Which psychological characteristics influence therapists' readiness to work with refugees?

Self-efficacy and locus of control as transdiagnostic factors in Middle Eastern refugees

Background: Many refugees report high levels of psychopathology. As a countermeasure, some psychological interventions aim at targeting mental health difficulties in refugees transdiagnostically. However, there is a lack of knowledge about relevant transdiagnostic factors in refugee populations.Objective: To inform intervention efforts empirically, we investigated whether self-efficacy and locus of control are transdiagnostically associated with symptoms of depression, anxiety, somatisation, psychological distress, and a higher-order psychopathology factor ('p') in Middle Eastern refugees residing in Germany.Method: In total, 200 Middle Eastern refugees took part in this cross-sectional study, comprising 160 male and 40 female refugees. Participants were, on average, 25.56 years old (SD = 9.19), and 182 (91%) originally came from Syria, while remaining refugees were from Iraq or Afghanistan. They completed measures of depression, anxiety, somatisation, self-efficacy, and locus of control.Results: In multiple regression models adjusting for demographic factors (gender and age), self-efficacy and external locus of control were transdiagnostically related to depression, anxiety, somatic symptoms, psychological distress, and a higher-order psychopathology factor. Internal locus of control had no detectable effect in these models.Conclusions: Self-efficacy and external locus of control appear critical in the mental health of refugees and may be important mechanisms in overcoming posttraumatic stress and resettlement stressors. Our findings support the need to target self-efficacy and external locus of control as transdiagnostic factors of general psychopathology in Middle Eastern refugees.

Refugees and asylum seekers who have experienced trauma: Thematic synthesis of therapeutic boundary considerations

OBJECTIVE

Therapeutic boundaries are limits to appropriate behaviours within a therapist-client relationship (e.g. related to accepting gifts, self-disclosures, therapist neutrality and advocacy). Therapeutic boundary considerations are fundamental in the care of refugees and asylum seekers. Research on the experiences of therapists navigating such boundaries is sparse and warrants further exploration. The aim of this qualitative systematic review was to thematically synthesise literature regarding therapists' (psychologists, psychotherapists, counsellors) experiences of implementing flexible therapeutic boundaries with refugee and asylum seeker clients and determine how such applications have been helpful for therapeutic interventions.

METHOD

Six databases were searched. Following full-text screening, 21 papers were included in the analysis. Boundary theory underpinned the analysis.

RESULTS

Three major themes were developed: (i) Changes to Therapeutic Practice & Therapeutic Intervention, (ii) Re-Conceptualisation of Therapy as 'Clinical Political' and Re-Conceptualisation of Therapist Identity and (iii) Careful Monitoring of Personal Boundaries-Not becoming 'Hardened' or 'Haunted'. Papers described how, when used in a reflective, considerate way, flexible therapeutic boundaries can strengthen the therapist-client alliance and positively impact therapeutic interventions. Many therapists acknowledged making conscious efforts to re-conceptualise therapeutic work with refugee and asylum seeker clients from advocacy standpoints. However, systemic constraints, and lack of guidance, made this difficult to navigate and contributed to therapist burn-out.

CONCLUSIONS

Boundary considerations manifested as interpersonal, structural and cultural changes to practice. These have implications for clinical practice and developing guidelines on boundary practices with refugees and asylum seekers. Future research should explore promoting therapist well-being and training needs for therapists supporting this population.

