535752 research-article2014
ISP0010.1177/0020764014535752International Journal of Social PsychiatrySlobodin and de Jong
E CAMDEN SCHIZOPH
Article
Mental health interventions for traumatized asylum seekers and refugees: What do we know about their efficacy?
International Journal of Social Psychiatry 1–10 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0020764014535752 isp.sagepub.com
Ortal Slobodin1 and Joop TVM de Jong2,3
Abstract Background: The prevalence of trauma-related problems among refugees and asylum seekers is extremely high due to adverse experiences associated with forced migration. Although the literature presents a considerable number of guidelines and theoretical frameworks for working with traumatized refugees and asylum seekers, the efficacy, feasibility and applicability of these interventions have little empirical evidence. Aims: The purpose of this article is to critically review the literature to provide a rationale for developing culturally sensitive, evidence-based interventions for refugees and asylum seekers. Methods: A literature review integrating research findings on interventions designed especially for traumatized asylum seekers and refugees was conducted. Retained studies had to use some quantitative measurements of post-traumatic stress and to have pre- and post-measurements to evaluate the efficacy of the intervention. Studies included in this review cover a wide variety of interventions, including trauma-focused interventions, group therapy, multidisciplinary interventions and pharmacological treatments. Results: The majority of studies with traumatized refugees and asylum seekers reported positive outcomes of the intervention in reducing trauma-related symptoms. There is evidence to support the suitability of cognitive-behavioral therapy (CBT) and narrative exposure therapy (NET) in certain populations of refugees. Other intervention studies are limited by methodological considerations, such as lack of randomization, absence of control group and small samples. Conclusions: This review has again highlighted the shortage of guiding frameworks available to investigators and clinicians who are interested in tailoring interventions to work with refugees and asylum seekers. Theoretical, ethical and methodological considerations for future research are discussed. Keywords Refugees, asylum seekers, intervention, trauma, symptoms, review
Introduction Refugees and asylum seekers are forced migrants. The United Nations High Commissioner for Refugees (UNHCR) estimated that there were 43.3 million forcibly displaced people worldwide at the end of 2009. Of these, 15.2 million were refugees and 983,000 asylum seekers (The United Nations Refugee Agency, 2009). Generally, refugees have a lawful right to enter a country for the purposes of seeking asylum, regardless of how they arrive or whether they hold valid travel or identity documents. Asylum seekers are individuals whose application for asylum or refugee status is pending in the administrative or legal processes (Harris & Zwar, 2005). The process of migration has been described as occurring in broadly three stages, each of them involves the potential for traumatogenic experiences: (a) pre-migration; (b) migration – the physical relocation to the new place
and (c) post-migration – the assimilation within the cultural framework of the new society, through learning its cultural rules (Bhugra, 2001). Prior to migration and during this process, refugees are exposed to exceptionally high rates of traumatic events such as war, violence, torture and persecution (Gerritsen et al., 2006; Steel et al., 2004). Some refugees become subjects of human 1i-psy
(intercultural psychiatry), Amsterdam, The Netherlands Institute of Social Science Research, University of Amsterdam, Amsterdam, The Netherlands 3School of Medicine, Boston University, Boston, MA, USA 2Amsterdam
Corresponding author: Ortal Slobodin, i-psy (intercultural psychiatry), George Westinghousestraat 2, 1097 BA Amsterdam, The Netherlands. Email: [email protected]
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trafficking who may be held for ransom or trafficked for the purpose of forced marriage, sexual exploitation or labor exploitation through the use of force, fraud or coercion (United States Committee for Refugees and Immigrants, 2011). Nevertheless, post-migration adverse experiences, such as lack of social support, acculturation difficulties, poverty, discrimination and changes in identity and concept of self, further complicate the mental problems in those who have been previously traumatized (Bhugra & Becker, 2005; Laban, Gernaat, Komproe, Schreuders, & De Jong, 2004; Silove, Sinnerbrink, Field, Manicavasagar, & Steel, 1997; Walsh, 2007). Many asylum seekers who live in detention camps are exposed to threatening conditions (e.g. sexual harassments, denial of adequate food, inadequate health care, isolation etc.), as well as to continuous uncertainty about their own future and the future prospects of those who were left behind (Carta et al., 2013; Laban et al., 2004). These adverse experiences often lead to extremely high prevalence of psychiatric disorders among refugees and asylum seekers, including depression, post-traumatic stress disorder (PTSD), anxiety, psychosomatic disorders, grief related disorders and crises of existential meaning (Gerritsen, et al., 2006; Laban et al., 2004; Steel et al., 2004). It is estimated that PTSD prevalence among refugees ranges between 20% and 74%, and depression ranges between 39% and 64% (Gerritsen et al., 2006; Laban et al., 2004; Mares & Jureidini, 2004; McColl & Johnson, 2006; Sieberer, Ziegenbein, Eckhardt, Machleidt, & Calliess, 2011). The level of distress depends on many variables, such as duration of the relocation, the similarity between the culture of origin and the culture of settlement, language and social support systems, acceptance by the new nation and employment and education opportunities (Bhugra & Becker, 2005; Cebulla, Daniel, & Zurawan, 2010; Shah, 2004; Walsh, 2007). The refugee patient’s complex problems represent a challenge for all care levels. Language barriers, cultural differences in symptom presentation and clinical severity cause difficulties in understanding symptoms and ailments. General practitioners, who are the main responsibility for treating these patients, often experience that the general treatment conditions are insufficient and that mental health services do not offer adequate help, especially regarding traumatization (Varvin & Aasland, 2009). Furthermore, mental health professionals working with refugees and asylum seekers are facing multiple difficulties in providing adequate care. Interventions with refugees and especially with asylum seekers are threatened by the instability and uncertainty of treatment. Asylum seekers are often relocated to another center or just ‘disappear’ to unknown destination and cannot be followed. If the appeal for asylum is refused, the group health insurance is shortly terminated, thus resulting in a pre-mature termination of therapy. Refugees and asylum seekers are also at high risk of drop out of treatment due to different
expectations of treatment, language problems, interpretation of symptoms and difficulties in communicating with the therapist (Bhatia & Wallace, 2007; Van Loon, van Schaik, Dekker, & Beekman, 2011). Finally, since mental health problems are one of the reasons that could grant asylum, therapists are often asked to indicate their patients’ illness. Some asylum seekers start to believe that the improvement of their stress symptoms may decrease their chance of getting a positive asylum decision (Renner, Bänninger-Huber, & Pelzer, 2011), and may even exaggerate experiences of trauma in order to strengthen their claims (Keller et al., 2003; Laban et al., 2004). These complicated considerations undoubtedly effect the therapeutic alliance, the outcome of treatment and the therapist’s attitudes toward the patient, and pose a serious challenge to mental health professionals. For many years, most psychological treatments used in rehabilitation programs appear to be a mixture of various psychotherapeutic elements, not based on a consistent theory, and lack evidence on their effectiveness (Başoğlu, 2006). Because most efficacy studies do not include minorities in their sample, the literature in the field has long debated whether the standard PTSD interventions, such as cognitive-behavioral therapy (CBT) or eye movement desensitization and reprocessing (EMDR), are applicable to the refugee population or whether a phased model starting with stabilization is preferable. While some clinicians (e.g. Başoğlu, 2006) argue that traumatized refugees should be treated according to the standardized protocols of CBT and EMDR, others (Laban, Hurulean, & Attia, 2009; National Institute for Clinical Excellence (NICE), 2005) argue that treatment should initially focus on daily living problems and a restoration of coping skills. According to the NICE (2005), trauma-focused therapy as the initial stage of therapy should be considered as inappropriate and ineffective. Nevertheless, refugee and asylum seeker patients tend to feel ambivalent about engaging in trauma-focused CBT, mainly for the fear of repatriation (Vincent, Jenkins, Larkin, & Clohessy, 2012). Several authors (Bekker &Van Mens-Verhulst, 2008; Bernal & Sáez-Santiago, 2006) have argued that the lack of evidence-based treatments makes therapists in the field confused and uncertain about the appropriate intervention. In particular, training was needed regarding assessment and therapeutic issues, involving culturally appropriate interventions, cultural awareness, working with interpreters, legal and social issues and trauma work (Maslin & Shaw, 2003). The aim of the current article is to review the evidence-based data regarding mental health interventions designed especially for traumatized asylum seekers and refugees.
