Cognitive behavioral therapy for symptoms of trauma and traumatic grief in refugee youth

A community-based study of the impact of trauma exposure on school-aged children's self-concept and improvements following TF-CBT

BACKGROUND

Experiencing trauma in childhood has been associated with more severe psychopathology and a greater risk of engaging in harmful behavior later in life. Traumatic exposure can also erode a child's self-concept. Negative self-concept has been associated with shame, self-doubt, and helplessness in the face of adverse experiences. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is an evidence-based model for children; however, research on its effectiveness in improving children's self-concept is limited.

OBJECTIVE

To investigate the impact of trauma on school-aged children's self-concept and improvements following TF-CBT.

PARTICIPANTS AND SETTING

A demographically diverse sample of trauma-exposed school-aged children referred to community-based agencies in Canada and a normative sample of school-aged children randomly selected from the general population in the United States.

METHOD

A longitudinal design was used to assess trauma-exposed children's self-reported self-concept using the short-form Tennessee Self-Concept Scale - Second Edition (TSCS:2; Fitts & Warren, 1996) prior to and following TF-CBT.

RESULTS

Trauma-exposed children had a significantly more negative mean self-concept compared to that of the normative sample. Improvements following TF-CBT - and not the passage of time alone - were found with gains maintained six months post-therapy.

CONCLUSIONS

School-aged children awaiting treatment at community-based agencies are likely to hold clinically concerning negative views of themselves. TF-CBT was effective in significantly improving their self-concept with continued and lasting improvements observed after the therapy had been completed.

Cultural Considerations and Response to Trauma for Displaced Children at the Border

The United States has long been the leading destination for Latin Americans seeking refuge. However, in the last 7 years, many children from Mexico and northern Central America, composed of El Salvador, Honduras, and Guatemala, have joined this migratory flow. The experience of forced migration is intense, chronic, and complex for children in their home countries, during their journey, and on arrival in the United States. Their stories can inform clinical practices, such as Psychological First Aid and Trauma-Focused Cognitive Behavioral Therapy, to promote resilience in children in vulnerable conditions.

Is Trauma Focused-Cognitive Behavioral Therapy (TF-CBT) Effective in Reducing Trauma Symptoms among Traumatized Refugee Children? A Systematic Review

In 2019, more than 25.9 million children under 18 were displaced due to unending political conflicts. Trauma Focused-Cognitive Behavioral Therapy (TF-CBT) has a high level of empirical evidence to support its efficacy in processing trauma and behavioral problems in non-refugee children. Yet, little is known about its long-term effectiveness in refugee children. This study conducted a systematic review that assessed the evidence of the effectiveness of TF-CBT in reducing trauma symptoms among refugee children under 18 years of age. A systematic review was conducted from peer-reviewed literature databases (12 databases): PsycINFO, PubMed, Scopus, Google Scholar, ProQuest Dissertations and Theses (PQDT), Cochrane Library, MEDLINE, PROSPERO, EBSCOHost, Campbell Collaboration Library of Systematic Reviews, Social Sciences Index, and grey literature sources published from 1990 to 2019. The search yielded 1650 articles, and 4 peer reviewed studies were identified that met inclusion criteria and yielded a sample size of 64 refugee children from 21 different countries. All 4 studies provided evidence that supported TF-CBT's effectiveness in decreasing trauma symptoms and sustainment during the follow-up assessment among refugee children participants. Despite TF-CBT effectiveness for trauma symptoms treatment, there is still limited evidence to suggest that TF-CBT is effective for all refugee children due to the pilot nature of the studies, and its underutilization in traumatized refugee children from different cultural backgrounds. Future studies should conduct more TF-CBT interventions with diverse refugee children to provide more empirical support for its effectiveness with that population.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40653-021-00370-0.

Defining a combined constellation of complicated bereavement and PTSD and the psychosocial correlates associated with the pattern amongst refugees from West Papua

BACKGROUND

Refugees are at risk of experiencing a combined constellation of complicated bereavement and posttraumatic stress disorder (PTSD) symptoms following exposure to complex traumas associated with personal threat and loss. Features of identity confusion are central to both complicated bereavement and PTSD and these characteristics may be particularly prominent amongst refugees from traditional cultures displaced from their homelands, families, and kinship groups. We investigate whether a combined pattern of complicated bereavement and PTSD can be identified amongst West Papuan refugees participating in an epidemiological survey (n = 486, response rate: 85.8%) in a remote town in Papua New Guinea.

