Journal of Systemic Therapies, Vol. 28, No. I, 2009, pp.

36-51

HOME-BASED FAMILY THERAPY:

AN ILLUSTRATION OF CLINICAL WORK
WITH A LIBERIAN REFUGEE
LAURIE L. CHARLES
University of Massachusetts, Boston

¡n this paper the author provides a case illustration of home-based systemic

therapy performed in the U.S., with a female survivor from a war-affected
region of West Africa. Providing clinical services in a person's home has
been shown to be an effective way to engage those who are otherwise un-
likely to seek out mental health services. In this paper, first-person narrative
vignettes about the therapy endeavor illustrate how working in the context
ofthe client's home assisted the clinician in eliciting rich information about
the resourcefulness ofthe client in constructing a new life for herself in her
host country. Such information tends to be overlooked in literature about work
with refugee survivors of war.

Every Friday at 10 a.m., 1 travel to West Africa. I drive one hour from my subur-
ban neighborhood, down city streets, across the big bridge, and through neighbor-
hoods I never have reason to visit otherwise. When I arrive at my destination, 45
minutes after I've begun, I am at an apartment building with a distinct 1970s look
to it. Parking my car neatly in a tiny guest spot near the office, I walk to the second
floor of a building adjacent to the apartment office. Outside her door, I knock, and
a few minutes pass before a smiling, well-coiffed young woman, Véronique,'
welcomes me inside. For the next hour I will be a guest in her home, her personal
representation of a small piece of Liberia, West Africa, transplanted to a living
room in the U.S.

The author extends her gratitude to the anonymous reviewers for their helpful comments on the
manuscript. Thanks also to the refugee resettlement professionals involved in this case, for their
many contributions to the work presented here.
Correspondence concerning this article should be addressed to Laurie L. Charles, Ph.D., Family
Therapy Program, Department of Counseling & School Psychology, University of Massachusetts
Boston, 100 Morrissey Blvd., Boston, MA 02125. Email: laurie.lopez_charles@umb.edu
'Not her real name.

36
Home-Based Family Therapy 37

INTRODUCTION

Today, on the day I write this, over 44 million people are living in the world
as refugees. Refugees, displaced by war and political conflict in their home
countries, are often survivors and witnesses of torture and mass violence. They
represent a unique clinical population for mental health providers in the U.S.; most
humanitarian disasters which displace families and result in their refugee status
occur outside U.S. borders (Jacobs, 2007).
In this article, I illustrate a clinical case that demonstrates that home-based family
therapy allowed me a unique perspective which greatly informed my clinical work
with a Liberian woman displaced to the U.S. by war. In presenting the case, I do
not intend to generalize the work to all war-displaced refugees or all Liberians.
However, I do intend to illustrate how a critical examination of the cultural and
social context of a person's life (see Melendez & McDowell, 2008) resulted in a
discovery-oriented clinical process that was of particular fit in this case. Home-
based family therapy allowed me a perspective of the client that was uniquely
different from more traditional, trauma-based clinical methods commonly used
with war-affected populations.

Health care professionals in the U.S. are not typically exposed to human rights
concepts (Iacopino, 2002), and thus, may not know how to work with the torture
and war-related trauma that affects people displaced to the U.S. (Iacapino, as cited
in Engstron & Okamura, 2004a). Similarly in the field of family therapy, insuffi-
cient attention has been paid to international concerns affecting families, despite
the recognition and widespread interest in multiculturalism and a welcoming at-
titude toward international learners (McDowell, Fang, Griggs, Speirs, Perumbilly,
& Kublay, 2006).
Even clinicians who work with immigrants and refugees may inadvertently
overlook the ways in which their clients' pre-migration experiences may have been
influenced by war and political conflict in their home countries. One way family
therapists and other systemic clinicians can improve their ability to recognize if a
client has experienced politically motivated violence is by educating themselves
about the historical and contemporary political and human rights conditions of
the countries from which their clients originate (Fabri, 2001).^ Educating one's
self in both routine and continuous ways about the international concerns that factor
into the everyday life of refugees in the U.S. can greatly enhance clinicians' under-
standing of the complexity of a refugee client's situation, as well as the adapta-
tions they must make (Richman, 1998) in their post-migration world.
Although the majority of the world's refugees come from non-Western coun-
tries (Bracken & Petty, 1998), the majority of clinical literature about work with
^One simple and thorough way to do this is to visit a website like Human Rights Watch (www.hrw
.org) to read about specific countries' records of human rights abuses and violations, as well as
political, economic, and societal factors that are relevant to the country situation.
38 Charles