Method To locate studies for this review, we searched PsycINFO, Entrez-PubMed and PsycARTICLES. Keywords ‘trauma’,
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Slobodin and de Jong ‘asylum seekers’, ‘refugees’, ‘treatment’ and ‘intervention’ were selected. These search terms narrowed the list of articles to those of interest (studies of intervention used to treat conditions of trauma among asylum seekers and refugees and those that have already been screened for quality by the peer review process). In addition, we consulted previous review articles (Crumlish & O’Rourke, 2010; McFarlane & Kaplan, 2012; Murray, Davidson, & Schweitzer, 2010; Palic & Elklit, 2011) and contacted researchers who are known to be engaged in treatment research with these populations. The studies we retained had to meet two criteria. They had to use some quantitative measurements of posttraumatic stress and to have pre- and post-measurements to evaluate the efficacy of the intervention. The studies included in this review cover a wide variety of interventions, including trauma-focused interventions, multidisciplinary interventions and pharmacological treatments.
Findings from the studies: mental health interventions for refugees and asylum seekers While not claiming to be exhaustive, this review seeks to describe the current, pivotal, findings with treating traumarelated problems among refugees and asylum seekers. Many treatment strategies and techniques have been developed and used worldwide to help asylum seekers and refugees. However, only a minority of them used a known research methodology which allows generalization. A systematic review (Crumlish & O’Rourke, 2010), including a total of 10 randomized-controlled intervention studies among refugees and asylum seekers with PTSD, revealed that no PTSD treatment has been firmly supported by research. There was evidence for the efficacy of narrative exposure therapy (NET) and CBT. Nevertheless, a later systematic review by Palic and Elklit (2011), which included a wider spectrum of prospective designs (not only randomized-controlled trials (RCTs)), concluded that CBT and NET are two well-studied and effective interventions among refugees. In a recent work, McFarlane and Kaplan (2012) reviewed research evidence on psychosocial interventions for adult survivors of torture and trauma (resettled refugees, asylum seekers, displaced persons and persons resident in their country of origin). They identified a total of 40 studies from 1980 to 2010 that investigated interventions for adult survivors of torture, including RCTs (11/40), non-RCTs (8/40) and single cohort studies (21/40). While single cohort studies were the most common approach in the field, RCTs examining the efficacy of applied treatments with asylum seekers and refugees were very few and included small samples. RCTs mainly examined individual psychotherapies that targeted PTSD symptoms.
NET NET incorporates CBT and testimony therapy. It is specifically targeted at the refugee populations by acknowledging the narrative tradition common to many cultures. Neuner et al. (2010) carried out an RCT with 32 asylum seekers in Germany. Participants with PTSD received treatment as usual (public mental health care) or 5–17 sessions of NET. The amount of ‘treatment as usual’ was not known. After treatment, NET participants had significantly improved PTSD and pain symptoms compared to treatment as usual. There were no improvements in depression. However, at 6 months, all participants except one still had PTSD. In a RCT, Hensel-Dittmann et al. (2011) compared the outcome of NET and stress inoculation training (SIT) among refugees and asylum seekers in Germany. This study revealed that a significant reduction in PTSD symptoms was found for NET, but not for SIT. Major depression and other comorbid disorders did not decrease in both groups. In another NET trial, PTSD caseness at follow-up was significantly lower among NET participants than among supportive counseling or psychoeducation participants (Neuner, Schauer, Klaschik, Karunakara, & Elbert, 2004). The advantage of NET over supportive counseling was not consistent across studies (Neuner et al., 2008), although both interventions were superior to the notreatment condition (Neuner et al., 2008; Ruf et al., 2010). Finally, Halvorsen and Stenmark (2010) reported moderate therapeutic gains in 16 torture survivor refugees on PTSD and depression measures. Taken together, NET appears as an effective intervention in reducing PTSD symptoms in traumatized refugees. However, it does not have any advantage over treatment as usual when it comes to anxiety and depression (Palic & Elklit, 2011).
CBT CBT interventions for traumatized refugees are relatively well researched and support the use of trauma-focused CBT among refugees. The majority of firm evidence is centered in special variants of CBT, which incorporates cultural knowledge into standard CBT methods for Southeast Asians. By using cultural study of symptoms and their meaning, Hinton and his colleagues (Hinton et al., 2005; Hinton, Hofmann, Pitman, Pollack, & Barlow, 2008) tested the applicability of a somatic-focused CBT to traumatized Cambodian refugees. The treatment which is called ‘Flexibility and Sensation-Reprocessing Therapy’ was based on a careful analysis of symptom presentation among Cambodian refugees. This cultural phenomenology of illness experience included a study of sensation-related catastrophic cognitions, trauma associations, metaphors and cultural expectations for treatment. In a RCT, Hinton et al. (2005) reported that 12 patients (60%) in the immediate treatment group were in remission from PTSD after
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their course of CBT, while none were in remission in the control group. However, most of CBT trials were performed among Cambodian refugees and half of them (2 of 4) were pilot studies with a moderate to high risk of bias (Hinton et al., 2004; Otto et al., 2003). Integrating CBT with other types of interventions has also revealed positive results. Snodgrass et al. (1993) studied the effects of a 3-month CBT treatment that included coping skills group with 11 Vietnamese refugees with PTSD symptoms. Treatment consisted of six 3-hour weekly sessions (including relaxation, CBT, psychoeducation, self-talk and role modeling of stressful scenarios). Significant reductions in PTSD symptoms and improved ability to relate to others were found in treatment group but not in the control group (no-treatment).
EMDR In a pilot RCT comparing EMDR and stabilization in 20 traumatized refugees and asylum seekers, it was found that EMDR and stabilization were equally accepted by patients, with a high drop-out for both conditions. No participant dropped out of the EMDR condition because of unmanageable distress. While improvement for EMDR participants was small, EMDR was found to be no less efficacious than stabilization. The authors concluded that because EMDR showed some improvement and stabilization showing some deterioration between pre-treatment and post-treatment, there is a rationale to integrate the two approaches (Ter Heide, Mooren, Kleijn, de Jongh, & Kleber, 2011).
Family interventions Given the importance of the family in the aftermath of trauma and the theoretical ease of including the social and cultural context in systemic approaches to therapy (Mendenhall & Berge, 2010; Shamai, 1999; Woodcock, 2001), family interventions are argued to be a suitable approach for refugees (Allen & Bloom, 1994; Figley & Figley, 2009; Ter Heide et al., 2011; Weine et al., 2003, 2004, 2005; Zagelbaum & Carlson, 2011). Although some authors have described their experience with traumatized refugee families, there is a dearth of evidence-based data that would confirm the applicability of systemic family intervention to these groups (Coulter, 2010; Weine et al., 2008). In one of the few RCTs, Weine et al. (2008) showed that multi-family group intervention increased the number of mental health visits of Bosnian refugees compared to no-treatment control group. This difference was constant over time (6, 12 and 18 months following intervention), and was observed in both primary participants and their family members. However, this study did not evaluate the efficacy of the intervention in reducing depression or PTSD symptoms. In another study of Kataoka et al. (2003),
CBT therapy with 2-hour optional multi-family group sessions were assigned to Latino immigrant children in the United States and their families (37% of parents attended at least one session). Results showed that PTSD and depressive symptoms significantly decreased in the intervention group, but not in the control group. There was no report whether engaging in the multi-family group sessions had any advantage over CBT-only. In this study, only a portion of the participants were randomized.
