were at variance to the concept of the psychosocial rehabilitation programme offered. With the influx of Afghan refugees into Australia, reports of a high prevalence of mental disturbance amongst these refugees and the younger generation growing up in the Australian cultural environment, mental health workers will need to cultivate culturally appropriate practices. This would include being aware of the Muslim culture and how it affects Afghan clients in their day to day life and activities and their own attitudes in treating these clients. These aspects were discussed during clinical review of clients and appropriate modifications were introduced in the occupational therapy and rehabilitation programme in a residential setting. Consideration was given to developing family or community-based rehabilitation services. Further qualitative research is urged to develop culturally responsive alternative forms of therapy that will be of benefit to this population.
References Awad, A. (2013). Growing up Arab in Australia. Age. Retrieved 4 April 2013, from http://www.dailylife.com. au/action/printArticle?id=4160721
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Bhui, K., Warfa, N., Edonya, P., McKenzie, K. & Bhugra, D. (2007). Cultural competence in mental health care: A review of model evaluations. 2007. BMC Health Services Research, 7, 15. Budman, C., Lipson, J. G. & Meleis, A. I. (1992). The cultural consultant in mental health care: The case of an Arab-American adolescent. Journal of Osteopsychiatry, 62, 359–370. DIAC Database (2012). Retrieved 4 January, 2012, from http://www.foundationhouse.org.au Fazel, M. & Stein, A. (2002). The mental health of refugee children. Archives of Disease in Childhood, 87, 366–370. Hiegel, J. P. (1983). Collaboration with traditional healers: Experience in refugee’s mental care. International Journal of Mental Health, 12 (3), 30–43. Humbert, T. K., Burket, A., Deveney, R. & Kennedy, K. (2011). Occupational therapy practitiners’ perspectives regarding international cross-cultural work. Australian Occupational Therapy Journal, 58, 300–309. Iwama, M., Thomson, N. A. & Macdonald, R. A. (2009). The kawa model: The power of culturally responsive occupational therapy. Disability and Rehabilitation, 31 (14), 1125–1135. Kirmayer, L. J., Narasiah, L., Munoz, M., Rashid, M., Ryder, A. G., Guzder, J. et al. (2011). Common mental health problems in immigrants and refugees: general approach in primary care. Canadian Medical Association Journal, 183 (12), E959–E967. Leamy, M., Bird, V., Le Boutillier, C., Williams, J. & Slade, M. (2011). Conceptual framework for personal recovery in metal health. Systemic Review and Narrative Synthesis, 199, 445–452. Lipson, J. G. (1993). Afghan refugees in California – Mental health issues. Issues in Mental Health Nursing, 14 (4), 411–423. Lu, F. G., Lim, R. F. & Mezzich, J. E. (1995). Issues in the assessment and diagnosis of culturally diverse individuals. In: J. Oldham & M. Riba (Eds.), Review of psychiatry (Vol. 14, pp. 477–510). Washington, DC: American Psychiatric Press. McGorry, P. (1995). Working with survivors of torture and trauma: The Victorian Foundation for Survivors of Torture in perspective. Australian and New Zealand Journal of Psychiatry, 29 (3), 463–472. Morioka-Douglas, N., Sacks, T. & Yeo, G. (2004). Issues in caring for Afghan American elders: Insights from
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literature and a focus group. Journal of Cross-Cultural Gerontology, 19, 27–40. Occupational Therapy Australia (2013). Retrieved 17 April, 2013, from http://www.otaus.com.au/about/what-dooccupational-therapists-do Panesar, N. (2011). Whose choice is mental health rehabilitation? Australian and New Zealand Journal of Psychiatry, 45, 899. Porter, M. & Haslam, N. (2005). Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons: A meta-analysis. The Journal of the American Medical Association, 294 (5), 602–612. Queensland Health Multicultural Services (2011). Retrieved 4 April, 2013, from http://www.health.qld.gov.au/multicultural Richerson, P. J. & Boyd, B. (2008). Migration: An engine for social improvement. Nature, 456, 18. Rintoul, A. (2010). Understanding the mental health and wellbeing of Afghan women in South East Melbourne. Melbourne: Foundation House. Silone, D., McIntosh, P. & Becker, R. (1993). Risk of retraumatisation of asylum seekers in Australia. Australian and New Zealand Journal of Psychiatry, 27 (4), 606–612. South Eastern Region Migrant Resource Centre (2010). Afghani Community Profile – Older people. Melbourne: Migrant Resource Centre. Stedman, A. & Thomas, Y. (2011). Reflecting on our effectiveness: Occupational therapy interventions with Indigenus clients. Australian Occupational Therapy Journal, 58, 43–49. Sulaiman-Hill, C. M. R. & Thompson, S. C. (2012). “Thinking too much”: Psychological distress, sources of stress and coping strategies of resettled Afghan and Kurdish refugees. Journal of Muslim Mental Health, 6 (2), 63–86. United Nations (2010). Convention relating to the Status of Refuges (Online). Retrieved 15 April, 2013, from http:// www2.ohchr.org/english/law/refugees.htm United Nations’ High Commission for Refugees (2013). The UN Refugee Agency. Retrieved 21 March, 2013, from http://unhcr.org.au/unhcr/index.php?option=com_con tent&view=category&layout=blog &id=46&Itemid=92 World Federation of Occupational Therapists (2012). Retrieved 17 April, 2013, from http://www.wfot.org.au/ aboutus/AboutOccupationalTherapy/DefinitionofOccu pationalTherapy.aspx