METHODS

Latent class analysis was applied to derive subpopulations of refugees based on symptoms of complicated bereavement and PTSD. Associations were examined between classes and traumatic loss events, post-migration living difficulties (PMLDs), and psychosocial support systems.

RESULTS

The four classes identified comprised a complicated bereavement class (11%), a combined posttraumatic bereavement class (10%), a PTSD class (11%), and a low symptom class (67%). Symptoms of identity confusion were prominent in the posttraumatic bereavement class. Compared with the low symptom class, the combined posttraumatic bereavement class reported greater exposure to traumatic loss events (OR 2.43, 95% CI 1.11-5.34), PMLDs (OR 2.24, 95% CI 1.01-4.6), disruptions to interpersonal bonds and networks (OR 3.3, 95% CI 1.47-7.38), and erosion of roles and identities (OR 2.18, 95% CI 1.11-4.27).

CONCLUSIONS

Refugees appear to manifest a combined pattern of complicated bereavement and PTSD symptoms in which identity confusion is a prominent feature. This response appears to reflect the combined impact of high levels of exposure to traumatic losses, PMLDs, and disruption of relevant psychosocial systems.

The structure and psychosocial correlates of complicated bereavement amongst refugees from West Papua

PURPOSE

Refugees may be at risk of experiencing a complicated form of bereavement. As yet, however, the nosological status of this putative category across cultures remains in question. We apply qualitative and quantitative methods to investigate the manifestations, prevalence, factorial structure and psychosocial correlates of complicated bereavement amongst refugees from West Papua, a population with no past exposure to western concepts of grief or to formal mental health services.

METHODS

Qualitative methods (focus groups and informant interviews) were used to identify cultural expressions of complicated bereavement derived from international classification systems, that is, DSM 5 persistent complex bereavement disorder (PCBD) and ICD-11 prolonged grief disorder (PGD) in developing a structured interview applied by trained field workers. Participants were adult West Papuan refugees and their offspring recruited from households (n = 486, response 85.8%) across nine villages in a remote town in Papua New Guinea.

RESULTS

The qualitative data obtained from focus groups (n = 20) and informant interviews (n = 4) with local psychiatrists supported the cultural validity of complicated bereavement. 16% (n = 78) of the sample met criteria for PCBD based on DSM-5 criteria and 103 (21%) met criteria for PGD based on ICD-11 criteria. Confirmatory factor analysis yielded a six-factor model of complicated bereavement with a moderately good fit to the data. The model included dimensions of anger/negative appraisal (AN), avoidance/giving up, estrangement from others, and confusion and diminished identity. In contrast, the DSM-5 three-factor model and the ICD-11 two-factor model each yielded a poor fit. Cumulative traumatic losses (β = 0.16, P = 0.03), duration since displacement [(β = 0.10, P = 0.02)] and postmigration living difficulties (β = 0.20, P = 0.01) were associated with an aggregated index of complicated bereavement, supporting the concurrent validity of the structure identified.

CONCLUSIONS

Culture and exposure to persecution and displacement may contribute to the content and configuration of the complicated bereavement reaction, an issue that requires recognition in international classification systems and clinical practice.

Working with unaccompanied asylum-seeking young people: cultural considerations and acceptability of a cognitive behavioural group approach

This paper outlines a psychological skills group for unaccompanied asylum-seeking young people with a focus on cultural adaptations in the context of a UK mental health service. Unaccompanied asylum-seeking young people have typically experienced multiple losses, traumatic experiences, significant disruption and psychosocial stressors. These experiences occur during a key developmental period and outside of the context of a supportive family environment. Mental health difficulties are estimated to be present in 41–69% of this population. Prevalence rates are higher than among children seeking asylum with their families or children who are not from refugee or asylum-seeking backgrounds. Cognitive behavioural approaches were considered to be applicable and useful when working with this client group. Group approaches may offer unique benefits for this population through peer support and normalization. The group described was planned around three key themes: physical health needs, emotional wellbeing and resilience-building. A number of adaptations were made to meet the needs of this population which included engagement, considering physical health needs, sleep, language needs, issues related to power, race and status, and thinking about the needs of the group as young people. Attendance ratings, session rating scale outcomes, preliminary effectiveness data and qualitative feedback from young people identified that this is an acceptable approach for these young people. Unaccompanied asylum-seeking young people require a broad package of care; however, making adaptations to routine practice allowed access to evidence-based interventions to support mental health and wellbeing.