Group interventions Research on group interventions among asylum seekers is even rarer than individual approaches. Drozdek (1997) recruited 120 Bosnian concentration camp survivors in the Netherlands who were asylum seekers at the time. Most were diagnosed with PTSD and were offered psychodynamic group therapy, psychodynamic group therapy plus medication or medication only. Control group was composed of participants with PTSD who refused treatment. No significant differences between the active interventions were found for PTSD diagnosis. Recently, Drozdek, Kamperman, Bolwerk, Tol, and Kleber (2012) evaluated the effectiveness of three different trauma-focused daytreatment group programs for treatment of PTSD in male asylum seekers and refugees from Iran and Afghanistan. The results of this study indicated that group psychotherapy combined with nonverbal treatments significantly improved the mental health of asylum seekers and refugees with PTSD, as compared to a waiting list group. Similarly, Renner et al. (2011) examined the efficacy of group intervention in reducing post-traumatic symptoms, anxiety, and depression symptoms among Chechen refugees in Austria. Results indicated that the group intervention was significantly superior to no-treatment condition, but was equally effective as CBT. Individual EMDR yielded negative results.
Multidisciplinary interventions In addition to standard trauma-focused methods, several studies employed a more integrative approach in working with refugees and asylum seekers. Two studies evaluated the efficacy of multidisciplinary treatment (psychotherapy, family therapy and/or medication) in reducing psychiatric symptoms in Hmong refugees (Westermeyer, 1988; Westermeyer, Vang, & Neider, 1984) compared to a control group of non-help-seeking participants. Both studies suggested that depression and psychopathology among Hmong refugees improved with multidisciplinary outpatient treatment, and the gains were maintained after 2 years. However, the fact that the intervention and control groups differed on relevant variables at baseline limits their conclusions. In the last decade, several non-experimental studies (without a
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Slobodin and de Jong control group) using multidisciplinary treatment were published. All of them used psychotherapy, psychopharmacological treatment and usually physiotherapy (Arcel et al., 2003; Brune et al., 2002; Carlsson, Mortensen, & Kastrup, 2005; Palic & Elklit, 2009). Except for Carlsson et al. (2005), moderate to large effect sizes were found for PTSD, anxiety, depression and global function. Given that the majority of these studies are non-experimental, future controlled studies of multidisciplinary treatments are warranted (Palic & Elklit, 2011).
Naturalistic interventions One of the prominent issues in the research of ethnic minorities is the preference for naturalistic designs (McFarlane & Kaplan, 2012), which is based on both theoretical and ethical/practical rationales (Silove, Manicavasagar, Coello, & Aroche, 2005; Van Wyk & Schweitzer, 2013). In a systematic literature review, Van Wyk and Schweitzer (2013) examined the outcomes of naturalistic interventions (provided within treatment setting) to people from refugee background. They identified only 7 eligible studies and pointed out a significant variation in the outcomes of naturalistic intervention studies, with a trend toward showing decreased symptomatology at post-intervention. However, conclusions were limited by methodological problems of the studies reviewed, particularly poor documentation of intervention methods and lack of control group.
Pharmacological interventions The pharmacological treatments of choice today for PTSD are antidepressants from the subgroup selective serotonin reuptake inhibitors, especially sertraline (Sonne, Carlsson, Elklit, Mortensen, & Ekstrøm, 2013). There may be an assumption that evidence from drug trials in the general population applies to the refugee population in a way that psychological interventions do not (Stein, Ipser, & Seedat, 2006). However, sufficient evidence is lacking to draw conclusions on the efficiency of psychopharmacological treatments of traumatized refugees with PTSD (Crumlish & O’Rourke, 2010; Rohlof, 1995; Sonne et al., 2013). Moreover, the NICE (2010) asserted that drug treatments for PTSD should not be used as a routine first-line treatment for adults (in general use or by specialist mental health professionals) in preference to a trauma-focused psychological therapy. Prescribing pharmacological treatment to individuals coming from another culture requires a careful consideration of issues such as variability of medication effects in different ethnic groups, compliance rates and sensibility to side effects (Kroll et al., 1990; Lin, Poland, & Lesser, 1986; Lin & Shen, 1991). High-quality drug trials should be conducted in refugee populations, to guide treatment when psychological interventions are
unavailable or poorly tolerated (Crumlish & O’Rourke, 2010). Of note, a large Danish RCT (n = 150) of antidepressant treatment (sertraline or venlafaxine) and/or CBT with traumatized refugees was assigned for 2013 (Sonne et al., 2013).
Discussion The treatment of refugee populations is only recently considered as a distinct area in the field of mental health (De Jong & Van Ommeren, 2002; Miller & Rasco, 2004). This review points out the heterogeneous types and qualities of interventions assigned for traumatized refugees and asylum seekers and the shortage of evidence-based treatments for these populations. Currently, two directions of intervention are wellresearched and revealed promising results: the cultural sensitive CBT and the NET; both incorporated culturally sensitive attitude and techniques into the standard protocols. Both strategies were studied with RCTs and yielded large effect sizes. Other intervention studies are limited not only by methodological problems (e.g. lack of RCTs, little samples, etc.) but also by trying to use standardized approaches to PTSD instead of basing them on a local understanding of trauma and psychological distress in this population (Crumlish & O’Rourke, 2010). Contrary to some professionals’ view (Laban et al., 2009; NICE, 2005) that stabilization should be preferred over trauma-focused therapy when working with refugee population, findings suggest that when culturally adapted, standardized protocols of trauma-focused interventions, such as CBT, could be suitable for traumatized refugees. To our knowledge, there is no firm evidence that exposure to traumatic contents in the therapeutic setting causes repatriation, fragmentation or worsening of symptoms. However, further research is needed in order to identify potential barriers to treatment. Several theoretical and methodological considerations in refugee trauma research arise from this review. First, attention should be given to the complexity of employing RCTs in refugee populations (Goodkind, LaNoue, Lee, Freeland, & Freund, 2012; Kataoka et al., 2003; Silove et al., 2005). It has been argued that RCTs are of use only when studying narrowly defined groups of people under artificial laboratory conditions, and thus their external validity is questionable (Fuller, 1999). Goodkind et al. (2012), who studied the efficacy of community intervention for trauma in American Indian and Alaska Native youth, indicated that a control group is not an appropriate design when working with small communities, because the interconnectedness of families increases the risk for contamination across groups. Moreover, studies of immigrants and refugees are often conducted within regular assistance programs that do not allow for randomization due to practical and ethical considerations (i.e. it is unfair to prevent