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doi: 10.1111/1440-1630.12094
Feature Article
Experiences in occupational therapy with Afghan clients in Australia Pamela Maroney, Marianne Potter and Vinod Rai Thacore Adult Mental Health Program, Doveton Community Care Unit, Monash Health, Doveton, Victoria, Australia
Background/aim: With a steady increase of refugees arriving in Australia from Afghanistan coupled with reports that prevalence of mental illness amongst Afghan refugees in South-East Melbourne is particularly high, mental health providers will need to acquire cultural competence to provide effective treatment. There is a dearth of literature on the subject of rehabilitation of Afghan psychiatric clients in the Australian context, providing the impetus for this article. To illustrate the impact of Afghan socio-cultural beliefs and attitudes on the implementation of occupational therapy and rehabilitation programmes in a mental health facility and adaptations to accommodate the needs of the clients and their families. Method: Two case vignettes of Afghan clients are presented to illustrate the variance in goals and expectations of the clients and their families to that of the occupational therapy and rehabilitation programmes offered. Conclusion: Family expectations and involvement, culturespecific factors and religion play significant roles in the presentation and treatment of clients from the Muslim culture and require modification in implementation of rehabilitation programmes. A need for developing family or community-based services is proposed coupled with culturally responsive practices. Culture sensitive models of occupational therapy will need to be developed as younger generations of refugee families acculturate and need psychological help to deal with conflicts with parents and elders who hold values different from those adopted by their children born and brought up in the Australian socio-cultural environment. These and other issues
Pamela Maroney BAppSc (OT); Occupational Therapist. Marianne Potter BSW; Social Worker. Vinod Rai Thacore FRANZCP; Consultant Psychiatrist. Correspondence: Pamela Maroney, Adult Mental Health Program, Doveton Community Care Unit, Monash Health, 20 Matipo Street, Doveton, Vic. 3177, Australia. Email: [email protected] Accepted for publication 7 October 2013. © 2014 Occupational Therapy Australia
mentioned above provide fertile fields for research in this evolving area of occupational therapy. KEY WORDS conceptual foundations, culture, mental health, populations/conditions, refugee.
Introduction Recently, globalisation has seen an unprecedented movement of people from one country and culture to another. While most people by choice immigrate in search of better opportunities and lifestyle (Richerson & Boyd, 2008), political refugees (United Nations, 2010), on the other hand have been forced to leave their homeland in a bid to escape life threatening situations to settle in socio-cultural environments quite alien to them. In the process, refugees may find themselves marginalised, subjected to racism and discrimination within the society they finally settle (Leamy, Bird, Le Boutillier, Williams & Slade, 2011). These factors put the refugees at risk of suffering from symptoms of anxiety, depression, post-traumatic stress disorder; and psychotic illnesses and psychological disorders among their children (Fazel & Stein, 2002; McGorry, 1995), with a potential for retraumatisation (Porter & Haslam, 2005; Silone, McIntosh & Becker, 1993) in the course of therapy and rehabilitation. A high prevalence of depression and anxiety has been reported by Afghan community members and health workers amongst the Afghan population in South-East Melbourne (Rintoul, 2010). Sulaiman-Hill and Thompson (2012) identified main sources of stress contributing to psychological ill-health among predominantly Muslim Afghan and Kurdish refugees in Australia as ‘spending too much time reflecting on past experiences and current international events, separation from family and feeling overwhelmed by resettlement challenges’. A high level of psychological distress and morbidity were observed in some individuals for several years after arrival. However, little literature is available on the mental health status of Afghanistan-born Australians and Afghan refugees in Australia (Queensland Health Multicultural Services, 2011).
