NSW Refugee Health Service (RHS) and NSW Service for the Treatment and Rehabilitation of Torture and Trauma Survivors (STARTTS)

31/10/00

The consultation was jointly organised by Afghan Community Association, STARTTS, and the NSW Refugee Health Service. It was held on the 31^st of October 2001 at the Afghan Community Hall in Blacktown. Approximately 50 community members attended, and many of them were STARTTS clients.

The aims of the consultation were to:

• Hear from the Afghan community members and   workers about the needs/ issues and concerns of the community
• Receive feedback on STARTTS services from the Afghan community and workers.
• Identify health issues affecting members of the Afghan community, and receive feedback on health services.
• Provide information about STARTTS and the NSW Refugee Health Service

The program included information about STARTTS services to the Afghan community, services provided by the NSW Refugee Health Service, and information about Afghan community in Australia.

Questions raised during the presentations mainly focused on the STARTTS waiting list and the needs of overseas trained health-professionals.

Following the presentations, there were small-group discussions focusing on a variety of topics including:

1. Feedback on STARTTS Services
2. Community’s understanding of the concept of counselling
3. Health issues Afghan community is facing
4. Health services Afghan community is accessing and feedback on these services
5. General settlement issues

The groups included: two women’s groups, community elders’ group and other community members’ group. This provided that the concerns raised were relevant to community members other than elders and leaders.

Afghan Community in NSW

Afghanistan has been enduring occupation and civil war for the last 21 years, resulting in the depletion of its resources and infrastructure and the decimation of government and traditional society.  The roots of internal conflict can be traced to 1978, when a Soviet backed military regime commenced systematic political repression against those it deemed “enemies of the revolution”. 

In 1979 the Soviet Union occupied Afghanistan and its army remained in the country until they were driven out a decade later. Following the Soviet retreat, a bloody civil war amongst the rival political and ethnic groups took place. During this period, tens of thousands of Afghans, primarily those from educated and middle-class backgrounds, were imprisoned, disappeared, tortured and killed.

At present, the Taliban militia, an Islamic fundamentalist group that has imposed severe restrictions on the rights and freedom of the general population, especially women, rules Afghanistan. The Taliban is not internationally recognised as the government of Afghanistan

Since 1978, two million Afghans have been killed, another two million internally displaced in their own country, and 6.2 million have become refugees in other countries. Consequently, Afghans comprise the world’s largest refugee population (UNHCR, 1999). Many Afghans were able to flee to neighbouring countries such as Pakistan, Iran or India, and from there some obtained admission to the USA, Europe or Australia. However, at least three million remain in Pakistan, often in squalid conditions in refugee camps with little international protection.

Afghans constitute the fourth largest group of arrivals to NSW under the Refugee & Humanitarian program. Between 1991 and 1999, 2420 Afghans have arrived in NSW and of those, 1147 (47%) were children aged 18 or under (Department of Immigration & Multicultural Affairs, 1999). The latest Census in 1996 recorded 5818 Afghanistan-born persons in Australia. The 1996 distribution by state and territory showed New South Wales had the largest number with 2933.

Most of the estimated 8000 Afghans, who currently live in Australia, came here via a period of asylum in a neighbouring country where they stayed in refugee camps. As with other refugees, Afghans face a range of settlement difficulties such as unemployment, lack of English, unsatisfactory accommodation and financial problems (Haidary & Bowles, 1995).

Since the end of 1999, many Afghans arrived to Australia by boats and were consequently detained in Immigration Detention Centres. Following the determination of their refugee status they were released in the community and granted 3-year Temporary Protection Visas (TPV). According to Centrelink statistics (March, 2001), there are currently 1698 Afghan TPV Holders in receipt of Special Benefit. Approximately 45 % of TPV Holders have settled in NSW (Centrelink, March 2001). The total number of Afghan TPV Holders in Australia is likely to be higher as many of them have found employment and are not registered with Centrelink.

TPV Holders in NSW are entitled to Medicare, Special Benefit and Family Tax Benefit, Job Matching, and Early Health Assessment. However, they are not entitled to a range of benefits of-shore refugees are entitled to including Intensive Job Network Assistance, free English classes, full range of Centrelink benefits, settlement assistance, public housing and family re-union.

The majority of the Afghan TPV Holders belong to the Hazara tribe which has been identified as an enemy of the largely Pashtun Taliban regime. That is one of the reasons, the Afghan TPV Holders receive little support from the Afghan community in Australia.

Afghan Community Support  Association (ACSA) of NSW and other community-based organisations

The ACSA is a non-political community – based organisation, receiving Community Settlement Services (CSS) funding from Department of Immigration and Multicultural Affairs (DIMA). The Association has a commitment to building links with the Afghan Community and service providers and to improving access for Afghans to all relevant services. Some of the ACSA’s objectives are:

• To reach a wide cross-section of Afghan people and to foster a sense of community and mutual support amongst them
• To develop a resource and information centre for Afghan people assisting their settlement in Australia.
• To educate the mainstream community about the needs and issues of Afghan people.