The role of psychotherapists' perceived barriers in providing psychotherapy to refugee patients

Access to psychotherapy is critical to improving mental health, but only a small proportion of refugees receive treatment in the regular psychotherapeutic care system in high-income countries. In previous research, outpatient psychotherapists reported several barriers to more frequent treatment of refugee patients. However, it is unclear to what extent these perceived barriers contribute to the poor provision of services to refugees. In a survey of N = 2002 outpatient psychotherapists in Germany, we collected data on perceived treatment barriers and on the integration of refugees into regular psychotherapeutic practice. Half of the psychotherapists reported that they do not treat refugee patients. In addition, therapies provided for refugees were, on average, 20% shorter than for other patients. Regression analyses showed direct negative associations between psychotherapists' overall perception of barriers with the number of refugees treated and the number of sessions offered to refugee patients, even when controlling for sociodemographic and workload-related characteristics. Correlation analyses on the level of specific types of barriers further revealed that particularly language-related barriers and lack of contact with the refugee population are negatively correlated with the number of refugees treated and the number of sessions for refugees. Our findings indicate that the integration of refugees into regular psychotherapeutic care could be improved by measures to connect psychotherapists with refugee patients as well as professional interpreters and to ensure coverage of costs for therapy, interpreters and related administrative tasks.

"It is worth hanging in there" - Psychotherapeutic experiences shaping future motivation for outpatient psychotherapy with refugee clients in Germany

BACKGROUND

A high prevalence of mental disorders in refugees contrasts with a low rate of treatment and limited access to health care services. In addition to pre-, peri- and post-migration stress, language, cultural barriers together with lack of information about cost reimbursement, and access to German (mental) health care institutions are discussed as barriers to use of available services. Such barriers together with insufficient experience of treating traumatized refugee clients may lower therapists' motivation and facilities to accept refugee clients. A model project called "Fearless" trained, and supervised therapists, translators, and peer counsellors to reduce these barriers and increase therapists' motivation and engagement in future treatment of refugees.

METHODS

From a total 14 therapists participating in the project N = 13 were available for semi-structured interviews. The interviews were scheduled during or after their outpatient psychotherapy of refugee clients and lasted one hour on average. Based on qualitative assessment strategies, open questions addressed the therapists' experience of challenges, enrichments, and motivation throughout the therapy. Therapists' responses were analyzed using content structuring qualitative content analysis.

RESULTS

Three major challenges modulated therapists' future motivation for treating refugee clients: specific bureaucratic efforts (e.g., therapy application), organizational difficulties (e.g., scheduling appointments), and clients' motivation (e.g., adherence, reliability). Still, most interviewed therapists (n = 12) evaluated the therapy as enriching and expressed their motivation to accept refugee clients in the future (n = 10).

CONCLUSION

Results recommend the reduction of bureaucratic effort (e.g., regular health insurance cover for all refugees) and implementation of organizational support (e.g., peer counsellors) in support of therapists' motivation for future treatment of refugee clients. Further structural support e.g., with organizing and financing professional translators and referring refugee clients to psychotherapists should be deployed nationwide. We recommend the training in, and supervision of, the treatment of refugee clients as helpful additional modules in psychotherapy training curricula to raise therapists' motivation to work with refugee clients.

Call to action: Addressing sleep disturbances, a hallmark symptom of PTSD, for refugees, asylum seekers, and internally displaced persons

Sleep difficulty is a recognized hallmark symptom of post-traumatic stress disorder (PTSD) yet often remains an enduring and neglected problem post-treatment. Around 4.4%- 88.0% of refugees, asylum seekers, and internally displaced persons report PTSD, of which 39%- 99% report sleep difficulties. These percentages substantially exceed those of the general population. Yet there has been a lack of research examining evidence-based stand-alone and add-on treatments for PTSD and related sleep disturbances among this population. Barriers to treatment encountered by this population often vary by their legal status or location, but generally include lack of access due to insufficient evidence-based treatments or mental health practitioner shortages, lack of psychoeducation on mental health, cultural stigma, language barriers, situational instability, and racial bias. The refugee population has been on the rise over the past 10 years, and the United Nations estimated the recent Ukraine-Russia conflict would lead to an additional 12 million people needing humanitarian assistance inside Ukraine and more than 6.9 million refugees fleeing to neighboring countries in the coming months. Given that refugees, asylum seekers, and internally displaced persons repeatedly encounter barriers to mental health care specific to their predicament, interventions designed to accommodate their situation are imperative for improving their sleep and mental health. We therefore call for there to be more research on integrative programs incorporating evidence-based treatments that allow for scalability, adaptability, and rapid dissemination to maximize impact in this population. Further, we encourage trainings among clinicians and researchers to increase knowledge and confidence in working with this population.

