Attachment style and interpersonal trauma in refugees

Cluster analysis of prolonged grief, posttraumatic stress, and depression symptoms in bereaved asylum seekers and refugees

Background: Refugees and asylum seekers (ASRs) are frequently exposed to loss in addition to a variety of other stressors and often display high levels of various psychological symptoms.Objective: The study aimed to primarily determine clusters of prolonged grief disorder (PGD), posttraumatic stress disorder (PTSD), and depression symptoms in bereaved ASRs and secondly identify predictors of cluster membership. Sociodemographic  - and flight-related variables were investigated in exploratory analyses.Method: ASRs in Germany (N = 92) with interpersonal loss exposure, i.e. at least one missing or deceased relative or friend, were assessed with interview-based questionnaires for PGD, PTSD, and depressive symptoms. We used k-means cluster analysis to distinguish symptom profiles and logistic regression analyses to identify predictors of cluster membership.Results: We found a three-cluster-solution. The PGD-cluster (30%) was characterised predominantly by PGD symptoms, while the PGD/PTSD-cluster (32%) had high PGD and PTSD and moderate depressive symptoms. The resilient cluster (38%) showed low symptoms overall. insecure residence status predicted membership in the PGD and PGD/PTSD clusters relative to the resilient cluster, whilst higher attachment anxiety predicted membership in the PGD/PTSD cluster relative to the other clusters. Explorative analysis revealed duration of stay as a significant predictor.Conclusion: Findings can extend the current knowledge about different symptom profiles among bereaved ASRs in Europe. Insights to attachment  - and migration-related variables distinguishing between these profiles offer starting points for interventions.

A Scoping Review of Instruments Used in Measuring Social Support among Refugees in Resettlement

This study aimed to systematically review current research on the application of existing social support scales in research with refugees in resettlement, assess their quality, and identify gaps in measurement to enhance research and practice. A scoping review was conducted on the extant literature published until March 2023. A team of researchers conducted search, sorting, and data extraction processes following best practices for scale development and validation. Of the 1185 studies collected from the search process, 41 articles were retained in the final analysis, from which 17 distinct social support instruments used in research with resettled refugees were identified. An assessment of all 17 instruments showed the presence of one or more limitations associated with construct, criterion, convergent, and/or discriminant validity. Test of reliability was assessed in all studies, with a range of 0.80 to 0.90. Our findings show that most of the research evaluating social support among resettled refugees is conducted without measurement instruments adequately validated in the resettlement context. This analysis highlights the need for rigorously developed social support scales that reflect the lived experiences, needs, and priorities of resettled refugees.

A balancing act: how interpreters affect the therapeutic alliance in psychotherapy with trauma-affected refugees-a qualitative study with therapists

Objective

The therapeutic alliance (TA) has the highest predictive value concerning the success of psychotherapy. The presented study aimed to explore how the presence of an interpreter affects the TA when working with trauma-affected refugees.

Method

Semi-structured interviews were conducted with seven psychologists working in an outpatient clinic specialized in mental health care for migrant and refugee patients with trauma-related mental health problems in Denmark. Interviews were transcribed verbatim and analyzed using a structuring content analysis approach.

Results

TA has been described as a dynamic therapist-interpreter-patient alliance triangle consisting of three distinct but highly intertwined and mutually influential dyadic alliances. Specific factors affecting the quality of the TA were identified, e.g., interpreter being emotionally attuned yet not overly involved; interpreter being barely visible yet present as a human being. Characteristics of trauma-affected refugee patients affecting the TA formation were also identified, e.g., a high level of personal distrust, different understandings of mental disorders and psychotherapy, stigmatization, perceptions of authorities.

Conclusion

The presence of interpreters was perceived ambivalently and the formation of a good TA seems to be a balancing act. Based on the findings, recommendations for forming and maintaining a good TA in interpreter-mediated psychotherapy are provided.