Trauma Without Borders: The Necessity for School-Based Interventions in Treating Unaccompanied Refugee Minors

This article explores migration trauma among Mexican and Central American unaccompanied refugee minors (URM) with the purpose of developing an understanding of migration as a tripartite process consisting of: pre-migration exposure to traumatic stressors, in-journey stressors, and post-migration stressors. The migration experience of these youth may be subjectively different depending on a wide range of factors. The complexities of migration are explored as a traumatic, tripartite process. These three salient components of migration may act as precursors, often resulting in psychological sequelae such as: post-traumatic stress disorder (PTSD), anxiety, and depression. Of all migrant groups, URM are more likely to develop psychiatric symptoms. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), Cognitive Behavioral Intervention for Trauma in Schools (CBITS), and Mental Health for Immigrants Program (MHIP) are among the most effective interventions in the treatment of PTSD, anxiety, and depression in refugee minors. Social workers in schools are in unique positions to provide mental health services to URM. A case example illustrating a cultural adaptation of TF-CBT in an urban public high school is included. Clinical implications of culturally responsive and trauma-informed treatment of URM in schools will be discussed. Additionally, this article will emphasize the importance of bridging the gap between research and culturally responsive, trauma-informed interventions for URM in schools.

Ghosts, tigers and landmines in the nursery: Attachment narratives of loss in Tamil refugee children with dead or missing fathers

OBJECTIVE

To build an account of how bereaved Tamil refugee and asylum seeker children, resettled in Australia, had processed the loss of their dead or missing fathers.

METHOD

Phenomenological and discourse analysis was applied to attachment narratives of nine children (aged 11-17 years) and their surviving mothers in families that lost fathers in war-related circumstances. The narratives were analysed through the lens of Crittenden's Dynamic-Maturational Model of Attachment and Adaptation (DMM) and Klass' cross-cultural model of grief.

RESULTS

Two divergent pathways - 'burying the past' and 'reifying the past' - emerged, encompassing the children's contrasting patterns of information processing regarding loss and trauma (dismissing or preoccupying) and representation of the past (distant-buried or rich-reconstructed). Each pathway reflected a strategic compromise between the constraints and resources presented to the child by the circumstances of the loss (ambiguous or confirmed), the response of their surviving parent (stricken or stoic) and the collective narrative surrounding the loss (silenced or valorised).

CONCLUSION

The DMM's conceptualisation of attachment as self-protective strategies for navigating danger was helpful in explaining the contrasting adaptations of refugee children to loss and trauma. However, to understand the multivalent meanings of these adaptations, there was a need to situate child-parent attachment relationships within the wider sociocultural reconfigurations arising from contexts of political violence.

Stories of trauma in family therapy with refugees: Supporting safe relational spaces of narration and silence

With the sharp increase of refugees' arrival and resettlement in western communities, adequate mental health care forms a pivotal dimension in host societies' responses to those individuals and communities seeking protection within their borders. Here, clinical literature shows a growing interest in the development of family therapy approaches with refugees, in which therapeutic practice engages with the pivotal role of refugee family dynamics in posttrauma reconstruction and adaptation in resettlement and aims at supporting posttrauma reconstruction through strengthening capacities to restore safety, meaning and connectedness within family relationships. In this article, we focus on the narrative restoration of meaning as central mode of posttrauma reparation and explore its specific dynamics and relational complexities in the context of therapeutic practice with refugee families. Hereto, we integrate theoretical and clinical scholarly work on trauma narration and its intersection with empirical findings on trauma communication in refugee families. Furthermore, we develop case reflections to illustrate different processes of engaging with trauma narration in refugee family therapy. This analysis develops an understanding of the multivoiced ways in which refugee families engage with traumatic suffering through different modes of expression that may entail both narration and silence and explores how family therapeutic practices can engage and mobilize voices of narration and silence as relational stories of restoration.