14 There has been a rising trend in asylum applications worldwide, with 2012 recording the highest number of refugees this century. Afghanistan remains the main country of origin of asylum-seekers (United Nations’ High Commission for Refugees, 2013). Over the past five years refugees from Afghanistan have steadily topped the list of those arriving in Australia from the Middle East and African countries (DIAC Database, 2012). With the influx of Afghan immigrants and refugees into Australia, mental health care providers are being called upon to treat and care for clients from diverse cultures. This can present therapeutic challenges, stemming from the traditional Afghan beliefs in the causation of illnesses and remedial procedures (MoriokaDouglas, Sacks & Yeo, 2004) and their non-familiarity with the Australian health care system (Queensland Health Multicultural Services, 2011). It is therefore imperative that mental health professionals acquaint themselves with the cultural and historical background of clients and their families, such as, their experience of emotional trauma, persecution, loss of family, uprooting from their country and community, post migration stress of resettling in a new country, adjusting to new social and cultural environment, and loss of identity and sense of belonging (Lipson, 1993). It will require health care professionals to develop trusting relationships with clients and their families if they are to provide culturally responsive and appropriate care (Bhui, Warfa, Edonya, McKenzie & Bhugra, 2007; Lu, Lim & Mezzich, 1995) and achieve desirable outcomes. It becomes necessary then for models of rehabilitation practiced in the western socio-cultural construct to be modified to ensure a culturally appropriate plan to treat clients from diverse cultures (Stedman & Thomas, 2011). In the Australian context, occupational therapists have supported the need for modifying their practices to provide client-centered interventions in treating indigenous clients (Stedman & Thomas, 2011) and the need to embrace and integrate ‘cultural awareness, complexity and connectedness’ into their practices (Humbert, Burket, Deveney & Kennedy, 2011; Iwama, Thomson & Macdonald, 2009). This article is confined to Afghan psychiatric clients referred to Monash Health services for psychosocial rehabilitation at the Doveton Community Care Unit, since they served to draw attention to the very specific issues requiring flexibility in the programme being offered. These include their vulnerability (Lipson, 1993), social and religious beliefs and expectations of clients and their families, which were at variance with the goals and aims of the western orientated concept of rehabilitation.
Doveton Community Care Unit (CCU) Doveton CCU is a 20-bed residential rehabilitation facility housed in a cluster style development, located in the © 2014 Occupational Therapy Australia
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residential area of Doveton, a suburb of Melbourne. Its mission is to assist individuals with psychiatric disabilities by providing access to a range of treatment modalities aimed at increasing their functioning and enabling them to live successfully in the community. The rehabilitation programme is targeted at improving clients’ independent living skills to their optimal levels and engaging them in more meaningful and purposeful activities, with an emphasis on their specific needs. The programme includes group and individual sessions focusing on psycho-education, coping skills based training, pre-vocational support, leisure and healthy lifestyle activities.
Aim The aim of this article is to illustrate (a) the impact of socio-cultural beliefs and attitudes of Afghan clients on the implementation of occupational therapy and rehabilitation programme at the CCU and (b) the adjustments made to accommodate the needs of clients and their families; with the aid of case vignettes of two clients with different clinical presentations. These issues provided the impetus for this qualitative presentation. Approval was gained from the Director of Research Services, Research Directorate, Monash Health to report the information relating to the case studies. Names and identifying information have been changed to ensure anonymity and confidentiality. Suggestions for further research in this area are offered.
Method Clients are admitted to the CCU with a brief record of their psychiatric history provided by the referring agency. Individual clients are allocated primary and secondary case managers. A detailed assessment is undertaken by a multidisciplinary team and progress charted and monitored during their admission. Parents and family members are interviewed periodically to gain their perception of the client’s illness and progress and to clarify any concerns they may have regarding the programme. The team managers collate information thus obtained and a plan for rehabilitation formulated in consultation with the multidisciplinary team. The client’s progress is discussed at regular ‘case reviews’. The information and progress recorded during their stay at the CCU formed the basis of the case vignettes presented below.
