adapting interventions for refugee youth: trauma systems therapy for somali adolescent refugees b....
TRANSCRIPT
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Adapting Interventions for Refugee Youth:
Trauma Systems Therapy for Somali Adolescent Refugees
B. Heidi Ellis
Alisa Miller
Saida Abdi
And the Project SHIFA team: Naima Agalab, Abdi Yusuf, Colleen Hayden, Molly Benson, Lee Staples, Ellen Devoe, Deb Socia, Hassan Warfa, Yolanda Coentro, Imani Seularine, Amy Spindel, Glenn Saxe, Lisa Baron, Bob Kilkenny
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Children’s Hospital Center for Refugee Trauma
A project under the Robert Wood Johnson Foundation’s Caring Across Communities program
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Overview
• Need
• Overview of Trauma Systems Therapy
• Process and principles of adapting treatment for refugees
• Questions for the field
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Local Data: Somali Youth Mental Health Needs
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Trauma exposure
Trauma exposedNot exposed
94%
•Youth reported having experienced on average 7 traumatic events (range 0-22)*
* Ellis, et al. (2008). Mental health of Somali adolescent refugees: The role of trauma, stress, and perceived discrimination. Journal of Consulting and Clinical Psychology, 76, 184-193.
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PTSD
33%38%
29%
Full PTSDPartial PTSDNo PTSD
•Nearly 2/3 of youth reported significant PTSD symptoms, and 1/3 screened positive for Full PTSD*
* Ellis, et al. (2008). Mental health of Somali adolescent refugees: The role of trauma, stress, and perceived discrimination. Journal of Consulting and Clinical Psychology, 76, 184-193.
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Service utilizationOf those with full PTSD, how many sought
services of any type?
92%
8%
No Services
Sought services
* Ellis, et al. (2008). Mental health of Somali adolescent refugees: The role of trauma, stress, and perceived discrimination. Journal of Consulting and Clinical Psychology, 76, 184-193.
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Goal
• Provide trauma informed care to Somali youth that is A) accessed
B) effective
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Challenge
• Few models of care for refugees
• Fewer with empirical support
• Fewer still adapted for Somali community/culture
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Revised Goal
• Adapt and evaluate a trauma intervention model for Somali adolescent refugees
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Trauma Systems Therapy for Refugees
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Social-Ecological Model
School
Peer GroupNeighborhood
Culture
Family
Individual
Social environmental interventions Self-R
egula
tion I
nterv
entio
ns
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Trauma Systems Therapy (TST)
. . . Is about a traumatized child who has trouble regulating emotions, a social environment that cannot help contain or even triggers this dysregulation, and the interface between emotion regulation and the social environment.
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Skill-based
Psychotherapy
Cultural leaders/ MAAs
Legal advocac
y
Home-Based
Service Elements
Psychiatry
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TST: Fit with refugees
• Emphasis on social environment and acknowledging core role of environmental stress in child’s symptoms
• Inclusion of advocacy
• Integration of systems
• Strong community-based components
• Fidelity is measured flexibly, via principles
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Adaptation #1:Continuum of care
Community education/
anti stigma
School/teacher trainings
School-based youth groups
TST
Prevention
Early identification
and intervention
Intensive intervention
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Adaptation #2: Continuum of cultural competence
Teachers and school staff educated in culture and trauma
Clinicians on SHIFA team gain expertise in Somali culture
Religious and Parent leaders educated about mental health, support youth access to care
Somali MAA staff gain knowledge of MH
Somali BUSSW graduates join MH profession
Raised awareness of School-based clinicians
Service system Somali community
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Process of Adapting
Interventions for Refugees
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Principles of Adaptation
1. True partnership with the community– Community Based Participatory Research
Clinical team
Leadership Team
Family Advisory BoardReligious leaders
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Principles of Adaptation
2. Flexible approach, learn as we go
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Process of Adaptation: Comprehensive Dynamic Trials- Continuous Quality Improvement
(CDT-QI; Rapkin & Trickett, 2005)
Intervention implemented and evaluated
TSTidentified for adaptation with Somali refugee group
Program Advisory Committee identified measures of fit and outcomes that are important to the community
“Lessons Learned” incorporated into intervention,adapted intervention implemented
Program Advisory Committee reviews and recommends adaptations as needed
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Principles of Adaptation
3. Evaluate in stages– Accessed?– Accepted?– Effective?
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Access
• 100% of those referred for services enrolled in treatment (n=40)– 100% of those who have enrolled in treatment have
remained in treatment (duration of treatment range 0-7 months)
– 80% of those in individual treatment were referred from group
– 8 parents have contacted program asking for additional services for sibling
– 4 parents approached independently asking for services for their children
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Adapting interventions for Refugees:Questions for the field
• What constitutes an adaptation?– Change in language or content of the intervention?
– The infrastructure you build around the core intervention that allows access?
– The process of community outreach that accompanies the successful implementation of an intervention with a new group?
• Is the goal to be culture-specific, or to find adaptations that generalize among refugees?
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Evaluating interventions for Refugees:
Questions for the field• What constitutes a successful intervention
for refugees?– Is a change in symptoms among treated
individuals meaningful if most refugees are not engaging in services?
– Do we document, manualize, and ‘count’ collateral work outside the core intervention? Is this work actually an essential ingredient of the intervention?
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Do we need alternatives to the RCT?
• Limitations to RCT in Community Based Research (Rapkin & Trickett, 2005) – Random assignment
• Ethics of other conditions: what if there are no viable alternatives for this linguistic/cultural group? How does community perceive ‘denying’ a child a certain service?
– Independence• community involvement leads to change across the whole group from
which participants are drawn• Adjustment of one youth may affect adjustment of others
– Adherence to strict fidelity and no systematic way to capture or further incorporate “lessons learned”• Particularly important when working with groups for whom there is
little evidence base to draw from
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