The role of grief symptoms and a sense of injustice in the pathways to post-traumatic stress symptoms in post-conflict Timor-Leste

AIMS

Grief symptoms and a sense of injustice may be interrelated responses amongst persons exposed to mass conflict and both reactions may contribute to post-traumatic stress disorder (PTSD) symptoms. As yet, however, there is a dearth of data examining these relationships. Our study examined the contributions of grief and a sense of injustice to a model of PTSD symptoms that included the established determinants of trauma events, ongoing adversity and severe psychological distress. The study involved a large population sample (n = 2964, response rate: 82.4%) surveyed in post-conflict Timor-Leste.

METHODS

The survey sites included an urban administrative area (suco) in Dili, the capital of Timor-Leste and a rural village located an hour's drive away. Culturally adapted measures were applied to assess conflict related traumatic events (TEs), ongoing adversity, persisting preoccupations with injustice, symptoms of grief, psychological distress (including depressive symptoms) and PTSD symptoms.

RESULTS

We tested a series of structural equation models, the final comprehensive model, which included indices of grief symptoms and injustice, producing a good fit. Locating grief symptoms as the endpoint of the model produced a non-converging model. In the final model, strong associations were evident between grief and injustice (β = 0.34, s.e. = 0.02, p < 0.01) and grief and PTSD symptoms (β = 0.14, s.e. = 0.02, p < 0.01). The sense of injustice exerted a considerable effect on PTSD symptoms (β = 0.13, s.e. = 0.03, p < 0.01). In addition, multiple indirect paths were evident, most involving grief and a sense of injustice, attesting to the complex inter-relationship of these factors in contributing to PTSD symptoms.

CONCLUSIONS

Our findings support an expanded model of PTSD symptoms relevant to post-conflict populations, in which grief symptoms and a sense of injustice play pivotal roles. The model supports the importance of a focus on loss, grief and a sense of injustice in conducting trauma-focused psychotherapies for PTSD amongst populations exposed to mass conflict and violence. Further research is needed to identify the precise mechanisms whereby grief symptoms and the sense of injustice impact on PTSD symptoms.

Factorial structure of complicated grief: associations with loss-related traumatic events and psychosocial impacts of mass conflict amongst West Papuan refugees

INTRODUCTION

Definitions of complicated grief vary across diagnostic systems, being represented as persistent complex bereavement (PCB) in DSM-5 and prolonged grief disorder (PGD) in the proposed revision of the ICD system. A past study in a high-income country has identified a six-factor structure for complicated grief, but there are no data testing this or any other model across cultures. The present study reports findings from a survey amongst West Papuan refugees (n = 230, response rate = 92 %) residing in Port Moresby, Papua New Guinea.

MATERIALS AND METHODS

We applied culturally adapted measures of conflict-related traumatic event (TEs) (drawing specifically on domains of conflict and loss), symptoms of complicated grief adapted and modified to the culture, and a multidimensional psychosocial index of the broader effects of conflict and displacement.

RESULTS

Confirmatory factor analysis yielded a single higher order construct of complicated grief comprising six factors of yearning/preoccupation; shock/disbelief; anger/negative appraisal; behavioural change; estrangement from others/impairment; and a novel dimension of confusion/diminished identity. In contrast, our analysis failed to support DSM or ICD models of PCB or PGD. A Multiple Indicators Multiple Causes (MIMIC) model revealed that traumatic loss and the sense of injustice each were associated with the unitary construct of complicated grief and its subdomains of yearning/preoccupation; shock/disbelief; anger/negative appraisal (exclusive to injustice); and estrangement from others/social impairment (exclusive to TE domain of conflict and loss).

CONCLUSIONS

Conflict and loss associated with feelings of injustice may be especially pathogenic in generating the anger/negative appraisal component of complicated grief amongst refugees.