Case 1: Ahmed A 30-year-old single Muslim male, with a history of Bipolar Affective Disorder and several admissions for inpatient treatment, was referred to the CCU for psycho-education and with the aim of developing independent living skills. When unwell, Ahmed exhibited religious delusions and resorted to aggressive and violent behaviour
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towards his family and others in response to his perception that they did not worship Allah respectfully. Ahmed was born in Afghanistan. He was eight when he left with his family, due to war, finally arriving in Australia at the age of sixteen. Well behaved and studious as a child, he related well with family members. At the age of 15, he developed strong views about his religion and described himself becoming an ‘outcast’ as a result. At school, he was bullied with racist taunts by his peers and, being a quiet and shy person, became increasingly withdrawn. He then made a ‘deal with God’ that if he were spared certain problems, which he declined to disclose, he would devote his time to spreading the message of his religion. He later took to wearing traditional Muslim clothing and grooming. He did not do well at university as he found the curriculum overwhelming and dropped out after repeated failures. Thereafter, he worked for 3–4 years but did not continue as he was subjected to racial taunts and bullying. He then had no desire to return to work unless it was compatible with his religious beliefs. During his stay at the CCU it was difficult to secure appointment times with Ahmed as he was off-site on day leave to attend his Mosque to pray five times a day, or overnight leave with his family. He would attempt to postpone scheduled appointments or fail to attend. He did not associate with fellow co-residents. His social circle constituted his immediate family and a few friends from the local Mosque. His desire was to marry a Muslim woman who would worship at the Mosque and wear a traditional dress. He had poor insight into his illness. He reported fleeting suicidal thoughts, which he related to depressed mood but added that suicide was forbidden in his religion and feared going to hell if he harmed himself. He was ambivalent about medication and said that he was taking it only because he was on a community treatment order (CTO) and had no choice. His goal was eventually to be able to ‘see God’ and enter the ‘after life’ known in his faith as ‘paradise’. His ambition was to become an Imam (Leader of a Mosque) and spread the message; ‘there is no God but Allah and Mohammed is the messenger of Allah’, and convert others to Islam. His goal to obtain a job was in line with his Muslim belief in earning his own keep rather than depend on others. The activities of daily living and conventional adult lifestyle were relatively unimportant in the face of achieving his passage to ‘paradise’. Ahmed’s family wanted him to continue living at the CCU, given his past history of aggressive behaviour at home. His family brought in food for him and his mother cleaned his unit. His mother took him on a month’s leave to Afghanistan, and got him married. Having kept mentally stable he was eventually discharged home, under the care of the continuing care team, although his family requested that he stay at the
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CCU until his wife was able to migrate to Australia and become his carer. The family had concealed his mental illness from the Afghan Muslim community for fear of stigma.
Case 2: Salim A 23-year-old single male with a history of Depression with Psychotic features and Post Traumatic Stress Disorder was referred to the CCU with the aim to learn daily living skills and manage independently. He had several admissions to hospital in the context of depressive episodes and suicidal attempts, in response to command hallucinations. Issues within the family were contributing to deterioration in his mental state. Salim was born in Afghanistan in a family of ethnic minority group. ‘Very strong and healthy’ as a child, he prayed daily with his family and took part in festivals but did not attend a Mosque. The family had experienced significant war and trauma events, with several close members killed by extremists. Salim’s father fled the country, leaving his family. Salim was aged eight and revealed that this is when he first felt depressed. Father finally arrived in Australia eight years later and sponsored his family to join him. Salim felt safe in Australia but struggled academically in senior school and could not continue with his studies. He experienced some bullying and dated his depression from that period. He did not return to school. His ambition was to become a doctor. During his stay at the CCU, Salim resisted engaging in psychotherapy. He said he ‘hated answering questions’ and declined to undertake guided assessment questionnaires. He came across as downcast and withdrawn while talking about his illness as if engrossed in his own thinking. He was distressed at experiencing command hallucinations, which he reported hearing only after a doctor questioned him about them. He said that his parents believed that the voices belonged to ‘shaitan’ (satan) and he believed so too. He felt that medication was not working because the voices continued. Seeing doctors made him feel worse. Salim’s father was the head of the family and main decision maker. Salim’s mother did not speak English and his father declined an interpreter, choosing instead to translate for her. It was therefore not possible to obtain mother’s perspective of Salim’s illness directly. The family felt Salim was ‘dangerous’ to himself; ‘like a baby’, and so monitored him very closely. His mother indicated that he could not live without someone to look after him, to give him medication, do his washing and cleaning and expressed concern that he would be tempted to resort to alcohol and drug abuse if he ventured out. Salim’s parents indicated that they were distressed and burdened with his illness. His father lamented over what he himself had done wrong to deserve this situation and expressed his anger and disappointment at Salim for not listening to their advice. © 2014 Occupational Therapy Australia