Ambiguous loss of home: Syrian refugees and the process of losing and remaking home

This constructivist-interpretive study examines social-relational dimensions of change and loss following experiences of political terror, war and forced migration from the perspective of Syrian refugee men and women who were presently living in Jordan (n=31). A process model derived from the analysis theorizes four dimensions of ambiguous loss (safety and security, social connections and identities, connection to place, and dreams and imagined future) and to capture the cyclical process of losing and remaking a sense of home in displacement. Our findings underscore a more complex set of processes that remain outside the array of supports and services provided by many current practices and policies with displaced populations generally, and Syrian refugees specifically. Thus, the findings highlight the need for ecological, integrative policies, interventions and services that support refugees' attempts to remake the multifaceted and stable phenomenon that is home as they transition into new communities.

Knowledge of legal rights as a factor of refugee and asylum seekers' health status: a qualitative study

OBJECTIVES

To examine health behaviours of refugees and asylum seekers, in relation to their knowledge of public benefits and legal rights.

DESIGN

Qualitative study, utilising an open-ended, semi-structured interview guide to ensure information-rich data collection. Thematic content was analysed using qualitative research software.

SETTING

Participants were drawn from the Weill Cornell Center for Human Rights (WCCHR) in New York City, a single-center, human rights clinic with a globally representative patient population. All interviews were conducted at the Weill Cornell Medicine Clinical and Translational Science Center, a multidisciplinary space within an urban academic medical center.

PARTICIPANTS

Twenty-four refugees and asylum seekers currently living in the greater New York City area. Eligible participants were 18 years of age or older and had previously sought services from the WCCHR. The recruitment rate was 55%.

PRIMARY AND SECONDARY OUTCOME MEASURES

Themes and concepts in participants' health, knowledge, perceptions of and experiences with accessing healthcare and public benefits programmes.

RESULTS

Twenty-four participants represented 18 countries of origin and 11 primary languages. Several impediments to accessing healthcare and public benefits were identified, including pragmatic barriers (such as prohibitive costs or lack of insurance), knowledge gaps and mistrust of healthcare systems.

CONCLUSIONS

There is low health engagement by refugees and asylum seekers, as a result of multiple, complex factors impeding the ability of refugee and asylum seekers to access healthcare and other public benefits for which they are eligible-with resultant detrimental health effects. However, there is an opportunity to utilise novel approaches, such as digital technologies, to communicate relevant information regarding legal rights and public benefits to advance the health of vulnerable individuals such as refugees and asylum seekers.

Attachment processes in posttraumatic stress disorder: A review of mechanisms to advance theories and treatments

Current conceptualisations of posttraumatic stress disorder (PTSD) are driven by biological, learning, and cognitive models that have shaped current treatments of the disorder. The strong influence of these models has resulted in a relative neglect of social mechanisms that can influence traumatic stress. There is abundant evidence from experimental, observational, and clinical studies that social factors can moderate many of the mechanisms articulated in prevailing models of PTSD. In this review it is proposed that attachment theory provides a useful framework to complement existing models of PTSD because it provides explanatory value for social factors can interact with biological, learning, and cognitive processes that shape traumatic stress response. The review provides an overview of attachment theory in the context of traumatic stress, outlines the evidence for how attachment factors can moderate stress responses and PTSD, and considers how harnessing attachment processes may augment recovery from and treatment of PTSD. This review emphasizes that rather than conceptualizing attachment theory as an independent theory of traumatic stress, there is much to gain by integrating attachment mechanisms into existing models of PTSD to accommodate the interactions between cognitive, biological, and attachment processes.

Family-based mental health interventions for refugees across the migration continuum: A systematic review

This study reviewed the literature on family-based mental health interventions for refugees across migration contexts and settings to identify types of interventions and intervention components, implementation approaches and to assess effectiveness. The review used a systematic approach, and ten intervention studies were retained for analysis. The findings identified three primary types of family-based mental health interventions used with diverse refugee communities in settings in the Global North and South-parenting groups, multiple family groups and home visiting interventions. Findings indicated that non-specialized or peer providers were frequently utilized to deliver the interventions though additional details on the workforce and workforce development strategies are needed to better understand how to sustain and support such providers. The findings suggest that family-based mental health interventions are potentially effective for improving a range of child and caregiver mental health outcomes and improving family processes and functioning among refugee families. However, the empirical evidence is quite limited to date, with a need for additional rigorous studies, especially with refugee families in humanitarian settings, to further build the evidence base.

