Counselling And Psychotherapy With Refugees
Before clinicians begin working with immigrants and refugees, they should understand the context of immigration in the United States, both today and historically. The U.S. government has repeatedly used immigration policy as a tool to deny citizenship to people of color, including through the Naturalization Act of 1790 and the Chinese Exclusion Act of 1882, said Germán Cadenas, PhD, an assistant professor of counseling psychology at Lehigh University in Bethlehem, Pennsylvania, who studies the psychology of undocumented immigrants.
Counselling And Psychotherapy With Refugees
Cadenas recommends that psychologists connect with advocacy groups such as Informed Immigrant, the Coalition for Humane Immigrant Rights, and Immigrants Rising for policy updates and explanations of some of the more complex issues that impact immigrants and refugees.
Dick Blackwell's unique framework is based on work carried out at the Medical Foundation for the Care of Victims of Torture. It offers a flexible approach to the special circumstances of displaced and traumatized clients from different cultural and political backgrounds. The author considers four levels of experience - political, cultural, interpersonal and intrapsychic - and explores each of these in relation to both the client and therapist. He also includes practical information on advocacy, supervision and working with interpreters.Author Biography:Dick Blackwell is a psychotherapist and organisational consultant, group analyst and family therapist. He has more than 16 years' experience as a psychotherapist and supervisor at the Medical Foundation for the Care of Victims of Torture, and has written numerous articles on working with refugees and on the political and social contexts of psychotherapy.
High levels of trauma-related psychological distress have been documented among ethnically diverse refugees. As the number of refugees worldwide continues to grow, determining the efficacy of established methods of trauma-focused therapy for this population is crucial. This meta-analysis examined the results of randomized controlled trials of psychotherapeutic intervention for traumatized adult refugees. Comparisons of 13 trauma-focused therapies to control groups from 12 studies were included in the analysis. The aggregate effect size for the primary outcome, posttraumatic stress disorder (PTSD), was large in magnitude, Hedge's g = .91, p
We employed a qualitative study design, conducting semi-structured in-depth interviews with 10 purposely selected psychotherapists working with refugees in Germany. Respondents were from varying theoretical background and had varying levels of experience. Data were analyzed using a thematic approach, following a mix of deductive and inductive coding.
Results show that psychotherapy with refugees can be very successful, at least from the psychotherapist perspective, but also poses significant challenges. Our findings underline the importance of developing, testing, and institutionalizing structured and structural approaches to training psychotherapists in cross-cultural therapy at scale, to accommodate the rising mental health care need of refugees as a client group.
Asylum seekers and refugees are exposed to various traumatic events pre-, peri-, or post-migration, which put them at high risk to develop mental health issues [4, 5]. Recent reviews on the prevalence of mental health issues among young and adult refugees and asylum seekers in Europe reported higher prevalences of post-traumatic stress disorder, anxiety disorders, depression, and other mental health issues compared to the general population [6,7,8], although with substantial variation by origin and other factors.
However, this does not mean that no challenges in working with this group exist. In contrast to the fairly elaborate literature on barriers in access to psychotherapy and on the general effectiveness of psychotherapy with refugees, little research has been done on how psychotherapists, who often are not specifically trained in working with refugee clients [28], experience the cross-cultural psychotherapeutic process, which we define as a therapeutic encounter between a psychotherapist and a client of different cultural backgrounds. The little available research highlights issues such as communication difficulties, differences in illness attribution belief systems, differences in expectations towards treatment, and issues related to trust as main challenges [15, 26, 31,32,33].
Unrealistic and different expectations of clients about what psychotherapy can do for them were mentioned as one of the key challenges, with the potential to undermine trust and client openness early into the therapeutic relationship. Participants assumed that such expectations were grounded in a lack of knowledge, and thus emphasized the importance of taking the time to inform clients about the role of psychotherapists and what psychotherapy can and cannot do for them in straightforward language. In that context, participants underlined the importance of being adequately informed about the asylum procedures and the ability to refer clients to the responsible bodies as an essential strategy for their work with their refugees, even if in principle not their responsibility.