this population is exclusively reliant on the language and constructs of Western

psychiatry. Uncritical reliance on these methods effectively disregards clients'
indigenous understandings about mental process, healing, and suffering (Miller,
Muzurovic, Worthington, Tipping, & Goldman, 2002). Nevertheless, it is com-
monly accepted clinical practice to work with displaced survivors of war using
models of treatment commonly applied to other traumatized populations. For
example, treatment for survivors of war has centered on cognitive behavior
therapy and insight-oriented approaches (McCullough-Zander & Larson, 2004).
Yet, the premises and assumptions inherent in these approaches are based on
Euro-American norms of mental health and are not necessarily appropriate across
cultures.
In particular, DSM-IV diagnoses of post-traumatic stress disorder (PTSD) have
guided treatment styles and approaches with survivors of war. Several authors have
criticized this approach as insufficient and exclusive of the historical and politi-
cal context in which war-related trauma originates (Engstron & Okamura, 2004a;
Fischman, 1998; Hernández, 2002). Allodi (1991) suggested that the PTSD model
reduces what is often a complex political/historical problem to the level of indi-
vidual psychology (p. 28). Taking a clinical approach that is based on the assump-
tion of individual pathology risks ignoring the full context of a client's migration
transition, and can promote a clinical stance that inadvertently undermines criti-
cal awareness about a client's resources, resilience, and capacities for survival.
Ironically, these very qualities are inherent to anyone who manages to achieve
refugee status.
War affected populations such as refugees displaced from their home countries
are, as Summerfleld (1998) noted, "largely directing their attention not inwards,
to 'trauma,' but onwards, to their devastated social world" (p. 34). The social world
of a client is ofparamount interest to systemically trained clinicians. Thus, family
therapists working from a systems lens can be especially valuable partners in
community-based services with refugees, whose presenting physical or mental
health complaints^ originate with environmental and socio-political conditions out
of their own control. Examining a refugee client's already existing resources and
competencies is also taking a strengths-based approach, which has a long tradi-
tion in family therapy.

The Value of Home-Based Work with Refugees

While many activists and health providers advocate the importance of building
partnerships within refugee and asylum seeker communities, many therapists may
have difficulty fully appreciating—in thought as well as action—the complexi-
ties ofthe refugee client's world outside their offices. Understanding the nuances

^It has been said that many refugees, asylum seekers, and survivors of torture do not necessarily
distinguish between physical and mental health.
Home-Based Family Therapy 39

of a refugee clietit's home life, before and after the displacement, can be espe-
cially challenging in the best of circumstances, but are especially so when influ-
enced by linguistic and cultural complexities.
Chester (as cited in Engstrom & Okamura, 2004b) noted that home-based
therapy with refugee survivors of war can be especially helpful in that it allows
clinicians to broaden a client's sense of community. Being part of a community
helps bring refugees a sense of validation and self-worth and provides a support-
ive network to replace the loss of family and neighborhood (Richman, 1998). As
one reviewer of this article put it, "going into the client's home reverses the tradi-
tional hierarchy of therapist/client, because the client has become the Host and
the therapist the Guest, [and] puts the client in a position where she has some-
thing to offer, not just something to take."
In addition to allowing a therapist the opportunity to observe aspects of a
refugee's world from the inside, home-based work also:

• brings a heightened sense of familiarity with client families;

• allows the therapist to see & hear first-hand the intimate details of the families'
daily lives;
• places the therapist on the family's physical territory;
• helps the therapist deal with the circumstances of most concern to the client rather
than vice-versa;
• leaves therapists with a vivid image of family in their natural surroundings (Snyder
&McCollum, 1999).

Home-based services with survivors of war provide rehabilitation to a client

within the client's context, as they reconstruct "a network of support and services
in the natural environment" (Engstrom & Okamura, 2004b). By working regu-
larly with a client in her home, a home-based therapist sits as a guest in the world
the refugee client is reconstructing.
The geographical closeness that comes from being a guest in a client's home, and
a routine part of his/her weekly activities, can also expertly position a clinician to
identify resources that readily exist in the client's social context. Witnessing a client's
inherent resources, noticing her resiliency at using them, and expanding their util-
ity as a clinician can greatly enhance the quality—and relevance—of treatment
interventions. Interventions that are consistent with the client's worldview are
likely to be more sustainable over time.

HOME-BASED THERAPY IN A COMMUNITY-BASED CENTER:

A PARTERNSHIP FORMED OVER A CUP OF COFFEE

The clinical work with Véronique that is described in this paper took place through
a partnership with a refugee resettlement program situated in the eastern U.S.
Funded by the U.S. Office of Refugee Resettlement and other sources, refugee
40 Charles

resettlement programs routinely offer access to a variety of health, legal, and edu-
cational services to individuals granted official refugee status. The work descrihed
in this paper took place in the context of such a program.