16 He described having lost trust in Salim and felt angry at the impact that his illness was having on the family. Parents hoped that he would recover and return to his studies. That Salim had won first prize in a painting competition was of no interest to the father. Father declined to attend a carer support group due to concerns that the Afghan community would become aware of Salim’s condition and source of ‘entertainment’ within the community. However, the family accepted a few sessions of family therapy. Salim said that he found comfort in his religion and praying three times a day, which helped cope with his problems. He said that he would never give up trying to deal with his difficulties (Islam considers giving up hope as a sign of lack of faith in God and a sin). He indicated that depression was not recognised in his country. He felt that seeking help and advice from his parents would improve his situation. Salim’s parents were initially extremely resistive of him coming to the CCU, as they feared for his safety, but finally agreed. Salim seemed ambivalent about coming to CCU. On the one hand he said that he wanted to make his parents happy and be at home, on the other, he was keen come to the CCU to gain ‘freedom and independence’ and to be able to do more things by himself. During his stay at CCU, Salim did not relate much with other residents and spent most of his time in his room drawing and painting, his hobby. He did not show much interest in developing self-sufficiency as he felt that he did not need it. Parents brought in his meals. Salim’s father visited regularly to see if he was coping. Salim tended to spend more time at home with his family than at CCU but continued to attend social activities and maintain contact with his previous community case manager. Ultimately, despite strong advice from the treating team to let Salim continue with his rehabilitation at the CCU, his parents decided to take him home due to their ongoing concerns that since he could not be under constant supervision of the staff, he would be at risk of self harm. Receiving no encouragement from his family Salim felt quite stressed at the thought of staying on at CCU to attain his goals and decided to go home to be followed up by the community treating team.
Issues encountered in rehabilitation of Afghan clients Some issues arising during rehabilitation of Afghan clients at Doveton CCU are highlighted as follows: ● Reluctance to engage in mental health services for fear of social stigma and ridicule and religious or traditional beliefs concerning causes of mental illness leading to problems of compliance with therapy or medication and accessing social supports. ● Obtaining comprehensive information about a client posed barriers due to language problems and reluctance to use interpreters for fear of information leak© 2014 Occupational Therapy Australia
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ing out into the community. Access to female members of the family was restricted due to cultural reasons and their perceptions regarding clients’ problems not readily attainable. Engaging male clients in the rehabilitation programme which has a strong focus on improving independent living skills, like cooking, cleaning and shopping, appeared of no interest as cultural norms for males tend to be in conflict with these tasks. Being a minority group within the CCU client population and therefore not having others to socialise with from their own cultural background or have common interests in activities, Afghan clients tended to isolate themselves. Being away from family environment, gaining independence from family and individuation, a primary aim of rehabilitation at CCU, does not often fit well with their cultural norms and traditions. Regular activities were difficult to implement in certain areas, requiring adjustments in staff expectations and incorporation of culturally compatible attitudes of clients and their families into the programme.
Modifications implemented Taking into account the needs and expectations of the Afghan clients and their families, a shift was made, to make the programme more flexible and culturally responsive. This necessitated moving away from focus on independent living and: ● focusing on male clients gaining access to support groups in the community, ● developing family relationships through psychoeducation since the client is ultimately to be discharged home to live. Offering ongoing family support and therapy, ● providing literature on mental health, illnesses and facilities available in printed Afghani language, ● considering use of tools for culturally appropriate assessment of goals, motivation to learn living skills, interests and areas to be improved, ● allowing access to family members to fulfil their cultural roles, e.g., allowing mother or other family members to attend to domestic chores like providing meals or cleaning, ● allowing time for prayers and structuring activities and appointments around those times.