The services ACSA provides include casework, community development (information sessions, newsletter, community radio, networking, lobbying and advocacy), and numerous projects such as women’s support groups, Saturday Language School and youth groups.

In addition to ACSA, the Independent Afghan Solidarity association is active in providing volunteer welfare settlement services.

NSW Refugee Health  Service

The NSW Refugee Health Service aims to protect and promote the health of refugees and people of refugee-like background living in NSW.

The Refugee Health Service is keen to hear from members of the Afghan community as to particular health needs  and to receive  feedback on health services.

Roles of the service include:

• Consultation and support to mainstream health care workers working with refugees
• Training for health service providers on refugee health and related issues, including development of resource materials
• Liaising between agencies that work with refugees and local health services
• Delivering health information to refugees, including orientation to the health system in NSW
• Providing clinical health assessments, advice and referrals
• Facilitating and conducting research in refugee health needs, problems and service delivery issues
• Advocacy at the health policy level and on a case-by-case basis, to promote health equity for refugees

The Refugee Health Service aims to assist recent refugee arrivals as well as those here for longer times, depending on need.  It also offers services to asylum seekers living in NSW whilst their case for residency on humanitarian grounds is being processed.

Most of the Service’s activities are conducted through partnerships with the wide range of specialised and mainstream health services that help to address the needs of refugees and others of non-English speaking background in NSW.  Collaborations with agencies beyond the health system also form an important part of the unit’s function.

• Clinical assessments for newly arrived refugees or for asylum-seekers

Information was given regarding the Health Information Program that provides information about health services to newly arriving refugee groups in a number of community languages.

Update on STARTTS and the developments since the last consultation

The Mission Statement of STARTTS is to develop and implement ways to facilitate the healing process of survivors of torture and refugee trauma, and to assist and resource individuals and organisations who work with them to provide appropriate, effective and culturally sensitive services.

This hasn't changed much since the last consultation but the practice has - including  a variety of innovations and changes:

• Changes in coverage of greater Sydney area and NSW.  STARTTS currently has two offices (Auburn and Carramar) and the outreach services operate from 14 locations (including Hunter and Illawarra)
• New programs - greatest change has been the implementation of the Early Intervention Program which provides psychosocial assessment and short-term counselling for the newly arrived refugees.
• Other changes include: a constant increase in group work, development of the Families In Cultural Transition Program, and improvements and increase in our Training Program (at least 6000 individuals have been trained since the Program was implemented).

Clients of STARTTS include: individual, families and communities from refugee and refugee like backgrounds who have survived torture and trauma, and other traumatic experiences in the context of organised violence.

When STARTTS first commenced in 1988, most clients were from Vietnam, Laos and South and Central America.  This has changed as refugee crises have occurred and Australia has received refugees from the countries of former Yugoslavia, Middle East, Africa and East Timor. The challenge for STARTTS is to continue to meet the diverse needs of these communities.

The majority of STARTTS referrals for 1999-2000 came from the countries of former Yugoslavia and Middle East followed by the countries of South East and South Asia. Half of the STARTTS clients come from the area covered by the South West Sydney Area Health Service and 30 % come from the area covered by the West Sydney Area Health Service.

Afghan Community and STARTTS

Afghan clients have been seen at STARTTS since 1988. In total, 379 Afghan clients were referred to STARTTS (General Services and Early Intervention Program) from 1988 to 2000. Out of 379, 17 clients are currently on the waiting list and 28 are currently receiving counselling from the STARTTS General Services. Majority of referrals were self- referrals (99), and the second highest referrals source was the Department of Immigration and Multicultural Affairs (DIMA) (60) followed by community welfare agencies (36).

Table 1: General Services                        

Table 2: EIP and General Service Clients included

In terms of gender, 257 referrals were male while only 122 were female. This differs from general STARTTS gender ratio where at least 40 % of clients are female. There were a high number referrals of clients under 20 years old (83 persons) with most referrals falling in the 20-50 years old bracket.  The high numbers of children seen at STARTTS indicate the need for specific intervention targeting this age group.

Table 3: General Services and EIP

Table 4: General Services and EIP

Additionally to direct clinical services, Afghan clients at STARTTS access the following services:

• Middle-Eastern Men’s Group
• Middle Eastern Women’s Group
• Youth Program (primarily residential)
• Specialist Migrant Placement Officer
• Families in Cultural Transitions (FICT) Program

There were also a number of community development strategies utilised to assist the Afghan community develop internal networks and support structures. The strategies include assistance with establishing the Saturday school and community hall and assistance with organising around specific issues (eg. culture/art, spiritual, settlement). STARTTS has also produced a significant amount of written psycho-educational resources in Dari/Farsi language. These include self-help booklet (“Becoming Ourselves Again”), better sleep pamphlet, various STARTTS pamphlets, and a relaxation tape.