The Structure of the Community-Based Milieu

The program milieu was a community based-model of care specifically designed
to meet the needs of refugees and survivors of war and political torture. The
program staff, although few, had identified and developed community partners
who in turn provided a network of professional services, often pro bono, to the
program's refugee clientele. Program funding often provided transportation (i.e.,
taxis) for clients to visit network service providers in the community. At the time
the author became involved with the program, program staff had identified a small,
but growing, number of clients who they thought might benefit from mental health
support. However, these clients were either unwilling or unable to take advantage
of these services, which had been offered successfully with other demographic
groups in the program population, through a partnership with a university-based
therapy clinic. For instance, while some Central Americans had a high rate of clinic
usage, clients from the Balkans and Africa did not.
It is not uncommon for refugee mental health services to go unused for reasons
such as lack of transportation, the need for childcare, or the stigma of being thought
of as "crazy." Similarly, McCullough-Zander & Larson (2004) found the cost of
services "may be prohibitive to refugees, who as a group tend to have low incomes"
(p. 62). For many refugee clients, services provided in the community where they
live allows for access to health care that might otherwise be unattainable. For
Véronique, who had been shot twice in both legs during the war in her country
and who did not own a car, traveling to an office—even at the expense of some-
one else—to talk to a therapist once a week was not a viable option.

Developing a Home-Based Therapy Component in the Milieu

At the time that program staff had been reflecting on how to provide mental health
services in alternative ways, the author, who had previously worked for a number
of years as both a home-based family therapy clinician and supervisor, had coin-
cidentally sought out the program as a volunteer. Over a meeting at a bookstore
café, the author and a program staff administrator formed an informal, impromptu
partnership; it was agreed that the author would provide home-based services, pro
bono,'' for two clients at a time. The program staff would consult with the refugee

''Several months after the partnership began, program staff received monies to fund the author's
clinical work. The amount of $50.00 per session was agreed upon. Nine months after the partner-
ship began, a separate grant, to fund a team of home-based therapists and supervisor (the author),
was awarded. The author's relocation a few months later ended the partnership—but not, fortunately,
the increase in the provision of home-based clinical services.
Home-Based Family Therapy 41

resettlement caseworkers, in order to triage clients, and would provide, through

the refugee resettlement caseworker, case support as needed.

CASE EXAMPLE: VERONIQUE, THE PIONEER

First Meeting: A Woman, in need of "Someone to Talk to"
I was eager to meet with Véronique, but I was very aware that Véronique had not
sought me out. Why would she? "Therapy" exists in a very different form in Africa
than it does in the U.S. (Nwoye, 2004), and I did not expect that Véronique had
told anyone she wanted to see a therapist. Indeed, most refugees and survivors of
war who have been displaced only come to the attention of mental health profes-
sionals after some other issue, such as a physical complaint.
My services had actually been requested by Véronique's caseworker, Lina, a
refugee herself, who had identified Véronique as someone in need of "support."
Lina had spoken to Véronique about having a therapist come to visit her in her
home, and Véronique was willing to give it a try. For my first meeting, I coordi-
nated a joint session with Lina and Véronique, as recommended by Sveass &
Reichelt (2001).
I could see right away that Véronique had a trusting relationship with Lina, and
perhaps because ofthat, was amenable to and interested in my visits. I also learned,
from Véronique herself, that she saw me as someone who could provide "sup-
port," and as "someone to talk to." However, in the first two or three sessions,
Véronique didn't talk much at all. I had had over a decade of clinical experience
by the time I met Véronique; I had even lived for many months in West Africa,
not far from the country where she was born. However, despite my seasoning as
a clinician and a traveler, I was in new territory with Véronique.
r had read a version of Véronique's story in her refugee case file; the story was
graphic, violent, and heartbreaking. Although I wanted to know more about what
had happened to her, focusing on that part ofher past seemed premature and voy-
euristic. According to Engstrom & Okamura (2004a), overt discussion about refu-
gee clients' traumas is not always a necessary precursor to healing work. In their
view, "healing work can be done without retelling the torture story" (p. 298).

Vignette #1: Mapping Veronique's Migration:

From Peace Camp to "Here"
Veronique's displacement had begun over a decade earlier, and at the time I met
her, she had lived in the U.S. one year. Most of her displacement had been spent
in a refugee camp. I noted in my first visit that after a year in the U.S., Véronique
had a welcoming, lived-in home; she had happy, well-cared for children, all in
school, and she had her only surviving sister, Eugenie, living with her. Eugenie
was also enrolled in high school, despite being older than most people in her class.
42 Charles

Most noted by me on those early visits was Véronique's quick smile and con-
tagious laugh. She often had other people around (African neighbors, also refu-
gees), and seemed very comfortable with all the activity in her house. I also noticed
that Véronique was more comfortable with her cell phone than I was with mine!
I quickly assessed that Véronique had some refreshingly normal things going on
in her life that I wanted to know more about. Here she was, a woman with a story
made from the stuff of nightmares who had found the resources to build another
life for herself, in another country, and in spite of her past.
As Singer (2005) found in her study of clients' experiences of therapy, cli-
ents have tremendous stores of expertise that therapists don't ask about. Cli-
ents' hypotheses about their presenting problems. Singer (2005) noted, are as
sophisticated as those of any professional. As I found out about Veronique's
past, I also learned about her desire to work and be active. From sitting with her
and listening to her stories, I became increasingly curious about her store of
experience—that which was not attached to any professional hypothesis about
her as a traumatized refugee. What was she up to? What was the sophisticated
model she was using?