Discussion The role of occupational therapy in rehabilitation of psychiatric clients lies in providing customised interventions, enabling them to engage in activities of daily living that have personal meaning and value, develop skills necessary to function independently in the community of their choosing, consult with family members and care givers to help promote satisfying daily activities, evaluate
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outcomes to ensure goals are being met and to make changes to the intervention plans as required (World Federation of Occupational Therapists, 2012; Occupational Therapy Australia, 2013). There is a dearth of literature on the rehabilitation of psychiatric clients from the Afghan cultural background in the Australian context. This article describes issues which surfaced during occupational therapy and rehabilitation of Afghan clients and which called for flexibility and a culturally sensitive approach in their management. Both clients were well conversant in the English language. Their parents, however, were not, with the exception of Salim’s father. Culturally, female members of the family remain in the background and are not readily accessible for interviewing separately, as in the case of Salim, where the father acted as the mother’s spokesperson. The issues within the family reportedly causing deterioration in Salim’s depression could not be fully explored. Being a member of a small community and with the stigma associated with mental illness, Salim’s father declined to use an interpreter as there is a fear interpreters will not adhere to confidentiality requirements (South Eastern Region Migrant Resource Centre, 2010). For the same reason his parents rejected any attempts to become involved in support groups. Family ‘secrets’ are very tightly held within the family and not easily amenable to exploration. In Ahmed’s case, his family took him on leave to Afghanistan to get married. At no stage had the family discussed this plan with the staff. Traditional Afghan causes of illness include imbalance of hot and cold forces in the body; non-adherence to the principles of Islam and will of God; possession by evil spirits (jinn); given the evil eye; and witchcraft (Morioka-Douglas et al., 2004). Evil eye and witchcraft are mainly seen to cause mental illness. Depression may not be considered an illness (South Eastern Region Migrant Resource Centre, 2010). Mental disorders are highly stigmatised and as such there is extreme reluctance to attribute the symptoms to mental illness (Kirmayer et al., 2011). In the cases described above the mental disturbances were attributed to supernatural phenomenon and satan and improper adherence to religious practices. The cure was sought in regular prayer (Morioka-Douglas et al., 2004) with medication considered not of much use. Engaging in Islamic and traditional practices like prayer and use of amulets can have calming effects and clients may not feel the need to make their therapists aware of it. Such beliefs can lead to ambivalence towards and non-adherence to prescribed treatment. The occupational therapists need to be mindful of such cultural beliefs alongside negotiating the benefits of rehabilitation and continuation of medication. It has been suggested that employment of traditional healers (Hiegel, 1983) and cultural consultants (Budman, Lipson & Meleis, 1992), who can serve to bridge the gap between the medical model and the refugees’ world
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view, deserves consideration. Older Afghan Australians may prefer traditional treatments to medical treatments (South Eastern Region Migrant Resource Centre, 2010). Involvement of a senior family member or a trusted family friend who has a ‘balanced’ view on mental illness and who would, in confidence, accept and mediate in discussing different treatment modalities would assist in achieving mutually desired results. Consideration can also be given to enlisting willing members of the staff of the rehabilitation or allied health services with experience and awareness of the ethnic background and culture of the clients to mediate in achieving mutually desired outcomes. That a strong cultural stigma is attached to mental illness was evident in both the cases. Efforts to join support groups were therefore resisted by both parents. Yet, as Lipson (1993) has stated, traditional psychiatric approaches, such as, individual insight or supportive psychotherapy with psychoactive medication have had limited success with refugees while support groups composed of others from their background and experience appeared to have been helpful. Ahmed had established his own social group in the mosque where he spent considerable time. Salim continued to attend social activities, which he had been engaged in prior to coming to the CCU. This aspect of their rehabilitation was recognized and facilitated in both cases. Sulaiman-Hill and Thompson (2012) found that refugees employed certain coping strategies such as, getting outside in the fresh air and going for a walk or discussing concerns with family and friends rather than with people outside of the family, which were more useful in obtaining relief from psychological distress. As such, focus away from engagement in the group programme and more on culturally appropriate individual rehabilitation strategies may prove more effective. Studies indicate that family support can be most valuable in alleviating emotional distress in refugees and thus it is advisable to supplement their treatment by including their families and social network (Kirmayer et al., 2011). Connectedness to the family was noted as an important element in both the cases. However, this aspect can also generate its own stresses as was evident in Salim’s case. It was quite apparent that Salim’s desire for independence and expectations of his parents were in conflict. His father did not value Salim’s skills and passion as a painter, which he seemed keen to pursue, but expected him to return to his studies. The extreme protectiveness of the family, following his self-harming incidents, hindered Salim’s goal of achieving ‘freedom and independence’ for fear of alienation from his family. Ongoing family and individual psychotherapy was organised to address these issues since family support and cohesion were identified as important factors in Salim’s recovery, but achieved limited success. Catering for family and religious issues emerged paramount in management and rehabilitation of these © 2014 Occupational Therapy Australia