Recommendations STARTTS

RHS

Update on the follow-up to the recommendations for STARTTS

1.Community Outreach

Four information sessions were conducted for Afghan community members – three in Campbelltown and one in Hornsby.

2. Liaison with DOCS

Due to the current crisis and a number of unattached refugee minors from Afghanistan who are on a Temporary Protection Visa (TPV), STARTTS initiated liaison with DOCS to discuss provision of training for their staff members.

3. Support with the newsletter

STARTTS Middle Eastern Counsellor is currently on the Advisory Committee of the Afghan Community Support Association of NSW, thus being available for the provision of consultancy regarding the newsletter. Additionally, STARTTS psychoeducational material “Sleeping Better” was published in the newsletter.

4. Housing issues

STARTTS is a member of the Non-English Speaking Background (NESB) Housing Taskforce. Consequently, we have made contacts with Housing service providers other than the NSW Housing. Consequently, we are in a position to facilitate links between these service providers and Afghan community at an appropriate time. Furthermore, an information session was held for the Campbelltown Department of Housing staff focusing on Afghan community issues.

5. Young Women’s Youth Program

STARTTS has employed a Young Women’s Youth Worker who is currently completing a report into the needs of refugee young people. She is also working on increasing access of Afghan young women to the STARTTS Youth Program as well as identifying projects supporting refugee young women specifically.

6. Inclusion of physical exercise in the Middle Eastern Group’s Program

A volunteer was identified to provide self-defence classes for the women’s group. We are currently in the process of locating the appropriate venue. Additionally, a six-session gentle exercise program was held for the men’s group.

7. Raising Afghan Community issues

Seminars/training sessions

• Human Rights and Refugees seminar at Sydney University – focusing on Afghanistan and the current situation
• Presentation for Australian Centre for Languages (ACL) teachers and counsellors – Bankstown, Fairfield
• Presentations for teachers at: North Parramatta Public School. Also planning sessions for Macarthur Girls High School, Macquarie Boys High School, Arthur Phillip High School, Intensive English Centre Blacktown, Intensive English Centre Bankstown, Auburn Girls High School, and Marsden High School.
• Preparing a presentation/paper for the NSW Centre for Refugee Studies Conference – Refugee Convention: Where to from here? The paper will provide an overview of the issues for Afghan community in Australia. Another paper looking at the psychosocial impact of the implementation of Temporary Protection Visas (TPV) will be presented.

Media Work

• Interview with Sydney Morning Herald
• Interview with SBS for the Program “Tales from a Suit Case”
• Writing an article on counselling for Afghan refugees
• Approached by the FOXTEL Women’s Program, “Brilliant Lives”

  STARTTS Magazine “Transitions” published a number of articles focusing on Afghan issues in the last year. The next issue will include 3 articles.

8.  Other activities relevant to the current crisis

STARTTS has met with School Counsellors from Blacktown, Parramatta/Holroyd, Chester Hill, Marsden and Cabramatta to discuss the impact of current crisis in Afghanistan on Afghan students. Consequently, STARTTS will be providing groupwork in a number of schools (Chester Hill Intensive English Centre and possibly Evans Intensive English Centre, Bankstown Intensive English Centre and Holroyd Intensive English Centre).

9. Immigration information sessions

An information session for Afghan TPV Holders was held and more than 50 people attended.

10.  Other activities

STARTTS Early Intervention Program (EIP) held a number of group sessions for Afghan TPV Holders. The sessions included information, support and psychoeducation. Additionally, in collaboration with Friends of STARTTS (FOS) volunteers, ongoing English language classes are being held in Auburn. Finally, in collaboration with Employment and Education service providers, we have facilitated implementation of forklift, computer and job-search courses.   

Transcript of the small group results

Elderly People’s Group

1. Counselling and psychotherapy (group and individual) are new concepts for Afghan community in general and for new arrivals in particular. There is a need for further community education about these concepts as well as about STARTTS services. Use of ethnic media, Afghan Saturday Schools, Afghan Mosques (mainly Fridays) was suggested.
2. Family tension and conflicts resulting from age/culture gap between generations. This is an issue of great concern for the community.
3. Psychological difficulties experienced by the community members include: depression, sleep disorders, nightmares, memory and concentration problems, phobias, high levels of anxiety, and various psychosomatic problems.
4. Most commonly experienced physical health difficulties include: chest pains, stomach acid and ulcers.
5. The main sources of stress were identified as: family separation, lack of extended family supports, loneliness, concern for family members in refugee camps and settlement issues.
6. There is a perception that Afghanistan’s political situation and humanitarian needs have been forgotten by Western world particularly since the end of the Cold War. Of a particular concern is the existence of 20 million land mines in the country.