In my third meeting with Véronique, 1 brought a map with me to her apartment

and asked her to show me where she lived for most of her displacement—the "Peace
Camp," as she called it—and the region in Liberia where she had lived before the
war broke out. Each time I had been to Veronique's house, a number of other West
African females had been present—neighbors, friends, or customers waiting to get
their hair braided by Véronique. The day I brought the map—a copy I made, from of
a page in a World Atlas—Véronique and her female company gravitated to it on the
kitchen table. I felt myself fade into the background as the women began to speak
excitedly in Krahn, their native language (Liberia is an English-speaking country,
but Veronique's first language is Krahn).
I observed as the group sought out familiar names on the map, locating villages
and cities and towns once called home. The group began to describe to me, and to
each other, as they pointed to the map, the places they had lived and moved before
arriving in the U.S. Véronique recounted the details of the displacement that I had
read about in her file—her village home; where the camp was; where she had been
in the hospital after an injury received while she was in the camp.
It did not escape my notice that I hadn't asked Véronique to tell the story of her
displacement. The story seemed to evolve from her seeing her home, her country,
represented on my map. In short, the map was a hit. Here is some of the information
it helped me learn:
Véronique is from a small village in Liberia. Before she arrived in the U.S., she
spent 15 years in what she called the "Peace" (refugee) Camp in Cote d'Ivoire.
She was only 12 when she arrived in the camp, escaping the war in Liberia. The
day she escaped her village, Véronique saw her mother and sister shot. She tried to
go to them, but an aunt stopped her, and instead, made Véronique leave with her
youngest sister. (Many sessions later, Véronique told me that at that moment, she,
too, wanted to die. "If they were dead, I wanted to be dead, too.")
Home-Based Family Therapy 43

In the camp, Véronique grew up. She had two children. One day while walking to
the market to sell dried fish—Véronique worked while she lived in the camp, as did
many others—she was caught in some crossfire. Fighting from the neighboring war
in Liberia had spilled across the border. To this day, Véronique does not know for
sure who Is responsible for shooting her. She thinks it was soldiers.
The next thing Véronique remembers is waking up in a hospital in Abidjan some
days later. Her family had not been able to find her. Until she awoke, the hospital
staff did not know she was Liberian. Hospital staff in Abidjan repaired her legs the
best they could. Not long after that, Veronique's request for refugee status was
granted, and she arrived in the U.S. Since her arrival in the states, Véronique has
had three more surgeries on her legs. (Although Véronique walks with a limp, you'd
be surprised how well she gets around for someone who was shot in both legs less
than three years ago).
Véronique mentioned that she had a man in the camp, but it was several sessions
later before she identified him to me as her husband.

In the first few meetings with Véronique, I learned some important things about
the life she was constructing for herself in her new world. To keep busy, Véronique
attended English classes four days a week. She walked to meet her children at the
bus stop after school, and rode the bus to medical appointments when she could
not get transportation from her caseworker. Véronique told me she hated staying
home all the time, that she missed being active, and that she had never been inac-
tive in Africa. She told me, laughing, "I want very much to work—just like every-
one else in America!"

Vignette #2: Becoming Comfortable as a Guest in Veronique's World

A routine for my meetings with Véronique quickly developed. I met her on Fri-
day mornings, when she did not have English class, usually around 10 a.m. Occa-
sionally, as we were talking at the kitchen table, someone would knock on the
door. Usually Véronique or someone else in the home would answer it, but sev-
eral times, I did. One of those times stands out for me: Véronique was seated
comfortably on the sofa, working on a client's hair. I, too, was on the sofa. When
the bell rang, Véronique and I shared a quick look of permission, after which I
jumped up to get the door myself.
It was easy for me to adapt to the slow pace of my visits with Véronique, which
lasted anywhere from 20 minutes to an hour and a half—depending on what was
happening in Veronique's world that Friday. During one visit, a well-dressed white
man dropped by. He was clearly not there to have his hair braided, and probably
wondered about me, the casually-dressed Latina woman sitting in Veronique's home.
I remained quiet as his eyes met mine at the kitchen table; he greeted me with a nod,
which I returned. We did not introduce ourselves or speak to each other. Instead, 1
watched as the stranger stayed standing, rescheduling his visit with Véronique in
front of me. After he left, Véronique told me he was her church minister.
44 Chartes

