A group-based approach to stabilisation and symptom management in a phased treatment model for refugees and asylum seekers

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.

Trauma and resettlement: lessons learned from a mental health screening and treatment programme for Syrian refugees in the UK

Resettlement schemes can offer refugees an opportunity to rebuild their lives and to heal from loss and trauma. Mental health services in host countries may have an important role to play in aiding refugees in this journey to recovery. However, facilitating the process of healing for refugees raises challenges for mental health services working within Western medicalised settings. Recovery and wellbeing for resettled refugees also depends upon an interaction of variables at a wider systemic level, that go beyond the direct remit of mental health services. Based on the experience of delivering a mental health screening and treatment programme for resettled Syrian refugees in the UK over a 5-year period, this paper reflects on these challenges and suggests that future resettlement schemes in the UK be designed in accordance with the principles of trauma-informed care. This means putting safety, trust, choice, collaboration, empowerment and respect for inclusion and diversity at the core of the services provided for resettled refugees.

Review: Cultural adaptations to psychosocial interventions for families with refugee/asylum-seeker status in the United Kingdom - a systematic review

BACKGROUND

Young people with refugee or asylum-seeker status (R/AS) often present with complex mental health needs, in the context of traumatic life experiences. Generic mental health services in the United Kingdom (UK) may be ill-equipped to manage the unique experiences of these young people. Culturally adapted interventions (CAI) could provide a culturally sensitive approach to mental health support for refugee children experiencing difficult symptoms. A systematic review was conducted to determine the different types of cultural adaptation in the included studies, and to determine the efficacy of CAIs in comparison to generic treatment.

METHODS

Systematic searches of eleven databases were completed in December 2020. Any psychosocial interventions conducted in the United Kingdom aimed at providing mental health support for refugee young people and families were included. This was to ensure the potential inclusion of all studies regardless of their adherence to the traditional framework of assessment and intervention in high-income countries, for example randomised control trials.

RESULTS

Eleven studies of varying methodology, participant group, intervention type and outcome measures were included in this review. Studies used a variety of cultural adaptations including surface-level and deep-level adaptations. Studies showed some support for the use of CAIs with young people with R/AS, with varying degrees of symptom reduction. It was not possible to compare the effectiveness of CAIs against 'treatment-as-usual', nor to determine the effectiveness of different CAI components.

CONCLUSIONS

Whilst there is evidence for the use of CAIs with R/AS young people, the heterogeneity between studies limits the generalisability of these results. The available research is not sufficient to provide conclusive evidence of the use of CAIs over 'treatment-as-usual'. Research and clinical implications are highlighted. Future research could examine the most effective components of CAIs and aim to increase the evidence base of interventions for young people and families with R/AS.

Complex post-traumatic stress disorder in asylum seekers and victims of trafficking: treatment considerations

Asylum-seekers experience high levels of traumatic events pre-, post- and during migration. Poly-traumatisation is associated with complex post-traumatic stress disorder (CPTSD), which has not yet been extensively explored in this population. CPTSD is a prevalent and highly disabling disorder in the present population requiring culturally sensitive diagnostic and treatment approaches. In this service evaluation, we evidence the high prevalence of CPTSD in an asylum-seeking sample and its association with greater distress compared with PTSD. We outline the treatment needs of asylum seekers with CPTSD.

Stabilizing group treatment for childhood-abuse related PTSD: a randomized controlled trial

Background: Patients with PTSD related to childhood-abuse often experience additional problems such as emotional dysregulation and interpersonal difficulties. Psychotherapy focused on stabilization of symptoms, emotion-regulation, and skills training has been suggested as a treatment for this patient population, either as preparation for further treatment or as a stand-alone intervention. Objective: The present study tests the efficacy of treatment using a group-protocol for stabilizing treatment delivered adjunct with conventional individual therapy. Methods: In a delayed-treatment design with switching replication, a clinically representative sample of 89 patients with PTSD and histories of childhood abuse were randomly assigned to either 20-week stabilizing group treatment or a corresponding waiting-period, both adjunct with conventional individual therapy. After the waiting-period, patients in the control condition were offered group treatment. The primary outcome was psychosocial functioning, measured with interview - assessed Global Assessment of Functioning (GAF), while secondary outcome was self-reported PTSD symptoms. These were measured before treatment, after treatment and at 6 months follow up. The trial was preregistered at Clinical Trials (NCT02450617). Results: We found large within-group effect sizes in both conditions on GAF and moderate effects on PTSD symptoms. Linear mixed-models did not indicate significant differences in treatment trajectories between conditions. Conclusion: Stabilizing group treatment focused on emotional-regulation and skills-training does not improve outcomes beyond individual-treatment alone, and should not be recommended as first-line treatment for this patient-group.

Self-Practice of Stabilizing and Guided Imagery Techniques for Traumatized Refugees via Digital Audio Files: Qualitative Study

Background

Refugees have an increased risk of developing mental health problems. There are insufficient psychosocial care structures to meet the resulting need for support. Stabilizing and guided imagery techniques have shown promising results in increasing traumatized refugees’ emotional stabilization. If delivered via audio files, the techniques can be practiced autonomously and independent of time, space, and human resources or stable treatment settings.

Objective

This study aimed to evaluate the self-practice of stabilizing and guided imagery techniques via digital audio files for traumatized refugees living in a reception and registration center in Germany.

Methods

From May 2018 to February 2019, 42 traumatized refugees participated in our study. At T1, patients received digital audio files in English, French, Arabic, Farsi, Turkish, or Serbian for self-practice. Nine days later, at T2, a face-to-face interview was conducted. Two months after T2, a follow-up interview took place via telephone.

Results

At T2, about half of the patients reported the daily practice of stabilizing and guided imagery techniques. At follow-up, the average frequency of practice was once weekly or more for those experiencing worse symptoms. No technical difficulties were reported. According to T2 and follow-up statements, the techniques helped the patients dealing with arousal, concentration, sleep, mood, thoughts, empowerment, and tension. The guided imagery technique “The Inner Safe Place” was the most popular. Self-practice was impeded by postmigratory distress factors, like overcrowded accommodations.

Conclusions

The results show that self-practice of stabilizing and guided imagery techniques via digital audio files was helpful to and well accepted by the assessed refugees. Even though postmigratory distress factors hampered self-practice, “The Inner Safe Place” technique was particularly well received. Overall, the self-practiced audio-based stabilizing and guided imagery techniques showed promising results among the highly vulnerable group of newly arrived traumatized refugees.

EMDR With Traumatized Refugees: From Experience-Based to Evidence-Based Practice

Many refugees resettled in Western countries suffer from an accumulation of traumatic and current stressors that contribute to mental health problems and may complicate trauma-focused treatment. Consequently, the acceptability, safety, and efficacy of trauma-focused treatment with refugees have been a matter of clinical and scientific interest. In recent years, the evidence has accumulated for narrative exposure therapy and culturally adapted cognitive behavioral therapy. Although eye movement desensitization and reprocessing (EMDR) is practiced with resettled refugees, only five small studies of limited quality have been conducted on EMDR with this population. In the absence of strong evidence, therapists practising EMDR with refugees may be aided by transcultural psychiatric principles, especially matching of explanatory models. In addition, high-quality research is needed to reliably determine acceptability, safety, and efficacy of EMDR with traumatized refugees.