Case report: manualized trauma-focused cognitive behavioral therapy with an unaccompanied refugee minor girl

BACKGROUND

There is uncertainty whether young traumatized refugees should be treated with culturally adapted psychotherapy or with an evidence-based western approach. As yet, empirical studies on culturally adapted treatments for unaccompanied young refugees in industrialized host countries are not available. Studies do, however, suggest that trauma-focused treatment is promising for this group.

OBJECTIVE

We describe the treatment of an unaccompanied refugee minor girl with posttraumatic stress disorder (PTSD) who underwent manualized trauma-focused cognitive behavioral therapy (TF-CBT; Cohen, Mannarino, & Deblinger, 2006).

METHODS

A 17-year-old girl from East Africa, who came to Germany without a caregiver, was treated for PTSD resulting from several traumatic experiences and losses in her home country and while fleeing. She lived in a group home for adolescents. Baseline, post, and follow-up data are reported.

RESULTS

The girl participated in 12 sessions of manualized TF-CBT. Her caregiver from the youth services received another 12 sessions in line with the treatment manual. Symptoms decreased in a clinically significant manner; at the end of the treatment, the girl was deemed to have recovered from PTSD. Treatment success remained stable over 6 months.

CONCLUSIONS

Manualized TF-CBT is feasible for young refugees without significant cultural adaptations. It can, however, be seen as culturally sensitive.

Effectiveness of Trauma-Focused Cognitive Behavioral Therapy in a community-based program

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is a widely used treatment model for trauma-exposed children and adolescents (Cohen, Mannarino, & Deblinger, 2006). The Healthy Coping Program (HCP) was a multi-site community based intervention carried out in a diverse Canadian city. A randomized, waitlist-control design was used to evaluate the effectiveness of TF-CBT with trauma-exposed school-aged children (Muller & DiPaolo, 2008). A total of 113 children referred for clinical services and their caregivers completed the Trauma Symptom Checklist for Children (Briere, 1996) and the Trauma Symptom Checklist for Young Children (Briere, 2005). Data were collected pre-waitlist, pre-assessment, pre-therapy, post-therapy, and six months after the completion of TF-CBT. The passage of time alone in the absence of clinical services was ineffective in reducing children's posttraumatic symptoms. In contrast, children and caregivers reported significant reductions in children's posttraumatic stress (PTS) following assessment and treatment. The reduction in PTS was maintained at six month follow-up. Findings of the current study support the use of the TF-CBT model in community-based settings in a diverse metropolis. Clinical implications are discussed.

Trauma-focused cognitive behavioral therapy with unaccompanied refugee minors: a case series

BACKGROUND

Unaccompanied refugee minors (URMs) are a group who are vulnerable to developing posttraumatic stress symptoms (PTSS). However, they rarely receive the treatment that is indicated and there are no treatment studies focusing exclusively on this group of adolescents. This case study evaluates the feasibility of trauma-focused cognitive behavioral therapy (TF-CBT) for URMs with PTSS.

METHOD

A health care utilization sample of N = 6 was assessed prior to and after treatment with TF-CBT. Therapists were asked to report differences in treatment application and content in comparison to TF-CBT standard protocol.

RESULTS

We found moderate to high levels of PTSS at baseline and a clinically significant decrease in symptoms at posttest. Some modifications to the TF-CBT protocol were made with regard to affective modulation which required more sessions than usual whereas fewer caregiver sessions were conducted.

CONCLUSION

TF-CBT is feasible in reducing PTSS in severely traumatized URMs. Further research with controlled trials is necessary.

TRIAL REGISTRATION

The trial registration: ClinicalTrials.gov Identifier NCT01516827. Registered 13 December 2011.

Current, Continuous, and Cumulative Trauma-Focused Cognitive Behavior Therapy: A New Model for Trauma Counseling

The current dominant focus on treating single past traumas rarely addresses current, ongoing, or continuous interpersonal, intergroup, and systemic traumas or their cumulative and proliferation dynamics. The goal of this paper is to close this gap by introducing an alternative model that addresses these trauma types. The model incorporates eight precognitive, cognitive, behavioral, and social interventions. The behavioral interventions are (1) prioritizing safety and (2) addressing threats through behavior skills training inclusive of regulating personal and group-based emotions. The precognitive components are (3) stimulating the will to live and positive dispositional qualities and (4) identity work. The cognitive components are (5) psychoeducation, (6) stress inoculation, and (7) trauma narration. The social intervention is (8) advocacy, social justice and reconnecting to social networks. We discuss the evidence for each component and provide a case example to illustrate the model's utility. We also discuss future directions for research and model development.