Although I was in Veronique's home in a professional role, the fact that I also
saw myself as a guest precluded my being bothered by the many visitors she had
or by the many people I saw in her home. I knew from previous home-based work
that neighbors and friends in the home did not mean therapy was in jeopardy, that
it was not doable, or that something was wrong with Veronique's (or my) sense
of boundaries. Home-based clinicians are accustomed to such "distractions," yet,
even home-based therapists adhering to strict, westernized view of mental pro-
cess might see these extra people in the home as a threat to therapy, or as a lack of
boundaries. I did not.
I also knew from my own experience living in Africa that it would be very
unusual for Véronique to not have anyone else around her home. Most of the fami-
lies I had had contact with in West Africa, where I had lived as a development
worker, were full of "extra" people, coming in out, with no clear relationship to
anyone else except that they, like me, were welcome. So, while Veronique's ac-
tive household is not nearly as quiet as mine, it was normal for her, and I saw it as
perfectly appropriate. It also told me that she had somehow translated her past
into the present by developing a network of people that was active and thriving in
the aftermath of her forced migration.
Véronique also received many phone calls while I was present. One day, some-
one called her and, in Krahn, she spoke briefly to the caller and then hung up. I
asked Véronique if she had been speaking to her roommate, also a Liberian Krahn
speaker, who was at work. Véronique surprised me when she told me that the call
had come from West Africa. She had told the caller to check back in an hour.
I think it was this moment that I first felt I was doing a good job with Véronique
—that I was truly a welcome guest, despite my professional role in her life. I felt
it somewhat of a marker that she would postpone such a long distance call be-
cause we were talking at her kitchen table. I told Véronique next time she should
take the call if she wanted to; I did not mind one bit.

Vignette #3: Navigating Complex Systems:

The Utility of Simple Gestures
A therapist's job is to ask questions. For systemic therapists, questions are seen as
an intervention in themselves. However, I am not so sure Véronique was as moved
by my questions (except perhaps when I asked the miracle question, which I will
discuss a bit later), as she was with the concrete information I provided her dur-
ing some of my visits.

On one Friday, Véronique told me about a letter she had received from the Social
Security Administration (SSA). She didn't understand what it meant—could I help
her? When I saw the ten page letter, I could see why Véronique was confused. The
letter was in government-speak and difficult to comprehend. We studied it together,
and the last few paragraphs seemed especially declarative. The end of the SSA letter
Home-Based Family Therapy 45

told Véronique that if she wanted to work, she could apply to a vocational training
program. SSA would pay for it. More importantly, she would not lose her disability
benefits if she took this training and started work. The possibility of a real job ex-
cited Véronique very much.
1 suggested Véronique clarify what the letter said by calling the SSA—maybe, the
following week, as today was Friday. However, Véronique surprised me by grab-
bing the phone and calling the 800 number on the letter right then. She motioned
for me to put my head near hers, and both Véronique and I were listening when a
machine answered. The voice suggested Véronique call back between the hours of
10 p.m. and midnight. (Apparently the SSA was trying to increase service provision
and was experimenting with new hours). Véronique told me she'd call back later
that night.
Within two weeks, Véronique was enrolled in a childcare certification course that
would eventually lead to work in a daycare ("I take care of kids anyway so why not
do it for a job," Véronique joked, smiling).

Guidance navigating the social service and healthcare system in the U.S. is a
typical need of refugees and asylum seekers (Sveass & Reichelt, 2001). My im-
pression, after months of working with her, was that Véronique only seemed to
need initial guidance about how to navigate complex systems. Once directed, she
could follow through on her own. The example of calling the SSA in the moment,
while I was at her kitchen table, was quite instructive for me. 1 did not realize how
useful such a simple gesture on my part (putting my ear to the phone with her)
could be. Although Véronique had a support person (Lina), she could have asked
to help her with this issue, it was me who she asked; I was the one that was there
the day she got the letter.
I have not forgotten how overwhelming it felt to read and try and comprehend
the bureaucratic language of that letter. It humbled me to realize the kind of ne-
gotiations Véronique had to go through every day—negotiations that were chal-
lenging for me, a privileged, educated U.S. citizen. Further, Veronique's efficient
incorporation of me into her negotiation reminded me as a clinician that I should
never take Veronique's expertise for granted: she grabbed the phone and she put
it in my hand; she knew when she needed help and she was not afraid to ask for it.
In the months we worked together, Veronique's daily English classes .showed
in her increasingly sophisticated speech, and I witnessed, many times, how fear-
less she was about asking questions of others when she needed help. By the time
I'd ended my work with Véronique, she'd dealt successfully with the SSA, she
had had the training she needed to work in childcare, and she'd lost none of her
benefits as she had feared.