Thus, they rather recommended working without translators and using non-verbal approaches like sand play, where clients are asked to express their thoughts and feelings using forms and shapes in the sand, drawings, body language, and other non-verbal communication, especially in working with young refugees.
This underlines perhaps the biggest problem in addressing mental health of refugees and asylum seekers: Although substantial influx of refugees has long become a reality and elevated mental health care needs are well known, and although tools to adequately do so are well established in principle, health and social security systems have not only failed in enabling de facto access to mental health care, but also in preparing health system actors for the challenges they face in working with this new client group.
Our 15 included articles captured findings from 14 randomized controlled trials conducted in Denmark (1), Egypt (1), Germany (3), Norway (1), Sweden (1), Thailand (1), Uganda (2), and the United States (4). All studies were conducted among refugees or asylum seekers with experience of trauma. Interventions included Narrative Exposure Therapy (NET), Common Elements Treatment Approach (CETA), Stress Management (SM), Cognitive Behavioral Therapy (CBT), and Interpersonal Therapy (IPT). We obtained training materials for all interventions in the form of books, training manuals, and peer-reviewed articles. See Table 3 for additional study characteristics.
We tabulated the effectiveness of individual psychotherapies on participant attrition, anxiety, depression, and PTSD symptomology in Supplementary S5. In summary, all included psychotherapies (CBT, CETA, IPT, NET, and SM) had statistically significant positive effects on symptoms of PTSD. Findings on depression and anxiety outcomes varied across studies. For example, four studies on CBT consistently demonstrated improved symptoms of anxiety and depression when compared with a wait-list control [37,40,41] or exposure therapy [49]. In contrast, NET reduced symptoms of depression in three studies [26,36,50] but had no impact on depression in two other studies [35,46]. Researchers highlighted that refugees with a secure legal status reported less depression across all time points [50]. NET was reported to be equivalent to supportive counselling and psychoeducation according to indicators of depression and anxiety [48]. CETA was effective in reducing symptoms of depression and anxiety, and these results were not dependent on the gender of the participant or severity of trauma [29].
Our systematic search and realist-informed analysis of randomized controlled trials provided data which we then applied to a context-mechanism-outcome configuration to evaluate the success of community-based psychotherapy for trauma-affected refugees. The context within which most refugees seek care is generally in migrant-sensitive healthcare settings and community-based practices [2]. These practices improve access, lessen transportation and financial and migration status needs, and reduce mental health treatment related stigma with interdisciplinary primary care teams. Literature suggests that the way in which care is delivered, or the mechanisms of delivery, are fundamental to successful outcomes. In this study we found that the management of refugee mental health can be tasked-shifted from specialty care (e.g., psychiatry) to primary care [29,42,47,48]. Primary care may include physicians, nurse practitioners, nurses, social workers, settlement workers, and sometimes cultural navigators and even shared mental health care teams. Mental health programs and clinicians can adopt a trauma-informed approach and deliver culturally appropriate psychotherapy to refugees with common mental health conditions. Existing psychotherapeutic approaches, such as CBT, have been culturally adapted with success [40,41].
Several systematic reviews have examined the effectiveness of psychotherapies for refugees. NET and CBT have the most robust evidence base for refugee populations [55,56,57]. Interestingly, effect sizes for the effectiveness of NET are substantially larger when delivered by refugee community counselors as opposed to clinical practitioners [58]. However, the mechanisms by which this larger effect occurs remain unknown. Our realist synthesis suggests that a shared lived experience of trauma or shared culture between practitioners and patients may reduce stigma and improve understanding. Existing reviews also report that asylum seekers and displaced persons face the uncertainty of protection and fear of return to danger [59], and that insecure residence status increases the risk of mental health problems. As such, empirical evidence suggests that programs that are effective for PTSD in the general population may not completely overlap with those that are appropriate for PTSD in asylum seekers and refugees [57]. While trauma-focused therapies for refugees reduce symptoms of PTSD and depression, more research is needed on the role of cultural factors and programs in the treatment of refugee populations [60]. 041b061a72