Protocol of a feasibility trial for an online group parenting intervention with an integrated mental health component for parent refugees and asylum-seekers in the United Kingdom: (LTP + EMDR G-TEP)

OBJECTIVES

Conflicts expose families to a range of factors that could have a negative impact upon parental mental health which in turn leads to poor growth and development of children. Early support can improve parental mental health and parenting behaviours but currently, there is a lack of evidence on parenting interventions for forcibly displaced populations. This study aims to deliver an online parenting intervention with a mental health component for refugee and asylum-seeker parents to evaluate its feasibility and acceptability.

METHODS

This is a single-arm trial without a control group. The trial aims to recruit 14 refugee and asylum-seeker parents into an Online Learning Through Play and Eye Movement Desensitization and Reprocessing Group Traumatic Episode Protocol (LTP + EMDR G-TEP). The intervention will be delivered by trained research team members using online platforms.

RESULTS

The participants' sense of parenting competence, symptoms of traumatic stress, anxiety and depression will be measured at baseline and post-intervention. Semi-structured interviews at post-intervention will also be conducted.

DISCUSSION

This study will assess the feasibility and inform the design of a future randomized controlled trial which aims to evaluate the effectiveness of LTP + EMDR G-TEP intervention for parent refugees and asylum-seekers with young children.

Activating the attachment system modulates neural responses to threat in refugees with PTSD

Social attachment systems are disrupted for refugees through trauma and forced displacement. This study tested how the attachment system mitigates neural responses to threat in refugees with posttraumatic stress disorder (PTSD). Refugees with PTSD (N = 28) and refugee trauma-exposed controls (N = 22) viewed threat-related stimuli primed by attachment cues during a functional magnetic resonance imaging scan. Group differences and the moderating effects of avoidant or anxious attachment style and grief related to separation from family on brain activity and connectivity patterns were examined. Separation grief was associated with increased amygdala but decreased ventromedial prefrontal cortical (VMPFC) activity to the attachment prime and decreased VMPFC and hippocampal activity to attachment primed threat in the PTSD (vs trauma-exposed control) group. Avoidant attachment style was connected with increased dorsal frontoparietal attention regional activity to attachment prime cues in the PTSD group. Anxious attachment style was associated with reduced left amygdala connectivity with left medial prefrontal regions to attachment primed threat in the PTSD group. Separation grief appears to reduce attachment buffering of threat reactivity in refugees with PTSD, while avoidant and anxious attachment style modulated attentional and prefrontal regulatory mechanisms in PTSD, respectively. Considering social attachments in refugees could be important to post-trauma recovery, based within changes in key emotion regulation brain systems.

Trauma Exposure and Intimate Partner Violence Among Young Pregnant Women in Liberia

Intimate partner violence (IPV) is a global threat to women's health and may be elevated among those exposed to traumatic events in post-conflict settings, such as Liberia. The purpose of this study was to examine potential mediators between lifetime exposure to traumatic events (i.e., war-related trauma, community violence) with recent experiences of IPV among 183 young, pregnant women in Monrovia, Liberia. Hypothesized mediators included mental health (depression, posttraumatic stress symptoms), insecure attachment style (anxious and avoidant attachment), and attitudes indicative of norms of violence (attitudes justifying wife beating). We tested a parallel multiple mediation model using the PROCESS method with bias-corrected and accelerated bootstrapping to test confidence intervals (CI). Results show that 45% of the sample had experienced any physical, sexual, or emotional IPV in their lifetime, and 32% in the 2 months prior to the interview. Exposure to traumatic events was positively associated with recent IPV severity (β = .40, p < .01). Taken together, depression, anxious attachment style, and justification of wife beating significantly mediated the relationship between exposure to traumatic events and experience of IPV (β = .15, 95% CI = [0.03, 0.31]). Only anxious attachment style (β = .07, 95% CI = [0.03, 0.16]) and justification of wife beating (β = .05, 95% CI = [0.01, 0.16]) were identified as individual mediators. This study reinforces pregnancy as an important window for both violence and mental health screening and intervention for young Liberian women. Furthermore, it adds to our theoretical understanding of mechanisms in which long-term exposure to traumatic events may lead to elevated rates of IPV in Liberia, and points to the need for trauma-informed counseling and multilevel gender transformative public health approaches to address violence against women.