Final Meeting: A Pioneer, with Rights and Ideas

Eventually, I came to see Véronique as something of a pioneer—both in her apart-
ment complex and for others at home in West Africa. She seemed to be paving
46 Charles

the way for those in her community to prosper and to learn. People came to her
for help, and she was ready with advice for newcomers (many new refugees had
been settled in her apartment complex, and Lina was thinking of asking Véronique
to lead a support/information group for the new refugees). Her inquisitive nature,
common-sense initiative and vastly improving English helped her absorb a great
deal of information that she was quick to share with others.
Near the end of our time together, Véronique was preoccupied with how to re-
unite with family members that remained in West Africa. In particular, she be-
came increasingly concerned about her husband. Like the situation with the form
from the SSA, Véronique asked me for help.
I asked Véronique to explain to me what information she had about how to bring
her husband to the U.S. Véronique told me that her marriage had been a tribal
marriage, without formal documentation, that had taken place in the refugee camp.
Realizing that she needed proof of their union for U.S. authorities, Véronique had
already asked her husband to find one of the witnesses to the ceremony and ask
him to write (and fax) a letter to Véronique that he had witnessed the wedding.
She was now waiting for the letter, but was unsure where to go from that point. 1
wasn't sure either, but I told her I would find out.
Before my next meeting with Véronique, I made a face-to-face appointment
with Lina, who did not know that Véronique had a husband, and at first wondered
why Véronique had not said anything about it previously. At first it seemed to me
that Lina was offended. "Why has Véronique not told me this before?" she asked.
However, Lina minimized that curiosity and focused on helping Véronique fill
out the necessary state department paperwork that would bring her husband to
the U.S. Véronique could now do this because she had recently become a U.S.
"resident alien," which meant, among other things, she had the right to petition to
bring her husband to the U.S.

DISCUSSION

A recent study about refugee mental health revealed something less than surpris-
ing: refugees experience a recurring sense of loss around everyday meaning in
their lives. When contrasted alongside the pre-migration roles and activities that
had given their lives structure and coherence (Miller et al., 2002), the losses refu-
gees experience become especially poignant. In this article, I illustrated how in
my role as a home-based clinician, I was able to observe and witness the structure
and coherence with which one refugee had re-fashioned a life for herself after her
displacement.
Veronique's concerns about finding work, and occupying her time with pro-
ductive activity, seemed to be very much about finding meaning and worth in her
everyday life. She was trying to construct a new map for herself, one independent
of the territory she had previously traversed. My time as a guest in her home
Home-Based Family Therapy 47

provided me with a unique viewpoint, which I could not ignore: Véronique did
not see herself as someone who was traumatized. Nor did she identify herself as
a woman who was depressed or in need of counseling or therapy. Instead, she saw
herself as a woman in need of "support," a woman who wanted "someone to talk
to." Although Véronique had certainly experienced suffering and great loss, which
often haunted her in her dreams, I agree with Hernandez (2002) that focusing only
on these losses would have been clinically inappropriate and unethical.
I do not want to give the idea that I was incurious about the traumatic experiences
Véronique had faced. As a clinician, a conscientious U.S. citizen, a former resident
of West Africa, I was very curious about what had happened to Véronique. But 1
refrained from focusing on these experiences as a primary way to organize otir meet-
ings. I also channeled my curiosity by learning more about the war in Sierra Leone,
which had spilled over to Liberia and resulted in Veronique's displacement.
Véronique and 1 discussed her experiences of violence only when Véronique
brought them up, or I when sensed a legitimate clinical reason to have a discus-
sion about them. During these times, I learned that Véronique continued to expe-
rience occasional bad dreams, desperate missing of her dead mother and sister,
and most of all frustration at not being able to move her body around like she was
used to. It is very likely that in her phase of post-migration, Véronique was more
focused on certain needs than others when I met her, and perhaps that would change
over time.
Only once was I especially concerned about Véronique. On that day, she did
not show her typical quick smile or laugh. She talked less, smiled not at all, and
seemed especially sad. Pointing out my observation, I asked her what was hap-
pening. Several days earlier, Véronique said, she had learned of the unexpected
death of a 21 -year-old male cousin who lived in a nearby city. Her grief was pal-
pable. When I asked Véronique to tell me more about her experience of the grief,
she explained that it was the cousin's youth that had affected her most—the fact
that he had died such an early death. Her dreams became noticeably worse during
this time, and we talked the rest of the session about the ways her faith in God
promoted her healing and released her suffering. I believe that this description—
of her faith helping her deal with her difficulties—was part of her sophisticated
understanding (Singer, 2005) of how she made sense of both her problems and
her resources.
It was clear to me and others who knew Véronique that she was working hard
to construct a new narrative for her life, and that she appeared to be succeeding.
This new narrative was completely independent of any clinical impressions of her
as a traumatized woman with symptoms of post-war stress. Her nightmares, her
sadness, the memories that haunted her—these parts of Veronique's life were not
all of her life. They were a predictable human response to an inhuman situation
(Hernandez, 2002).
To me, Véronique was young, smart, and courageous. She was clever and in-
telligent, funny, and full of initiative. I admired her sense of humor, her resilience.
 '•s Charles