18 Afghani clients. Prayer and faith in God to heal and not give up hope is traditionally seen as important in healing illness. Familiarisation of the cultural issues of these clients was facilitated during review of their progress with the treating team by one of the authors who has had experience in working with clients of Muslim background; their beliefs and attitudes towards medication and causes of mental illness. During these meetings self-examination of personal attitudes towards these issues was encouraged. Insights thus gained assisted in developing a degree of functional cultural competence among the team members and facilitated a more culturally responsive and client centred therapy. Other pertinent issues emerged from the experience of providing occupational therapy and rehabilitation services to the Afghan clients. One of the cardinal requirements in occupational therapy is motivation to learn new behaviour, which would enable clients to achieve more independence and self-confidence. These elements in personality development and learning daily living skills were not seen to be important by the clients and their families in both cases. The clients were well catered for in their physical needs by their families. Ahmed’s ultimate goal was to be a preacher in the Islamic faith and had made his own arrangements to achieve this. Salim, on the other hand, was looking for more freedom and independence to manage on his own and pursue his artistic leanings but met with resistance and indifference from the family to achieve this. The agenda of the clients and their families for admission to the CCU were at odds with what the rehabilitation programme was accustomed to offer and appeared more as a facility for placement and containment of the clients rather than rehabilitation. Panesar (2011) has questioned the justification of compulsory admission for psychiatric rehabilitation and expressed concern regarding the impact it may have on client recovery as the clients may regard the process as coercive. He advocates a voluntary admission of clients for rehabilitation to preserve their autonomy and facilitate their recovery with the focus of occupational therapy reflecting the preference of clients and their carers. Both cases discussed above were referred for occupational therapy and rehabilitation while on a CTO. This raises an important issue concerning their motivation and right and responsibility for self-determination and active involvement in the psychosocial rehabilitation programme. Research is needed to develop more culturally appropriate psychosocial models of occupational therapy with broad applicability within the background of Islamic culture but also leaving scope for modification to cater for individual needs of Afghan clients. Qualitative studies could provide more relevant information than quantitative studies in this respect. Residential rehabilitation programmes require clients to spend considerable time away from their families. © 2014 Occupational Therapy Australia
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This would not appeal to refugee clients given the importance of family support and involvement and has a potential to re-awaken traumatic experiences of family separation and loss during migration. Consideration therefore needs to be given to referring Afghan clients in particular for compulsory residential rehabilitation. Efforts will need to be directed at developing home based occupational therapy and rehabilitation services and include Islamic based supportive psychotherapy that fits within the client’s own cultural beliefs and traditions. Occupational therapy programmes, as in other areas of health services, will need to evolve over time in response to changing Afghan population in Australia. For instance, to cater for the younger Afghan generations seeking psychiatric help as they acculturate to the Australian way of life and seek independence and self realization, away from the traditional family environment (Awad, 2013), and as they come into conflict with parents and elders who hold values and ideals different from their own. These and other issues mentioned above provide fertile grounds for research in this evolving area of occupational therapy.
Conclusion The two case vignettes of Afghan clients presented in this article served to highlight the socio-cultural and religious beliefs, which impacted on occupational therapy and rehabilitation process. The conventional psychiatric rehabilitation programme required adapting to take into account the goals and aims of the families and clients as these were at variance to the concept of the psychosocial rehabilitation programme offered. With the influx of Afghan refugees into Australia, reports of a high prevalence of mental disturbance amongst these refugees and the younger generation growing up in the Australian cultural environment, mental health workers will need to cultivate culturally appropriate practices. This would include being aware of the Muslim culture and how it affects Afghan clients in their day to day life and activities and their own attitudes in treating these clients. These aspects were discussed during clinical review of clients and appropriate modifications were introduced in the occupational therapy and rehabilitation programme in a residential setting. Consideration was given to developing family or community-based rehabilitation services. Further qualitative research is urged to develop culturally responsive alternative forms of therapy that will be of benefit to this population.
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