An exploratory study of embitterment in traumatized refugees

BACKGROUND

Refugees and asylum seekers are frequently exposed to violence, human rights violations and unstable living conditions before, during, and after their displacement. Elevated prevalence rates of psychiatric disorders in forcibly displaced persons are well documented. However, less is known about other problems related to common refugee experiences, such as embitterment, moral injury, and diminished self-efficacy, and how they are related to trauma exposure and post-migration living difficulties.

METHODS

A cross-sectional sample of 71 refugees and asylum seekers in treatment were examined regarding exposure to potentially traumatic events, post-migration living difficulties, moral injury appraisals, self-efficacy, and embitterment.

RESULTS

Elevated levels of embitterment were reported by 68% of participants. The regression analysis revealed that greater moral injury appraisals and low levels of self-efficacy were significantly associated with higher levels of embitterment.

CONCLUSION

The results provide first insights into embitterment and associated factors in refugee populations. Furthermore, they highlight the significance of moral transgressions and low levels of self-efficacy emerging from displacement and traumatic experiences for the development of mental health problems in a clinical sample of refugees. The findings have implications for future research, policy development and clinical practice.

Music therapy was noninferior to verbal standard treatment of traumatized refugees in mental health care: Results from a randomized clinical trial

Background: Many people with refugee backgrounds suffer from trauma-related complex social and psychological problems, and compliance with standard psychological treatment tends to be low. More culturally adaptable treatment options seem to be needed. Objective: We aimed to investigate whether the music therapy method: 'trauma-focused music and imagery' (tr-MI), characterized by a particular focus on arousal and affect regulation, would be equally effective as the standard psychological talk therapies for ameliorating trauma symptoms in Danish refugees. Methods: A pragmatic, noninferiority, parallel, randomized controlled trial with six-month follow-up was carried out at three clinics for refugees in the public mental health services of the Psychiatry (DK). Seventy-four adults diagnosed with posttraumatic stress disorder (PTSD) were allocated to either music therapy sessions (tr-MI, N = 39) or psychological treatment as usual (TAU, N = 35). Western classical music, new age music, and music from the participants' own national culture were used to generate inner imagery, following a phased treatment protocol. Homework entailed listening to music. The primary outcome was the measurement of trauma symptoms by the Harvard Trauma Questionnaire, section IV (HTQ-IV); secondary measures were somatoform and psychoform dissociation (DSS-20), SDQ-20), attachment (RAAS), and well-being (WHO-5). Treatment effects reflected by primary and secondary measures were estimated using linear mixed models. Results: Tr-MI was noninferior to TAU (mean difference at follow-up HTQ-IV: 0.14, CI (-0.10; 0.38), with a - 0.3 noninferiority margin). A high dropout rate of 40% occurred in the TAU group, compared to 5% in the music therapy group. Secondary measures generated small to medium effect sizes in both groups, with significant medium effect sizes for well-being and psychoform dissociation at follow-up in tr-MI. Conclusions: Tr-MI is an innovative form of psychological treatment in refugee mental health services. Trials comparing music therapy to standardized therapy are needed to substantiate the evidence base for tr-MI therapy.

Mental Health Conditions of Italian Healthcare Professionals during the COVID-19 Disease Outbreak

BACKGROUND

The COVID-19 pandemic in Italy represents a unique threat in terms of psychological distress. This cross-sectional study aims to investigate the psychological health of Italian healthcare professionals during the COVID-19 outbreak. We assessed participants' current psychological distress and coping strategies in the midst of the COVID outbreak (March-April 2020), and also asked them to retrospectively report how they remember feeling before the COVID-19 outbreak (December 2019). We examined associations between psychological distress and coping strategies with mental health and infection perceptions.