Refugee children: mental health and effective interventions

The mental health consequences of war and other forms of organized violence for children represent a serious global public health issue. Much of the research on the mental health of war-affected civilians has focused on refugees who have sought asylum in high-income countries and face the dual stress of a traumatic past and resettlement. This review will focus on the mental health of refugee children who have fled war as well as interventions to both prevent and treat adverse mental health outcomes. While war can have devastating mental health consequences, children raised in the midst of armed conflict also display resilience. Effective interventions for refugee children will be discussed both in terms of prevention and treatment of psychopathology, with a focus on recent developments in the field.

Complicated grief therapy as a new treatment approach

Complicated grief therapy (CGT) is a relatively new psychotherapy model designed to address symptoms of complicated grief. Drawn from attachment theory and with roots in both interpersonal therapy (IPT) and cognitive-behavioral therapy, CGT includes techniques similar to prolonged exposure (repeatedly telling the story of the death and in vivo exposure activities). The treatment also involves focusing on personal goals and relationships. CGT has been demonstrated to be effective in a trial in which participants with complicated grief were randomly assigned to CGT or IPT; individuals receiving CGT responded more quickly and were more likely to respond overall (51% vs 28%). This article briefly summarizes the conceptual underpinnings of CGT, discusses the empirical evidence for its efficacy, describes its techniques, and presents a case example of a client treated in a 16-session manualized CGT protocol. The article concludes with a description of future research directions for CGT.

Voices of dialogue and directivity in family therapy with refugees: evolving ideas about dialogical refugee care

In this article, we reflect on our evolving ideas regarding a dialogical approach to refugee care. Broadening the predominant phased trauma care model and its engaging of directive expertise in symptom reduction, meaning making, and rebuilding connectedness, these developing dialogical notions involve the negotiation of silencing and disclosure, meaning and absurdity, hope and hopelessness in a therapeutic dialogue that accepts its encounter of cultural and social difference. In locating therapeutic practice within these divergent approaches, we argue an orientation on collaborative dialogue may operate together with notions from the phased trauma care model as heuristic background in engaging a polyphonic understanding of coping with individual and family sequelae of forced displacement. This locating of therapeutic practice, as informed by each perspective, invites us to remain present to fragments of therapeutic positioning that resonate power imbalance or appropriation in a therapeutic encounter imbued with a social context that silences refugees' suffering. In a clinical case analysis, we further explore these relational complexities of negotiating directive expertise and collaborative dialogue in the therapeutic encounter with refugee clients.

Trauma-focused CBT for youth with complex trauma

OBJECTIVES

Many youth develop complex trauma, which includes regulation problems in the domains of affect, attachment, behavior, biology, cognition, and perception. Therapists often request strategies for using evidence-based treatments (EBTs) for this population. This article describes practical strategies for applying Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) for youth with complex trauma.

METHODS

TF-CBT treatment phases are described and modifications of timing, proportionality and application are described for youth with complex trauma. Practical applications include (a) dedicating proportionally more of the model to the TF-CBT coping skills phase; (b) implementing the TF-CBT Safety component early and often as needed throughout treatment; (c) titrating gradual exposure more slowly as needed by individual youth; (d) incorporating unifying trauma themes throughout treatment; and (e) when indicated, extending the TF-CBT treatment consolidation and closure phase to include traumatic grief components and to generalize ongoing safety and trust.

RESULTS

Recent data from youth with complex trauma support the use of the above TF-CBT strategies to successfully treat these youth.

CONCLUSION

The above practical strategies can be incorporated into TF-CBT to effectively treat youth with complex trauma.

PRACTICE IMPLICATIONS

Practical strategies include providing a longer coping skills phase which incorporates safety and appropriate gradual exposure; including relevant unifying themes; and allowing for an adequate treatment closure phase to enhance ongoing trust and safety. Through these strategies therapists can successfully apply TF-CBT for youth with complex trauma.