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treatment from some people while providing it to others) (McDonald, 2009; Rimpela, 2000; Silove et al., 2005). Some non-randomized studies used a control group of individuals who did not seek mental help (Westermeyer et al., 1984; Westermeyer, 1988) or refused it (Drozdek, 1997). These methods involve major methodological limitations, such as differences in baseline condition and other clinical and personality characteristics that may affect treatment outcomes. These complexities should not automatically lead health researchers to avoid RCT, but rather call for the development of more sophisticated methods of randomization, for example, those that involve dialogue with patients and take patients’ needs and preferences into account (Jadad, 1998). Another important issue arising from this review is the assessment of treatment efficacy. The majority of the studies reviewed here used the improvement of PTSD symptoms as an indicator to intervention efficacy. However, it may be instructive to include other dimensions of personality such as improvements in relationships, identity and meaning (Victorian Foundation for Survivors of Torture, 1998). In addition, because refugees often present more complex traumatic reactions to trauma reactions than those strictly specified in the diagnostic category of PTSD, effectiveness of PTSD treatments should address a boarder range of trauma-related symptoms (Palic & Elklit, 2011). In addition, the fact that many studies did not consider the impact of participant characteristics (demographic variables, comorbidity, general functioning, etc.) on intervention outcomes gives rise to questions about which factors mediate the efficacy of intervention. Future evaluation of intervention efficacy should take into account the chronic, long-lasting consequences of trauma among refugees and asylum seekers (Murray et al., 2010). Although many treatments for traumatized refugees revealed promising results, very few patients are actually free from PTSD at the end of the intervention. Therefore, Palic and Elklit (2011) asserted that focus on the long-term treatment effects is needed before any conclusion about treatment efficacy could be drawn. While aiming to present an up-to-date review of the central findings in the field, this review is obviously limited by its non-exhaustive literature search. Due to the limited number of evidence-based studies in the field, asylum seekers were not distinguished from refugees, although the two groups cope with different challenges. In addition, the fact that articles in this review included different refugee populations limits their generalizability and cannot supply conclusions toward the suitability of the interventions for other refugee statuses or origins. Nevertheless, this review has again highlighted the shortage of guiding frameworks available to investigators and clinicians who are interested in tailoring interventions to work with refugees and asylum seekers. The challenge is to develop evidence-based, culturally sensitive interventions
that would reflect the different worldviews and cultural backgrounds of clients (such as norms, customs, language, lifestyle, etc.), incorporating clients’ ethnic, linguistic, racial and cultural background into therapy (Zayas, Torres, Malcolm, & DesRosiers, 1996). Additionally, it is important to consider acculturation processes, such as acculturative stress, phases of migration, developmental stages, availability of social support and the one’s relationship to his or her country or culture of origin (Bernal & SáezSantiago, 2006). Finally is the concern expressed by many professionals (Harvey, 2007; Kramer & Bala, 2004; Papadopoulos, 2007; Tomasso, 2010) that existing research on refugee mental health has overlooked the large majority of refugees who display enormous capacities for resilience. Although trauma and its sequel are targets for comprehensive discussion, strength, growth and resilience have only recently become the focus of attention (Murray & Zautra, 2012). Because most resilience theories were developed within Western populations, which mainly emphasizes individual resilience, our understanding of resilience processes among non-Western cultures is very limited (Ungar, 2008). Many authors have underscored that individual models of resilience are not sufficient and at times may even be harmful (Bracken, 2002; Westoby, 2008). A community resilience framework provides an important way of understanding human adaptation, in particular among cultures with more collectivist values. Thus, there is a need for additional research of the similarities and differences in resilience processes across cultures (Ungar, 2008).
Conclusion This article reviewed the current literature describing mental health interventions for traumatized refugees and asylum seekers. Up to date, CBT and NET arose as two evidence-based and effective strategies for these populations. There is not enough data to confirm or refute alternative approaches, such as group intervention, family intervention or multidisciplinary approach in working with traumatized refugees and asylum seekers. In light of the lack of methodologically rigorous trials in the field, it is advisable that health promotion researchers should attempt to develop randomized designs that are both appropriate and feasible to refugee population rather than expending research efforts on alternative methods. Future research should go beyond the common, individualistic PTSD approach to include the broad experience of forced migration, while incorporating in-depth knowledge of cultural issues related to functioning and adaptation. A community resilience framework can provide an important way of understanding trauma and resettlement that is useful in guiding research, intervention and advocacy. Systemic interventions that recognize and foster communities’
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Slobodin and de Jong natural and adaptive ways of coping allow the community to sustain its sense of agency and self-respect and enhance positive adaptation in both individual and group levels. In addition to the development of therapeutic interventions for refugees, there is a need to consider the ethical dilemmas that these services raise for professionals, such as different expectation from interventions, mutual suspicion and distrust, and therapist’s involvement in advocacy aspects of the asylum procedure. Acknowledgements The authors gratefully thank Rob van Dijk for reviewing this article and for his excellent comments.
Conflict of interest The authors report no conflict of interests.
Funding The review was made possible with the support of i-psy (intercultural psychiatry).
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Slobodin and de Jong refugees from a Danish treatment centre for rehabilitation of traumatized refugees. Torture, 19, 248–270. Palic, S., & Elklit, A. (2011). Psychosocial treatment of posttraumatic stress disorder in adult refugees: A systematic review of prospective treatment outcome studies and a critique. Journal of Affective Disorders, 131, 8–23. Papadopoulos, R. K. (2007). Refugees, trauma and adversityactivated development (Special edition: Refugees and asylum seekers). European Journal of Psychotherapy, Counseling and Health, 9, 301–312. Renner, W., Bänninger-Huber, E., & Pelzer, K. (2011). Culturesensitive and resource oriented peer (CROP) – Groups as a community based intervention for trauma survivors: A randomized controlled pilot study with refugees and asylum seekers from Chechnya. Australasian Journal of Disaster and Trauma Studies, 1, 1–13. Retrieved from http://www. massey.ac.nz/~trauma/issues/2011-1/renner.htm Rimpela, A. (2000). Challenging current evaluation approaches: Lessons from the conference for the research community. In L. Norheim, & M. Waller (Eds.), Best practices, quality and effectiveness of health promotion. Helsinki, Finland: Finnish Centre for Health Promotion. Rohlof, J. G. B.M. (1995). Psychopharmacological treatment of traumatized refugees. Retrieved from: http://www.rohlof. nl/psychotropics.htm Ruf, M., Schauer, M., Neuner, F., Catani, C., Schauer, E., & Elbert, T. (2010). Narrative Exposure Therapy for 7 to 16-year-olds: A randomized controlled trial with traumatized refugee children. Journal of Traumatic Stress, 23, 437–445. Shah, A. (2004). Ethnicity and the common mental disorders. In D. Melzer, & R. Jenkins (Eds.), Social inequalities and the distribution of the common mental disorders (pp. 171–223). East Sussex, UK: Psychology Press Ltd. Shamai, M. (1999). Beyond neutrality – A politically oriented systemic intervention. Journal of Family Therapy, 21, 217– 229. Sieberer, M., Ziegenbein, M., Eckhardt, G., Machleidt, W., & Calliess, I. T. (2011). Psychiatric expert opinions on asylum seekers in Germany. Psychiatrische Praxis, 38, 38–44. Silove, D., Manicavasagar, V., Coello, M., & Aroche, J. (2005). PTSD, depression, and acculturation. Intervention, 3, 46– 50. Silove, D., Sinnerbrink, I., Field, A., Manicavasagar, V., & Steel, Z. (1997). Anxiety, depression and PTSD in asylum-seekers: Associations with pre-migration trauma and post-migration stressors. British Journal of Psychiatry, 170, 351–357. Snodgrass, L. L., Yamamoto, J., Fredrick, C., Ton-That, N., Foy, D. W., Chan, L., ... Fairbanks, L. (1993). Vietnamese refugees with PTSD symptomatology: Intervention via a coping skills model. Journal of Traumatic Stress, 6, 569–575. Sonne, C., Carlsson, J., Elklit, A., Mortensen, E. L., & Ekstrøm, M. (2013). Treatment of traumatized refugees with sertraline versus venlafaxine in combination with psychotherapy – Study protocol for a randomized clinical trial. Trials, 14, 137. Steel, Z., Momartin, S., Bateman, C., Hafshejani, A., Silove, D. M., Everson, N., ... Mares, S. (2004). Psychiatric status of asylum seeker families held for a protracted period in a remote detention centre in Australia. Australian and New Zealand Journal of Public Health, 28, 527–553.