Asylum seeking and refugee adolescents' mental health service use and help-seeking patterns: a mixed-methods study

Almost a third of all people who entered Germany to seek protection since 2010 were under the age of 18. Asylum-seeking and refugee (ASR) adolescents in Germany face reduced entitlements to healthcare and experience barriers in accessing mental healthcare, despite documented mental health needs. This mixed-methods study aims to describe the mental health needs and service use of ASR adolescents in Germany and identify the predictors of their help-seeking patterns. Here we report findings of cross-sectional data collected between February 2019 and November 2020 in schools and refugee accommodations in three German federal states. Our subsample consists of ASR between the ages of 11 and 18, coming from Syria, Afghanistan, and Iraq (N = 216). Cross-sectional data are supplemented by semi-structured interviews with nine mental health professionals in one region of the study. Our findings reveal an underutilization of mental health services relative to the emotional difficulties reported. Perceived and experienced access barriers, age, and externalizing and internalizing symptoms predict different help-seeking patterns. Psychotherapy-related social resources, as well as reporting of emotional difficulties, are predictors of actual or intended psychotherapeutic service utilization. Based on our quantitative and qualitative findings, we highlight the need for widespread, accessible, and low-threshold mental health initiatives designed to work with ASR adolescents, for additional assistance in navigating the mental healthcare system, as well as for support to important people in ASR adolescents' lives who fill the gap between mental health needs and accessible mental healthcare services.

Assessing Somatic Symptoms With the Patient Health Questionnaire (PHQ-15) in Syrian Refugees

Somatic symptoms are common among Syrian refugees. To quantify somatic symptom load, sum score models derived from the Patient Health Questionnaire (PHQ-15) have been frequently applied without psychometric justification. Across two studies (total N = 776), we (a) tested different PHQ-15 factor solutions in Syrian refugees, (b) investigated measurement invariance (MI) of the factor solutions compared with German residents, and (c) scrutinized whether sum score models adequately represent the data and differ in associations with external validators compared with factor scores. One-factor, three-factor, four-factor, and a reduced one-factor solution all displayed acceptable to good model fit. The four-factor solution showed the best fit, enabling differential symptom analyses. Sum score models often had poor model fit, necessitating independent investigations before applying them. For all factor solutions, (partial) strict MI between residents and refugees could be established. All scoring methods displayed high and comparable associations with functional impairment, depressive, and anxiety symptoms.

Refugees at Work: The Preventative Role of Psychosocial Safety Climate against Workplace Harassment, Discrimination and Psychological Distress

It is widely recognised that employment is vital in assisting young refugees’ integration into a new society. Drawing on psychosocial safety climate (PSC) theory, this research investigated the effect of organisational climate on young refugee workers’ mental health (psychological distress) through stressful social relational aspects of work (e.g., harassment, discrimination). Drawing on data from 635 young refugees aged between 15 and 26 in South Australia, 116 refugees with paid work were compared with 519 refugee students without work, and a sample of young workers from Australian Workplace Barometer (AWB) data (n = 290). The results indicated that refugees with paid work had significantly lower psychological distress compared with refugees with no paid work, but more distress than other young Australian workers. With respect to workplace harassment and abuse, young refugee workers reported significantly more harassment due to their ongoing interaction and engagement with mainstream Australian workers compared with unemployed refugees. Harassment played a vital role in affecting psychological health in refugees (particularly) and other young workers. While refugee youth experienced harassment at work, overall, their experiences suggest that their younger age upon arrival enabled them to seek and find positive employment outcomes. Although PSC did not differ significantly between the employed groups, we found that it likely negatively influenced psychological distress through the mediating effects of harassment and abuse. Hence, fostering pathways to successful employment and creating safe work based on high PSC and less harassment are strongly recommended to improve refugees’ mental health and adaptation.