and her pioneering spirit. I was often surprised at how, despite her bad legs, she
had such a high level of physical activity. She walked her children to the school
bus stop everyday. She took the bus herself to her English classes four days a week.
(Taxis, provided by the resettlement program, were reserved for trips to the phy-
sician who'd twice performed surgery on her legs).
Witnessing her everyday life during our brief visits provided a kind of back-
ground scenery about Veronique's life that contrasted powerfully with what was
represented in her refugee file. Helped along by the proximity I had to her life
while working with Véronique in her home, I chose to focus on those contrasting
elements. That focus led to clinical questions and "a-ha!" experiences I doubt I'd
have had otherwise.
It helped as well that the contrasts were in the foreground ofthe place Véronique
found most comfortable: her home. By being in her home, I was able to closely
observe some of the rituals of her life and the events of her everyday experience.
As a guest in her home, I was allowed a view of Véronique as someone quite at
ease in the world, in the way people are when they are on their own "turf (Snyder
& McCollum, 1999). Seeing her laugh, talk to neighbors, joke about her children,
eat her lunch on the fly in front of me so she could get to the bus stop in time
these moments forced me to notice things about Véronique that illustrated how
she was thriving, despite her past suffering; it was very powerful for me to wit-
ness this as a clinician.
Véronique, it seemed to me, had become an important figure in her local com-
munity. She was in regular phone contact with the rest of her surviving family
members, still displaced on another continent. Her struggle to work and make a
living, and her commitment to helping others in her community, seemed to ener-
gize her. She seemed to thrive with this responsibility rather than be overwhelmed
by it, as many of us might assume of someone with her background.
If someone were to ask me today: What was your most significant clinical
moment from your work with Véronique?, I would know exactly what to say. As
part of my initial assessment, I had asked Véronique the miracle question (see
Miller & de Shazer, 1998): "If you woke up tomorrow morning and discovered
that a miracle had occurred overnight, while you were sleeping, what would be
different? How would you know a miracle had occurred?" (Since my work with
Véronique, I have found this question incredibly powerful with refugees, who seem
to grasp its potential immediately.) Véronique answered the question quickly, her
response ready on the tip of her tongue, a beatific sense of wonder on her face:
"I'd run, and run, everywhere!. . . and then, I'd go to work!"

CONCLUSION

Visiting a client's home can be a compelling experience. While turning the typi-
cal therapy relationship on its bead, home-based work also provides unexpected
Home-Based Family Therapy 49

opportunities to learn about the everyday experience of a person's life. Such an

opportunity is of particular value for clinicians who work with those displaced by
war, whose voice is rarely heard in professional clinical literature, and whose
community has been obliterated by socio-political circumstances beyond their
control. Home-based therapy in clinical work with refugee families offers a unique
opportunity to witness how communities are being re-built, in situ, one person at
a time. Embracing one's role as a guest in a client's home can yield valuable data
about the client's life that can greatly enrich the therapy endeavor.
Insider methods of understanding are especially valuable for the maturity and
development of contemporary clinical practice with refugees. Overwhelming and
persistent attention to symptom-focused methodologies has limited clinicians'
understanding of the everyday experience of persons displaced to the U.S. by war
(Miller et al., 2002). A community-based approach—one that provides services
in the clients' natural environment—is a step in the direction of better understand-
ing about how people perform resilience during their everyday experiences in exile.
Similarly, home-based services in the context of a community-based service milieu
are more likely to result in the identification of client resources—their "miracles,"
and dreams for the future—because they promote insider understandings of experi-
ence. A focus on identifying refugee clients' resources and resilience from the in-
side need not mutually exclude facts about their previous suffering. Rather, they
provide important data about the competencies of women like Véronique, who find
ways to thrive in spite of previous experiences of suffering.^
Miller et al. (2002) suggested that undertaking such explorations requires in-
ductive methodologies that better allow refugees to identify what is meaningful
in their experience. Inductive methods of research make "few explicit assump-
tions about sets of relationships" (Fetterman, 1989, p. 15), instead focusing on
learning about the multiple realities that make up existing relationship patterns or
phenomena. Inductive methods lend themselves easily to clinicians who value and
are interested in eliciting information about resilience among people who have
experienced displacement due to war. Furthermore, because they focus on under-
standing phenomena from an insider position (Fetterman, 1989), inductive meth-
odologies are also consistent with the stance that can be taken in home-based family
therapy work.
Developing more global worldviews and understandings about clients' every
day experiences in the U.S. broadens the clinician's area of expertise to include
sociopolitical contexts that affect all humanity. Therapists have an ethical impera-
tive to address the social dimensions of clients' experiences and to disseminate
the information learned to others about the psychological cost of human rights
abuses (Fischman, 1998).
'None of the clients 1 have worked with who are displaced to the U.S. as a result of war in their
home countries have ever referred to their experience as "trauma." One man, an asylum seeker,
called his past experience "the suffering," and his current life, "the healing." These terms make
sense to me.
50 Charles