Stein, D. J., Ipser, J. C., & Seedat, S. (2006). Pharmacotherapy for post traumatic stress disorder (PTSD). Cochrane Database System Reviews, CD002795. Ter Heide, F., Mooren, T., Kleijn, T. M., de Jongh, A., & Kleber, R. J. (2011). EMDR versus stabilization in traumatized asylum seekers and refugees: Results of a pilot-study. European Journal of Psychotraumatology, 2, 5811–5821. Tomasso, L. (2010). Approaches to counseling resettled refugee and asylum seeker survivors of organized violence. International Journal of Child Youth and Family Studies, 1, 244–264. Ungar, M. (2008). Resilience across cultures. British Journal of Social Work, 38, 218–235. The United Nations Refugee Agency. (2009).UNHCR policy on refugee protection and solutions in urban areas. Retrieved from http://www.unhcr.org/4ab356ab6.pdf United States Committee for Refugees and Immigrants. (2011). Human trafficking victims. Retrieved from http://www. refugees.org/our-work/child-migrants/human-traffickingvictims-1.html Van Loon, A., van Schaik, D. J. F., Dekker, J. J., & Beekman, A. T. F. (2011). Effectiveness of an intercultural module added to the treatment guidelines for Moroccan and Turkish patients with depressive and anxiety disorders. BMC Psychiatry, 11, 13–19. Van Wyk, S., & Schweitzer, R. D. (2013). A systematic review of naturalistic interventions in refugee populations. Journal of Immigrants and Minority Health. Advance online publication. doi:10.1007/s10903-013-9835-3 Varvin, S., & Aasland, O. G. (2009). Physicians’ attitude towards treating refugee patients. Tidsskrift for den Norske Laegeforening, 129, 1488–1490. Victorian Foundation for Survivors of Torture. (1998). Rebuilding shattered lives. Melbourne, Victoria, Australia: Author. Vincent, F., Jenkins, H., Larkin, M., & Clohessy, S. (2012). Asylum seekers’ experiences of trauma focused cognitive behavior therapy: A qualitative study. Behavioral and Cognitive Psychotherapy, 41, 579–593. Walsh, F. (2007). Traumatic loss and major disasters: Strengthening family and community resilience. Family Processes, 46, 207–227. Weine, S., Kulauzovic, Y., Klebic, A., Besic, S., Mujagic, A., Muzurovic, J., ... Rolland J. (2008). Evaluating a multiplefamily group access intervention for refugees with PTSD. Journal of Marital and Family Therapy, 43, 149–164. Weine, S. M., Knafl, K., Feetham, S., Kulauzovic, Y., Besic, S., Lezic, A., ... Pavkovic, I. (2005). A mixed-methods study of refugee families engaging in multi-family groups. Family Relations, 54, 558–568. Weine, S. M., Raijna, D., Kulauzovic, Y., Zhubi, M., Huseni, D., Delisi, M., ... Pavkovic, I. (2003). The TAFES multifamily group intervention for Kosovar refugees: A descriptive study. The Journal of Nervous and Mental Disease, 191, 100–107. Weine, S., Muzurovic, N., Kulauzovic, Y., Besic, S., Lezic, A., Mujagic, A., ... Pavkovic, I. (2004). Family consequences of refugee trauma. Family Process, 43, 147–160. Westermeyer, J. (1988). A matched pairs study of depression among Hmong refugees with particular reference to predisposing and factors and treatment outcome. Social Psychiatry and Psychiatric Epidemiology, 23, 64–71.
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ISP0010.1177/0020764014535752International Journal of Social PsychiatrySlobodin and de Jong
E CAMDEN SCHIZOPH
Article
Mental health interventions for traumatized asylum seekers and refugees: What do we know about their efficacy?
International Journal of Social Psychiatry 1–10 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0020764014535752 isp.sagepub.com
Ortal Slobodin1 and Joop TVM de Jong2,3
Abstract Background: The prevalence of trauma-related problems among refugees and asylum seekers is extremely high due to adverse experiences associated with forced migration. Although the literature presents a considerable number of guidelines and theoretical frameworks for working with traumatized refugees and asylum seekers, the efficacy, feasibility and applicability of these interventions have little empirical evidence. Aims: The purpose of this article is to critically review the literature to provide a rationale for developing culturally sensitive, evidence-based interventions for refugees and asylum seekers. Methods: A literature review integrating research findings on interventions designed especially for traumatized asylum seekers and refugees was conducted. Retained studies had to use some quantitative measurements of post-traumatic stress and to have pre- and post-measurements to evaluate the efficacy of the intervention. Studies included in this review cover a wide variety of interventions, including trauma-focused interventions, group therapy, multidisciplinary interventions and pharmacological treatments. Results: The majority of studies with traumatized refugees and asylum seekers reported positive outcomes of the intervention in reducing trauma-related symptoms. There is evidence to support the suitability of cognitive-behavioral therapy (CBT) and narrative exposure therapy (NET) in certain populations of refugees. Other intervention studies are limited by methodological considerations, such as lack of randomization, absence of control group and small samples. Conclusions: This review has again highlighted the shortage of guiding frameworks available to investigators and clinicians who are interested in tailoring interventions to work with refugees and asylum seekers. Theoretical, ethical and methodological considerations for future research are discussed. Keywords Refugees, asylum seekers, intervention, trauma, symptoms, review
Introduction Refugees and asylum seekers are forced migrants. The United Nations High Commissioner for Refugees (UNHCR) estimated that there were 43.3 million forcibly displaced people worldwide at the end of 2009. Of these, 15.2 million were refugees and 983,000 asylum seekers (The United Nations Refugee Agency, 2009). Generally, refugees have a lawful right to enter a country for the purposes of seeking asylum, regardless of how they arrive or whether they hold valid travel or identity documents. Asylum seekers are individuals whose application for asylum or refugee status is pending in the administrative or legal processes (Harris & Zwar, 2005). The process of migration has been described as occurring in broadly three stages, each of them involves the potential for traumatogenic experiences: (a) pre-migration; (b) migration – the physical relocation to the new place
and (c) post-migration – the assimilation within the cultural framework of the new society, through learning its cultural rules (Bhugra, 2001). Prior to migration and during this process, refugees are exposed to exceptionally high rates of traumatic events such as war, violence, torture and persecution (Gerritsen et al., 2006; Steel et al., 2004). Some refugees become subjects of human 1i-psy
(intercultural psychiatry), Amsterdam, The Netherlands Institute of Social Science Research, University of Amsterdam, Amsterdam, The Netherlands 3School of Medicine, Boston University, Boston, MA, USA 2Amsterdam
Corresponding author: Ortal Slobodin, i-psy (intercultural psychiatry), George Westinghousestraat 2, 1097 BA Amsterdam, The Netherlands. Email: [email protected]
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trafficking who may be held for ransom or trafficked for the purpose of forced marriage, sexual exploitation or labor exploitation through the use of force, fraud or coercion (United States Committee for Refugees and Immigrants, 2011). Nevertheless, post-migration adverse experiences, such as lack of social support, acculturation difficulties, poverty, discrimination and changes in identity and concept of self, further complicate the mental problems in those who have been previously traumatized (Bhugra & Becker, 2005; Laban, Gernaat, Komproe, Schreuders, & De Jong, 2004; Silove, Sinnerbrink, Field, Manicavasagar, & Steel, 1997; Walsh, 2007). Many asylum seekers who live in detention camps are exposed to threatening conditions (e.g. sexual harassments, denial of adequate food, inadequate health care, isolation etc.), as well as to continuous uncertainty about their own future and the future prospects of those who were left behind (Carta et al., 2013; Laban et al., 2004). These adverse experiences often lead to extremely high prevalence of psychiatric disorders among refugees and asylum seekers, including depression, post-traumatic stress disorder (PTSD), anxiety, psychosomatic disorders, grief related disorders and crises of existential meaning (Gerritsen, et al., 2006; Laban et al., 2004; Steel et al., 2004). It is estimated that PTSD prevalence among refugees ranges between 20% and 74%, and depression ranges between 39% and 64% (Gerritsen et al., 2006; Laban et al., 2004; Mares & Jureidini, 2004; McColl & Johnson, 2006; Sieberer, Ziegenbein, Eckhardt, Machleidt, & Calliess, 2011). The level of distress depends on many