Psychological distress in refugees: The role of traumatic events, resilience, social support, and support by religious faith

Many refugees have been exposed to potentially traumatic events and report elevated levels of psychological distress. However, refugees vary greatly in the severity of mental health problems. Intra- and interpersonal factors help some refugees to cope effectively. To shed light on these factors, we scrutinized how potentially traumatic events, resilience, social support, and support by religious faith are associated with psychological distress in refugees in Germany and German residents. We assessed data from 205 German residents and 205 refugees (total N = 410). Questionnaires assessing psychological distress, potentially traumatic events, resilience, social support, and perceived support by religious faith were disseminated online in Arabic and German. Refugees reported higher levels of psychological distress, more exposure to potentially traumatic events, less social support, less resilience, and more perceived support from their faith than German residents. Using a pathway model, lower social support and resilience partially accounted for group differences of higher psychological distress in refugees. This study points to the importance of social support and individual resilience in explaining mental health discrepancies between refugees and residents. This, in turn, may inform future intervention studies to reduce elevated levels of psychological distress experienced by refugees.

Helping in the context of refugee immigration

We review psychological approaches of helping behavior in the context of refugee immigration. Refugee migration, compared with nonrefugee migration, is characterized by greater forcedness and related perils. Taking into account perceptions of forcedness and perils, we examine potential helpers' responses at each of four successive stages toward helping people in perilous, distressing, or emergency situations: (1) noticing and recognizing distressing, help-demanding conditions; (2) taking responsibility; (3) knowing how to help; and (4) transfer of one's knowledge into action. In so doing, we discuss the role of different motives and functions of providing help (e.g. preserving refugees' dependency or facilitating their autonomy) and implications of unequal power relations between help providers and refugees.

A network meta-analysis of psychosocial interventions for refugees and asylum seekers with PTSD

INTRODUCTION

Refugees and asylum seekers are vulnerable to common mental disorders, including post-traumatic stress disorder (PTSD). Using a network meta-analysis (NMA) approach, the present systematic review compared and ranked psychosocial interventions for the treatment of PTSD in adult refugees and asylum seekers.

METHODS

Randomised studies of psychosocial interventions for adult refugees and asylum seekers with PTSD were systematically identified. PTSD symptoms at postintervention was the primary outcome. Standardised mean differences (SMDs) and ORs were pooled using pairwise and NMA. Study quality was assessed with the Cochrane Risk of Bias (RoB) tool, and certainty of evidence was assessed through the Confidence in Network Meta-Analysis application.

RESULTS

A total of 23 studies with 2308 participants were included. Sixteen studies were conducted in high-income countries, and seven in low-income or middle-income countries. Most studies were at low risk of bias according to the Cochrane RoB tool. NMA on PTSD symptoms showed that cognitive behavioural therapy (CBT) (SMD=-1.41; 95% CI -2.43 to -0.38) and eye movement desensitisation and reprocessing (EMDR) (SMD=-1.30; 95% CI -2.40 to -0.20) were significantly more effective than waitlist (WL). CBT was also associated with a higher decrease in PTSD symptoms than treatment as usual (TAU) (SMD -1.51; 95% CI -2.67 to -0.36). For all other interventions, the difference with WL and TAU was not significant. CBT and EMDR ranked best according to the mean surface under the cumulative ranking. Regarding acceptability, no intervention had less dropouts than inactive interventions.

CONCLUSION

CBT and EMDR appeared to have the greatest effects in reducing PTSD symptoms in asylum seekers and refugees. This evidence should be considered in guidelines and implementation packages to facilitate dissemination and uptake in refugee settings.