METHODS

Self-administered questionnaires were distributed online to healthcare professionals (N = 580) residing in different Italian regions from 26 March to 9 April 2020. The questionnaire measured changes in psychological states, coping strategies, and demographic variables testing variations in mental health and infection risk perception among Italian healthcare workers.

RESULTS

Overall, approximately 33.5 per cent of healthcare professionals in our sample meet the threshold for psychiatric morbidity. Participants perceive their current psychological health to be worse during the COVID-19 emergency outbreak as compared to before the outbreak, and this was especially true among women.

CONCLUSIONS

Both immediate and long-term monitoring psychological assistance services for healthcare workers should be implemented by national institutions to re-establish the psychological well-being and enhance the self-confidence and resilience of hospital personnel.

Mental Health Conditions of Italian Healthcare Professionals during the COVID-19 Disease Outbreak

Background

The COVID‐19 pandemic in Italy represents a unique threat in terms of psychological distress. This cross‐sectional study aims to investigate the psychological health of Italian healthcare professionals during the COVID‐19 outbreak. We assessed participants’ current psychological distress and coping strategies in the midst of the COVID outbreak (March–April 2020), and also asked them to retrospectively report how they remember feeling before the COVID‐19 outbreak (December 2019). We examined associations between psychological distress and coping strategies with mental health and infection perceptions.

Methods

Self‐administered questionnaires were distributed online to healthcare professionals (N = 580) residing in different Italian regions from 26 March to 9 April 2020. The questionnaire measured changes in psychological states, coping strategies, and demographic variables testing variations in mental health and infection risk perception among Italian healthcare workers.

Results

Overall, approximately 33.5 per cent of healthcare professionals in our sample meet the threshold for psychiatric morbidity. Participants perceive their current psychological health to be worse during the COVID‐19 emergency outbreak as compared to before the outbreak, and this was especially true among women.

Conclusions

Both immediate and long‐term monitoring psychological assistance services for healthcare workers should be implemented by national institutions to re‐establish the psychological well‐being and enhance the self‐confidence and resilience of hospital personnel.

Barriers to access to outpatient mental health care for refugees and asylum seekers in Switzerland: the therapist's view

BACKGROUND

More than 120,000 refugees and asylum seekers are currently living in Switzerland. The prevalence of mental disorders among this population is significantly higher than that in the general population. While effective treatment options and cross-cultural, specialized treatment centers exist, they tend to be overloaded by their target populations. General outpatient primary health care providers might be able to compensate for the lack of specialized treatment slots. To date, however, it is unknown how often and under what conditions (e.g., length of waiting lists) refugees and asylum seekers are treated outside of specialized centers and whether there are barriers that prevent providers in outpatient settings from treating more patients in this subgroup. The present study aimed to assess the challenges and barriers faced by psychiatrists and psychotherapists working in outpatient settings in Switzerland in treating refugees and asylum seekers to determine the potential capacity of this group to provide mental health care.

METHODS

An online survey was conducted during the winter of 2017/2018. The survey was constructed in three official languages and took 10-15 min to complete. Spearman's correlations, Mann-Whitney U-Tests, and Chi-squared tests were conducted to analyze the data.

RESULTS

Eight hundred and sixty-seven (N = 867) psychotherapists and psychiatrists working in outpatient settings completed the survey: 43% of them reported having treated between 1 and 9 refugees or asylum seekers in the past 12 months, and a further 13% reported treating 10 or more. Interpreters were used for almost every other patient with a refugee or asylum-seeker background. At the same time, the funding of interpreters, as well as the funding of treatment in general, were reported to be the biggest hurdles to treating more refugees and asylum seekers.

CONCLUSIONS

Given the low number of patients rejected for capacity reasons (between 2 and 5%) and the median waiting times for the admission of new patients ranging between 2 and 3 weeks, outpatient primary mental health care providers might treat more refugees and asylum seekers and relieve specialized treatment centers. However, barriers such as lack of funding of interpreters seem to hinder them. Appropriate steps by the authorities are needed to improve the current situation.