variables, such as duration of the relocation, the similarity between the culture of origin and the culture of settlement, language and social support systems, acceptance by the new nation and employment and education opportunities (Bhugra & Becker, 2005; Cebulla, Daniel, & Zurawan, 2010; Shah, 2004; Walsh, 2007). The refugee patient’s complex problems represent a challenge for all care levels. Language barriers, cultural differences in symptom presentation and clinical severity cause difficulties in understanding symptoms and ailments. General practitioners, who are the main responsibility for treating these patients, often experience that the general treatment conditions are insufficient and that mental health services do not offer adequate help, especially regarding traumatization (Varvin & Aasland, 2009). Furthermore, mental health professionals working with refugees and asylum seekers are facing multiple difficulties in providing adequate care. Interventions with refugees and especially with asylum seekers are threatened by the instability and uncertainty of treatment. Asylum seekers are often relocated to another center or just ‘disappear’ to unknown destination and cannot be followed. If the appeal for asylum is refused, the group health insurance is shortly terminated, thus resulting in a pre-mature termination of therapy. Refugees and asylum seekers are also at high risk of drop out of treatment due to different
expectations of treatment, language problems, interpretation of symptoms and difficulties in communicating with the therapist (Bhatia & Wallace, 2007; Van Loon, van Schaik, Dekker, & Beekman, 2011). Finally, since mental health problems are one of the reasons that could grant asylum, therapists are often asked to indicate their patients’ illness. Some asylum seekers start to believe that the improvement of their stress symptoms may decrease their chance of getting a positive asylum decision (Renner, Bänninger-Huber, & Pelzer, 2011), and may even exaggerate experiences of trauma in order to strengthen their claims (Keller et al., 2003; Laban et al., 2004). These complicated considerations undoubtedly effect the therapeutic alliance, the outcome of treatment and the therapist’s attitudes toward the patient, and pose a serious challenge to mental health professionals. For many years, most psychological treatments used in rehabilitation programs appear to be a mixture of various psychotherapeutic elements, not based on a consistent theory, and lack evidence on their effectiveness (Başoğlu, 2006). Because most efficacy studies do not include minorities in their sample, the literature in the field has long debated whether the standard PTSD interventions, such as cognitive-behavioral therapy (CBT) or eye movement desensitization and reprocessing (EMDR), are applicable to the refugee population or whether a phased model starting with stabilization is preferable. While some clinicians (e.g. Başoğlu, 2006) argue that traumatized refugees should be treated according to the standardized protocols of CBT and EMDR, others (Laban, Hurulean, & Attia, 2009; National Institute for Clinical Excellence (NICE), 2005) argue that treatment should initially focus on daily living problems and a restoration of coping skills. According to the NICE (2005), trauma-focused therapy as the initial stage of therapy should be considered as inappropriate and ineffective. Nevertheless, refugee and asylum seeker patients tend to feel ambivalent about engaging in trauma-focused CBT, mainly for the fear of repatriation (Vincent, Jenkins, Larkin, & Clohessy, 2012). Several authors (Bekker &Van Mens-Verhulst, 2008; Bernal & Sáez-Santiago, 2006) have argued that the lack of evidence-based treatments makes therapists in the field confused and uncertain about the appropriate intervention. In particular, training was needed regarding assessment and therapeutic issues, involving culturally appropriate interventions, cultural awareness, working with interpreters, legal and social issues and trauma work (Maslin & Shaw, 2003). The aim of the current article is to review the evidence-based data regarding mental health interventions designed especially for traumatized asylum seekers and refugees.
Method To locate studies for this review, we searched PsycINFO, Entrez-PubMed and PsycARTICLES. Keywords ‘trauma’,
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Slobodin and de Jong ‘asylum seekers’, ‘refugees’, ‘treatment’ and ‘intervention’ were selected. These search terms narrowed the list of articles to those of interest (studies of intervention used to treat conditions of trauma among asylum seekers and refugees and those that have already been screened for quality by the peer review process). In addition, we consulted previous review articles (Crumlish & O’Rourke, 2010; McFarlane & Kaplan, 2012; Murray, Davidson, & Schweitzer, 2010; Palic & Elklit, 2011) and contacted researchers who are known to be engaged in treatment research with these populations. The studies we retained had to meet two criteria. They had to use some quantitative measurements of posttraumatic stress and to have pre- and post-measurements to evaluate the efficacy of the intervention. The studies included in this review cover a wide variety of interventions, including trauma-focused interventions, multidisciplinary interventions and pharmacological treatments.
Findings from the studies: mental health interventions for refugees and asylum seekers While not claiming to be exhaustive, this review seeks to describe the current, pivotal, findings with treating traumarelated problems among refugees and asylum seekers. Many treatment strategies and techniques have been developed and used worldwide to help asylum seekers and refugees. However, only a minority of them used a known research methodology which allows generalization. A systematic review (Crumlish & O’Rourke, 2010), including a total of 10 randomized-controlled intervention studies among refugees and asylum seekers with PTSD, revealed that no PTSD treatment has been firmly supported by research. There was evidence for the efficacy of narrative exposure therapy (NET) and CBT. Nevertheless, a later systematic review by Palic and Elklit (2011), which included a wider spectrum of prospective designs (not only randomized-controlled trials (RCTs)), concluded that CBT and NET are two well-studied and effective interventions among refugees. In a recent work, McFarlane and Kaplan (2012) reviewed research evidence on psychosocial interventions for adult survivors of torture and trauma (resettled refugees, asylum seekers, displaced persons and persons resident in their country of origin). They identified a total of 40 studies from 1980 to 2010 that investigated interventions for adult survivors of torture, including RCTs (11/40), non-RCTs (8/40) and single cohort studies (21/40). While single cohort studies were the most common approach in the field, RCTs examining the efficacy of applied treatments with asylum seekers and refugees were very few and included small samples. RCTs mainly examined individual psychotherapies that targeted PTSD symptoms.
NET NET incorporates CBT and testimony therapy. It is specifically targeted at the refugee populations by acknowledging the narrative tradition common to many cultures. Neuner et al. (2010) carried out an RCT with 32 asylum seekers in Germany. Participants with PTSD received treatment as usual (public mental health care) or 5–17 sessions of NET. The amount of ‘treatment as usual’ was not known. After treatment, NET participants had significantly improved PTSD and pain symptoms compared to treatment as usual. There were no improvements in depression. However, at 6 months, all participants except one still had PTSD. In a RCT, Hensel-Dittmann et al. (2011) compared the outcome of NET and stress inoculation training (SIT) among refugees and asylum seekers in Germany. This study revealed that a significant reduction in PTSD symptoms was found for NET, but not for SIT. Major depression and other comorbid disorders did not decrease in both groups. In another NET trial, PTSD caseness at follow-up was significantly lower among NET participants than among supportive counseling or psychoeducation participants (Neuner, Schauer, Klaschik, Karunakara, & Elbert, 2004). The advantage of NET over supportive counseling was not consistent across studies (Neuner et al., 2008), although both interventions were superior to the notreatment condition (Neuner et al., 2008; Ruf et al., 2010). Finally, Halvorsen and Stenmark (2010) reported moderate therapeutic gains in 16 torture survivor refugees on PTSD and depression measures. Taken together, NET appears as an effective intervention in reducing PTSD symptoms in traumatized refugees. However, it does not have any advantage over treatment as usual when it comes to anxiety and depression (Palic & Elklit, 2011).