Women’s Group 1

STARTTS Services

1. Concept of counselling as used in Australia is not familiar to many newly arrived Afghan refugees. A counsellor is usually someone who gives advice, a “psychological teacher”. Consequently, it was suggested that counselling should be modified to include increased advice giving and client advocacy.
2. Family tension and conflict as already mentioned above – suggestion for a radio program on the impact of migration on family dynamics.
3. It was suggested that RHS and STARTTS should hold yearly consultations with Afghan community.
4. STARTTS should continue it’s efforts on increasing the community’s trust.
5. STARTTS was asked to provide more English and sewing classes as well as further group interventions.
6. STARTTS was also asked to provide more information about its services to the community.

Other Health Services and health problems

1. Dental health is a significant problem for the community particularly taking into account long waiting lists for public services and high costs of private services. Westmead Dental Clinic was particularly mentioned as the community wanting to have an easier access to its services.
2. Waiting lists for surgery and waiting time at Emergency Departments were also considered problematic.
3. Physical health problems include: rheumatoid arthritis, cancer (particularly stomach), heart problems, high blood pressure and high cholesterol, muscle stiffness,
4. Psychological health: depression, isolation, stress, sleep disorders. Participants connected physical and psychological health: “If we feel happy there is no pain” 
5. Many community members believed that they were receiving inadequate treatment and complained of the lack of final diagnosis. Also, delays in test results were mentioned.

General Settlement Issues

1. Participants believed that Charity organisations lacked understanding of refugee issues and consequently did not offer a sufficient assistance.
2. Community lacking information about Australia’s Migration Program and where they can receive free migration advice. Family re-union issues are highly significant and community members require access to free migration advice. This issue is affecting community members’ mental health and is presenting them with heavy financial burdens.
3. Community divisions and fragmentation – preventing successful organising and united voice when it comes to advocating for own issues.
4. Community lacking information about settlement services in general.
5. Lack of affordable, long-term accommodation for newly arrived refugees. Long waiting lists for Public Housing.

Women’s Group 2

Concept of Counselling

1. There is stigma attached to it particularly for single females
2. Counselling is a problem solving process.
3. STARTTS counselling services are perceived as valuable but remain a new concept for the community.
4. Consequently there is a need for more information sessions explaining the concepts. The sessions should be conducted: after school hours, close to station, preferably in Parramatta, Auburn and/or Granville (Parramatta Town Hall suggested) as well as Campbelltown.

STARTTS Services

1. An interest in family-support groups was mentioned as well as the use of home visits as means for community outreach when advertising the groups.
2. Women-specific information sessions were requested.
3. In the context of age/culture gap, family conflict and youth services, the participants suggested that STARTTS should employ a female Youth Worker and conduct Girls-only programs.
4. Information sessions for young people were suggested covering STARTTS, health issues, and culture/generation gap.
5. Thoughts about STARTTS: valuable, humanitarian, beneficial, happy with the counsellor and Campbelltown Outreach, valuable information sessions, supportive.
6. STARTTS Outreach in the community should include: ethnic media, Mosques, and ACL.

Health Services

1. Need expressed for an increase in men-specific services, as the participants believed that men’s health was worse than women’s.

Settlement issues

1. Immigration – Afghan community needs support in lobbying Australian Government to increase intake of Afghan refugees particularly assisting people waiting in refugee camps in Iran and Pakistan. In Iran, they are not accepted as refugees and in Pakistan there are significant difficulties with Government corruption.
2. Women at risk in Pakistan have severe difficulties accessing UNHCR.

Men’s Group

1. An additional Afghan background Counsellor at STARTTS
2. STARTTS should give priority to the clients who have lost the heads of their families (widows and single mothers).
3. Many family members are missing and there is a great need in the community for an access to tracing services.
4. Request for STARTTS to lobby the Federal Government re: TPV issues particularly addressing the family re-union and travel outside Australia issues.
5. There is a need for a community newsletter with information from Afghanistan as well as settlement information.
6. Increased liaison with Afghan Community Support Association by both, STARTTS and RHS is required.
7. Lack of cultural sensitivity
8. Physical Health Problems: peptic ulcers, general body aches and pains, nutrition issues. There are also low levels of access to preventative health services as well as lack of physical exercise (many exercise options too expensive).
9. Psychological difficulties are primari and are widespread in the community.
10. Concern was expressed about financial difficulties many Afghan newly arrived refugees are experiencing.
11. Another concern was that Afghanistan and the conflict there have been forgotten by the Western World. It was suggested that STARTTS should lobby the Australian Government to take action in that regard.
12. Need for regular and more frequent consultation was expressed.