The Relationship of Acculturation, Traumatic Events and Depression in Female Refugees

Recent research has identified significant correlations between traumatic events and depression in refugees. However, few studies have addressed the role of acculturation strategies in this relationship. This study explored the relationship between cultural orientation, traumatic events and depression in female refugees from Syria, Afghanistan, Eritrea, Iran, Iraq, and Somalia living in Germany. We expected acculturation strategies to moderate the effect of traumatic experiences on depression. The sample included 98 female refugees in Germany. The depression scale of the Hopkins Symptom Checklist (HSCL) represented the dependent measure. The trauma checklists derived from the Post-traumatic Diagnostic Scale (PDS) and the Harvard Trauma Questionnaire (HTQ) as well as the Frankfurt Acculturation Scale (FRACC) were used as independent measures for traumatic events and orientation toward the host culture as well as orientation toward the culture of origin, respectively. A moderation analysis was conducted to examine whether the relationship between the number of traumatic events and depression was influenced by the women's orientation toward the culture of origin and the host culture. We identified a significant model explaining 26.85% of the variance in depressive symptoms (Cohen's f2 = 0.37). The number of traumatic events and the orientation toward the host culture exerted significant effects on depressive symptoms. The moderating effect was not significant, indicating that the effect of the number of traumatic events was not influenced by cultural orientation. Based on our results, orientation toward the host culture as well as traumatic experiences exert independent effects on depressive symptoms in refugees.

The Impact of Adverse Childhood Experiences on Mobile Phone Addiction in Chinese College Students: A Serial Multiple Mediator Model

Mobile phone addiction is a universal phenomenon that has attracted a lot of attention in recent years. Previous researches revealed a significant relation between adverse childhood experiences (ACEs) and addiction. This study further investigated the association between ACEs and mobile phone addiction, and the mediating effects of attachment styles and interpersonal relationships. The cross-sectional design and multiple questionnaires, namely, the Revised Adverse Childhood Experience Questionnaire, the Mobile Phone Addiction Index, the Revised Adult Attachment Scale (AAS), and the Interpersonal Relationship Comprehensive Diagnostic Scale (IRCDS) were used in the sample of 345 university students. Correlation analysis revealed that adverse childhood experience, attachment anxiety, attachment avoidance, interpersonal relationship, and mobile phone addiction were significantly positively correlated with each other. Results of regression analysis showed that attachment style and interpersonal relationship played multiple mediation roles in the association between adverse childhood experience and mobile phone addiction. That is, (1) adverse childhood experience was positively related to mobile phone addiction, (2) both attachment anxiety and interpersonal relationship played partial and parallel mediating roles between adverse childhood experience and mobile phone addiction, and (3) attachment anxiety/avoidance and interpersonal relationship mediated the relationship between adverse childhood experience and mobile phone addiction sequentially. These results indicated that mobile phone addiction among college students who had adverse childhood experience can be relieved by way of the remission of attachment anxiety, reduction of attachment avoidance, and improvement of interpersonal relationship.

Sluggish cognitive tempo and exposure to interpersonal trauma in children

Background: Childhood adversity has been suggested, but not yet empirically examined, as a factor in sluggish cognitive tempo (SCT) in childhood.Objective: This study was an examination of SCT in relation to childhood adversity, and its association with exposure to non-interpersonal and interpersonal trauma.Method: Caregivers (N = 161) and a sub-sample of children, 8-17 years old, were recruited from mental health and pediatric practices/programs and interviewed.Results: SCT was positively associated with interpersonal trauma but not non-interpersonal trauma. Two hierarchical regression analyses revealed that interpersonal trauma exposure was associated with SCT score over and above symptoms of other psychopathologies.Conclusion: Results suggest that SCT is associated with interpersonal trauma exposure in children. Further research is needed to examine the association between SCT and interpersonal trauma exposure, and trauma-related biopsychosocial impairments.