CBT CBT interventions for traumatized refugees are relatively well researched and support the use of trauma-focused CBT among refugees. The majority of firm evidence is centered in special variants of CBT, which incorporates cultural knowledge into standard CBT methods for Southeast Asians. By using cultural study of symptoms and their meaning, Hinton and his colleagues (Hinton et al., 2005; Hinton, Hofmann, Pitman, Pollack, & Barlow, 2008) tested the applicability of a somatic-focused CBT to traumatized Cambodian refugees. The treatment which is called ‘Flexibility and Sensation-Reprocessing Therapy’ was based on a careful analysis of symptom presentation among Cambodian refugees. This cultural phenomenology of illness experience included a study of sensation-related catastrophic cognitions, trauma associations, metaphors and cultural expectations for treatment. In a RCT, Hinton et al. (2005) reported that 12 patients (60%) in the immediate treatment group were in remission from PTSD after
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their course of CBT, while none were in remission in the control group. However, most of CBT trials were performed among Cambodian refugees and half of them (2 of 4) were pilot studies with a moderate to high risk of bias (Hinton et al., 2004; Otto et al., 2003). Integrating CBT with other types of interventions has also revealed positive results. Snodgrass et al. (1993) studied the effects of a 3-month CBT treatment that included coping skills group with 11 Vietnamese refugees with PTSD symptoms. Treatment consisted of six 3-hour weekly sessions (including relaxation, CBT, psychoeducation, self-talk and role modeling of stressful scenarios). Significant reductions in PTSD symptoms and improved ability to relate to others were found in treatment group but not in the control group (no-treatment).
EMDR In a pilot RCT comparing EMDR and stabilization in 20 traumatized refugees and asylum seekers, it was found that EMDR and stabilization were equally accepted by patients, with a high drop-out for both conditions. No participant dropped out of the EMDR condition because of unmanageable distress. While improvement for EMDR participants was small, EMDR was found to be no less efficacious than stabilization. The authors concluded that because EMDR showed some improvement and stabilization showing some deterioration between pre-treatment and post-treatment, there is a rationale to integrate the two approaches (Ter Heide, Mooren, Kleijn, de Jongh, & Kleber, 2011).
Family interventions Given the importance of the family in the aftermath of trauma and the theoretical ease of including the social and cultural context in systemic approaches to therapy (Mendenhall & Berge, 2010; Shamai, 1999; Woodcock, 2001), family interventions are argued to be a suitable approach for refugees (Allen & Bloom, 1994; Figley & Figley, 2009; Ter Heide et al., 2011; Weine et al., 2003, 2004, 2005; Zagelbaum & Carlson, 2011). Although some authors have described their experience with traumatized refugee families, there is a dearth of evidence-based data that would confirm the applicability of systemic family intervention to these groups (Coulter, 2010; Weine et al., 2008). In one of the few RCTs, Weine et al. (2008) showed that multi-family group intervention increased the number of mental health visits of Bosnian refugees compared to no-treatment control group. This difference was constant over time (6, 12 and 18 months following intervention), and was observed in both primary participants and their family members. However, this study did not evaluate the efficacy of the intervention in reducing depression or PTSD symptoms. In another study of Kataoka et al. (2003),
CBT therapy with 2-hour optional multi-family group sessions were assigned to Latino immigrant children in the United States and their families (37% of parents attended at least one session). Results showed that PTSD and depressive symptoms significantly decreased in the intervention group, but not in the control group. There was no report whether engaging in the multi-family group sessions had any advantage over CBT-only. In this study, only a portion of the participants were randomized.
Group interventions Research on group interventions among asylum seekers is even rarer than individual approaches. Drozdek (1997) recruited 120 Bosnian concentration camp survivors in the Netherlands who were asylum seekers at the time. Most were diagnosed with PTSD and were offered psychodynamic group therapy, psychodynamic group therapy plus medication or medication only. Control group was composed of participants with PTSD who refused treatment. No significant differences between the active interventions were found for PTSD diagnosis. Recently, Drozdek, Kamperman, Bolwerk, Tol, and Kleber (2012) evaluated the effectiveness of three different trauma-focused daytreatment group programs for treatment of PTSD in male asylum seekers and refugees from Iran and Afghanistan. The results of this study indicated that group psychotherapy combined with nonverbal treatments significantly improved the mental health of asylum seekers and refugees with PTSD, as compared to a waiting list group. Similarly, Renner et al. (2011) examined the efficacy of group intervention in reducing post-traumatic symptoms, anxiety, and depression symptoms among Chechen refugees in Austria. Results indicated that the group intervention was significantly superior to no-treatment condition, but was equally effective as CBT. Individual EMDR yielded negative results.
Multidisciplinary interventions In addition to standard trauma-focused methods, several studies employed a more integrative approach in working with refugees and asylum seekers. Two studies evaluated the efficacy of multidisciplinary treatment (psychotherapy, family therapy and/or medication) in reducing psychiatric symptoms in Hmong refugees (Westermeyer, 1988; Westermeyer, Vang, & Neider, 1984) compared to a control group of non-help-seeking participants. Both studies suggested that depression and psychopathology among Hmong refugees improved with multidisciplinary outpatient treatment, and the gains were maintained after 2 years. However, the fact that the intervention and control groups differed on relevant variables at baseline limits their conclusions. In the last decade, several non-experimental studies (without a
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Slobodin and de Jong control group) using multidisciplinary treatment were published. All of them used psychotherapy, psychopharmacological treatment and usually physiotherapy (Arcel et al., 2003; Brune et al., 2002; Carlsson, Mortensen, & Kastrup, 2005; Palic & Elklit, 2009). Except for Carlsson et al. (2005), moderate to large effect sizes were found for PTSD, anxiety, depression and global function. Given that the majority of these studies are non-experimental, future controlled studies of multidisciplinary treatments are warranted (Palic & Elklit, 2011).
Naturalistic interventions One of the prominent issues in the research of ethnic minorities is the preference for naturalistic designs (McFarlane & Kaplan, 2012), which is based on both theoretical and ethical/practical rationales (Silove, Manicavasagar, Coello, & Aroche, 2005; Van Wyk & Schweitzer, 2013). In a systematic literature review, Van Wyk and Schweitzer (2013) examined the outcomes of naturalistic interventions (provided within treatment setting) to people from refugee background. They identified only 7 eligible studies and pointed out a significant variation in the outcomes of naturalistic intervention studies, with a trend toward showing decreased symptomatology at post-intervention. However, conclusions were limited by methodological problems of the studies reviewed, particularly poor documentation of intervention methods and lack of control group.
Pharmacological interventions The pharmacological treatments of choice today for PTSD are antidepressants from the subgroup selective serotonin reuptake inhibitors, especially sertraline (Sonne, Carlsson, Elklit, Mortensen, & Ekstrøm, 2013). There may be an assumption that evidence from drug trials in the general population applies to the refugee population in a way that psychological interventions do not (Stein, Ipser, & Seedat, 2006). However, sufficient evidence is lacking to draw conclusions on the efficiency of psychopharmacological treatments of traumatized refugees with PTSD (Crumlish & O’Rourke, 2010; Rohlof, 1995; Sonne et al., 2013). Moreover, the NICE (2010) asserted that drug treatments for PTSD should not be used as a routine first-line treatment for adults (in general use or by specialist mental health professionals) in preference to a trauma-focused psychological therapy. Prescribing pharmacological treatment to individuals coming from another culture requires a careful consideration of issues such as variability of medication effects in different ethnic groups, compliance rates and sensibility to side effects (Kroll et al., 1990; Lin, Poland, & Lesser, 1986; Lin & Shen, 1991). High-quality drug trials should be conducted in refugee populations, to guide treatment when psychological interventions are
unavailable or poorly tolerated (Crumlish & O’Rourke, 2010). Of note, a large Danish RCT (n = 150) of antidepressant treatment (sertraline or venlafaxine) and/or CBT with traumatized refugees was assigned for 2013 (Sonne et al., 2013).