Clinicians also have an ethical responsibility to address and disseminate infor-

mation about the social dimensions of these clients' experiences of resilience and
survival post-migration. Veronique's story, and the stories of all people displaced
by politically-motivated violence, are instructive about the human cost of war.
Stories of refugees' lives, from an insider perspective, can also be powerfully
instructive in understanding the ways refugees resiliently map out new lives for
themselves, despite horrific episodes of previous suffering. According to Linley
(2003), such positive adaptations to a new world beyond trauma may even serve
as a "springboard . . . to a higher level of functioning," because the adaptations
show what has been gained—rather than what has been lost—as a result of trauma
(Linley, 2003, p. 602).
Systemic family therapists can play an important role in increasing the territo-
rial space of clinical work with refugees, by widening the dominant clinical dis-
course about that which refugees have lost to include understandings ofthat which
has been gained. In this way, perhaps practitioners and researchers, too, can spring-
board to another platform of clinical discourse, and thus contribute to a more so-
phisticated level of scholarship and understanding about the needs and experiences
of war affected populations.

REFERENCES
Allodi, F. (1991). Assessment and treatment of torture victims: A critical review. Journal
of Nervous and Mental Disease, 179, 4-110.
Bracken, P., & Petty, C. (1998). Re-thinking the trauma of war. London: Free Associa-
tion Books.
Engstrom, D., & Okamura, A. (2004a). A Plague of our time: Human rights, and social
work. Families in Society, 85{3), 291-300
Engstrom, D., & Okamura, A. (2004b). Working with survivors of torture: Approaches to
helping. Families in Society, 850), 301-309.
Fabri, M. (2001). Reconstructing safety: Adjustment to the therapeutic frame in the tratment
of survivors of political torture. Professional Psychology, Research and Practice,
32{5), 452-457.
Fetterman, D. (1989). Ethnography Step by Step. Walnut Creek, CA: Sage.
Fischman, Y. (1998). Metaclinical issues in the treatment of psychopolitical trauma.
American Journal of Orthopsychiatry, 68{\), 27-38.
Hernández, P. (2002). Trauma in war and political persecution: Expanding the concept.
American Journal of Orthopsychiatry, 72(1), 16-25.
Iacopino, V. (2002). Teaching human rights in graduate health education. Health and
Human Rights Curriculum Project. Retrieved December 4, 2008, from http://depts
.Washington.edu/ccph/pdf_files/Iacopino.pdf). American Public Health Association
and François Xavier Bagnoud Center for Health and Human Rights.
Jacobs, G. (2007). The development and maturation of a humanitarian psychology. Ameri-
can Psychologist, 932-941.
Home-Based Family Therapy 51

Kleinman, A. (1980). Patients and Healers in the Context of Culture. Berkeley: Univer-
sity of California Press.
Linley, P. A. (2003). Positive Adaptation to Trauma: Wisdom as both process and out-
come. Journal of Traumatic Stress, 76(6), 601-610.
McCullough-Zanders, K., & Larson, S. (2004). 'The fear is still in me': Caring for survi-
vors of torture. American Journal of Nursing, IO4{\O), 54-64.
McDowell, T., Fang, S., Griggs, J., Speirs, K., Perumbilly, S., & Kublay, A. (2006). In-
ternational dialogue: Our experiences in a family therapy program. Journal of Sys-
temic Therapy, 25{ 1 ), 1-15.
Melendez, T., & McDowell, T. (2008). Race, class, gender, and migration: Family therapy
with a Peruvian couple. Journal of Systemic Therapies, 27(1), 30-43.
Miller, K., Muzurovic, J., Worthington, G. J., Tipping, S., & Goldman, A. (2002). Bosnian
refugees and the Stressors of exile: A narrative study. American Journal of Ortho-
psychiatry, 72(3), 341-354.
Miller, G., & de Shazer, S. (1998). Have you heard the latest rumor about. . .? Solution-
Focused therapy as rumor. Family Process, 37, 363-377.
Nwoye, A. (2004). The shattered microcosm: Imperatives for improved family therapy in
Africa in the 21st century. Contemporary Family Therapy, 26(2), 143-164.
Richman, N. (1998). Looking before and after: Refugees and asylum seekers in the west.
In P. Bracken & C. Petty (Eds.), Re-thinking the trauma of war (pp. 170-186).
London: Free Association Books.
Singer, M. (2005). A twice-told tale: A phenomenological inquiry into clients' percep-
tions of therapy. Journal of Marital and Family Therapy, 3I{2), 269-281.
Snyder, W., & McCollum, E. (1999). Their home is their castle: Learning to do in-home
therapy. Family Process, 38{2), 229-242.
Summerfield, D. (1998). The social experienceof war and some issues for the humanitar-
ian field. In P. Bracken & C. Petty (Eds.), Re-thinking the trauma of war (pp. 9-
37). London: Free Association Books.
Sveass, N., & Reichelt, S. (2001). Engaging refugee families in therapy: Exploring the
benefits of including referring professionals in first family interviews. Family Pro-
cess, 40(,\),95-\ \4.