Mental Health of Refugees and Torture Survivors: A Critical Review of Prevalence, Predictors, and Integrated Care

Civilian war trauma and torture rank among the most traumatic life experiences; exposure to such experiences is pervasive in nations experiencing both internal and external conflict. This has led to a high volume of refugees resettling throughout the world with mental health needs that primary care physicians may not be screening for and prepared to effectively address. In this article, we review the literature on demographics, predictors, mental health outcomes of torture, and integrated care for the mental health needs of refugees. We searched PubMed and PSYCINFO databases for original research articles on refugees and mental health published in the English language between 2010 and present. Nine percent of 720 adults in conflict areas in Nepal, with predominance of literate married males, met the threshold for Post-Traumatic Stress Disorder (PTSD), 27.5% for depression, and 22.9% for anxiety. While, PTSD rate has been documented as high as 88.3% among torture survivors from Middle East (ME), Central Africa (CA), South Asia (SA), Southeast Europe (SE). Depression was recorded as high as 94.7% among 131 African torture survivors and anxiety as high as 91% among 55 South African torture survivors. Torture severity, post-migration difficulties, and wait time to receive clinical services were significantly associated with higher rate of mental health symptoms. Mental health screening is not a standard component of initial physical exams for refugees, yet these individuals have had high trauma exposure that should inform clinical care. Integrated care models are lacking but would greatly benefit this community to prevent progression to greater severity of mental health symptoms.

Music therapy versus treatment as usual for refugees diagnosed with posttraumatic stress disorder (PTSD): study protocol for a randomized controlled trial

BACKGROUND

Meta-analyses of studies on psychological treatment of refugees describe highly varying outcomes, and research on multi-facetted and personalized treatment of refugees with post-traumatic stress disorder (PTSD) is needed. Music therapy has been found to affect arousal regulation and emotional processing, and a pilot study on the music therapy method Trauma-focused Music and Imagery (TMI) with traumatized refugees resulted in significant changes of trauma symptoms, well-being and sleep quality. The aim of the trial is to test the efficacy of TMI compared to verbal psychotherapy.

METHODS

A randomized controlled study with a non-inferiority design is carried out in three locations of a regional outpatient psychiatric clinic for refugees. Seventy Arabic-, English- or Danish-speaking adult refugees (aged 18-67 years) diagnosed with PTSD are randomized to 16 sessions of either music therapy or verbal therapy (standard treatment). All participants are offered medical treatment, psychoeducation by nurses, physiotherapy or body therapy and social counseling as needed. Outcome measures are performed at baseline, post therapy and at 6 months' follow-up. A blind assessor measures outcomes post treatment and at follow-up. Questionnaires measuring trauma symptoms (HTQ), quality of life (WHO-5), dissociative symptoms (SDQ-20, DSS-20) and adult attachment (RAAS) are applied, as well as physiological measures (salivary oxytocin, beta-endorphin and substance P) and participant evaluation of each session.

DISCUSSION

The effect of music therapy can be explained by theories on affect regulation and social engagement, and the impact of music on brain regions affected by PTSD. The study will shed light on the role of therapy for the attainment of a safe attachment style, which recently has been shown to be impaired in traumatized refugees. The inclusion of music and imagery in the treatment of traumatized refugees hopefully will inform the choice of treatment method and expand the possibilities for improving refugee health and integration.

TRIAL REGISTRATION

ClinicalTrials.gov ID number NCT03574228, registered retrospectively on 28 June 2016.

The impact of enhancing perceived self-efficacy in torture survivors

BACKGROUND

Perceived self-efficacy (SE) is an important factor underlying psychological well-being. Refugees suffer many experiences that can compromise SE. This study tested the impact of enhancing perceived SE on coping with trauma reminders and distress tolerance in tortured refugees.

METHODS

Torture survivors (N = 40) were administered a positive SE induction in which they retrieved mastery-related autobiographical memories, or a non-SE (NSE) induction, and then viewed trauma-related images. Participants rated their distress following presentation of each image. Participants then completed a frustration-inducing mirror-tracing task to index distress tolerance.

RESULTS

Participants in the SE condition reported less distress and negative affect, and improved coping in relation to viewing the trauma-related images than those in the NSE condition. The SE induction also led to greater persistence with the mirror-tracing task than the NSE induction.

CONCLUSIONS

These findings provide initial evidence that promoting SE in tortured refugees can assist with managing distress from trauma reminders, and promoting greater distress tolerance. Enhancing perceived SE in tortured refugees may increase their capacity to tolerate distress during therapy, and may be a useful means to improve treatment response.