Discussion The treatment of refugee populations is only recently considered as a distinct area in the field of mental health (De Jong & Van Ommeren, 2002; Miller & Rasco, 2004). This review points out the heterogeneous types and qualities of interventions assigned for traumatized refugees and asylum seekers and the shortage of evidence-based treatments for these populations. Currently, two directions of intervention are wellresearched and revealed promising results: the cultural sensitive CBT and the NET; both incorporated culturally sensitive attitude and techniques into the standard protocols. Both strategies were studied with RCTs and yielded large effect sizes. Other intervention studies are limited not only by methodological problems (e.g. lack of RCTs, little samples, etc.) but also by trying to use standardized approaches to PTSD instead of basing them on a local understanding of trauma and psychological distress in this population (Crumlish & O’Rourke, 2010). Contrary to some professionals’ view (Laban et al., 2009; NICE, 2005) that stabilization should be preferred over trauma-focused therapy when working with refugee population, findings suggest that when culturally adapted, standardized protocols of trauma-focused interventions, such as CBT, could be suitable for traumatized refugees. To our knowledge, there is no firm evidence that exposure to traumatic contents in the therapeutic setting causes repatriation, fragmentation or worsening of symptoms. However, further research is needed in order to identify potential barriers to treatment. Several theoretical and methodological considerations in refugee trauma research arise from this review. First, attention should be given to the complexity of employing RCTs in refugee populations (Goodkind, LaNoue, Lee, Freeland, & Freund, 2012; Kataoka et al., 2003; Silove et al., 2005). It has been argued that RCTs are of use only when studying narrowly defined groups of people under artificial laboratory conditions, and thus their external validity is questionable (Fuller, 1999). Goodkind et al. (2012), who studied the efficacy of community intervention for trauma in American Indian and Alaska Native youth, indicated that a control group is not an appropriate design when working with small communities, because the interconnectedness of families increases the risk for contamination across groups. Moreover, studies of immigrants and refugees are often conducted within regular assistance programs that do not allow for randomization due to practical and ethical considerations (i.e. it is unfair to prevent
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treatment from some people while providing it to others) (McDonald, 2009; Rimpela, 2000; Silove et al., 2005). Some non-randomized studies used a control group of individuals who did not seek mental help (Westermeyer et al., 1984; Westermeyer, 1988) or refused it (Drozdek, 1997). These methods involve major methodological limitations, such as differences in baseline condition and other clinical and personality characteristics that may affect treatment outcomes. These complexities should not automatically lead health researchers to avoid RCT, but rather call for the development of more sophisticated methods of randomization, for example, those that involve dialogue with patients and take patients’ needs and preferences into account (Jadad, 1998). Another important issue arising from this review is the assessment of treatment efficacy. The majority of the studies reviewed here used the improvement of PTSD symptoms as an indicator to intervention efficacy. However, it may be instructive to include other dimensions of personality such as improvements in relationships, identity and meaning (Victorian Foundation for Survivors of Torture, 1998). In addition, because refugees often present more complex traumatic reactions to trauma reactions than those strictly specified in the diagnostic category of PTSD, effectiveness of PTSD treatments should address a boarder range of trauma-related symptoms (Palic & Elklit, 2011). In addition, the fact that many studies did not consider the impact of participant characteristics (demographic variables, comorbidity, general functioning, etc.) on intervention outcomes gives rise to questions about which factors mediate the efficacy of intervention. Future evaluation of intervention efficacy should take into account the chronic, long-lasting consequences of trauma among refugees and asylum seekers (Murray et al., 2010). Although many treatments for traumatized refugees revealed promising results, very few patients are actually free from PTSD at the end of the intervention. Therefore, Palic and Elklit (2011) asserted that focus on the long-term treatment effects is needed before any conclusion about treatment efficacy could be drawn. While aiming to present an up-to-date review of the central findings in the field, this review is obviously limited by its non-exhaustive literature search. Due to the limited number of evidence-based studies in the field, asylum seekers were not distinguished from refugees, although the two groups cope with different challenges. In addition, the fact that articles in this review included different refugee populations limits their generalizability and cannot supply conclusions toward the suitability of the interventions for other refugee statuses or origins. Nevertheless, this review has again highlighted the shortage of guiding frameworks available to investigators and clinicians who are interested in tailoring interventions to work with refugees and asylum seekers. The challenge is to develop evidence-based, culturally sensitive interventions
that would reflect the different worldviews and cultural backgrounds of clients (such as norms, customs, language, lifestyle, etc.), incorporating clients’ ethnic, linguistic, racial and cultural background into therapy (Zayas, Torres, Malcolm, & DesRosiers, 1996). Additionally, it is important to consider acculturation processes, such as acculturative stress, phases of migration, developmental stages, availability of social support and the one’s relationship to his or her country or culture of origin (Bernal & SáezSantiago, 2006). Finally is the concern expressed by many professionals (Harvey, 2007; Kramer & Bala, 2004; Papadopoulos, 2007; Tomasso, 2010) that existing research on refugee mental health has overlooked the large majority of refugees who display enormous capacities for resilience. Although trauma and its sequel are targets for comprehensive discussion, strength, growth and resilience have only recently become the focus of attention (Murray & Zautra, 2012). Because most resilience theories were developed within Western populations, which mainly emphasizes individual resilience, our understanding of resilience processes among non-Western cultures is very limited (Ungar, 2008). Many authors have underscored that individual models of resilience are not sufficient and at times may even be harmful (Bracken, 2002; Westoby, 2008). A community resilience framework provides an important way of understanding human adaptation, in particular among cultures with more collectivist values. Thus, there is a need for additional research of the similarities and differences in resilience processes across cultures (Ungar, 2008).
Conclusion This article reviewed the current literature describing mental health interventions for traumatized refugees and asylum seekers. Up to date, CBT and NET arose as two evidence-based and effective strategies for these populations. There is not enough data to confirm or refute alternative approaches, such as group intervention, family intervention or multidisciplinary approach in working with traumatized refugees and asylum seekers. In light of the lack of methodologically rigorous trials in the field, it is advisable that health promotion researchers should attempt to develop randomized designs that are both appropriate and feasible to refugee population rather than expending research efforts on alternative methods. Future research should go beyond the common, individualistic PTSD approach to include the broad experience of forced migration, while incorporating in-depth knowledge of cultural issues related to functioning and adaptation. A community resilience framework can provide an important way of understanding trauma and resettlement that is useful in guiding research, intervention and advocacy. Systemic interventions that recognize and foster communities’
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Slobodin and de Jong natural and adaptive ways of coping allow the community to sustain its sense of agency and self-respect and enhance positive adaptation in both individual and group levels. In addition to the development of therapeutic interventions for refugees, there is a need to consider the ethical dilemmas that these services raise for professionals, such as different expectation from interventions, mutual suspicion and distrust, and therapist’s involvement in advocacy aspects of the asylum procedure. Acknowledgements The authors gratefully thank Rob van Dijk for reviewing this article and for his excellent comments.
Conflict of interest The authors report no conflict of interests.
Funding The review was made possible with the support of i-psy (intercultural psychiatry).
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