Treatment of Posttraumatic Stress Disorder

in Refugees: Latest Research Studies

Dr Angela Nickerson Senior Lecturer Director, Refugee Trauma and Recovery Program School of Psychology, UNSW Australia anickerson@psy.unsw.edu.au

Posttraumatic stress disorder in refugees

Guidelines for treatment of PTSD

Guidelines for treatment of PTSD

Australian Guidelines for the Treatment of Acute Stress Disorder and Posttraumatic Stress Disorder, Phoenix Australia, 2013

What is unique about refugee trauma?

What do we already know?

oRelatively small body of research on efficacious treatments for PTSD in refugees

o Studies have tended to focus on o Trauma-focused interventions

oMulti-modal approaches

o Emerging evidence for trauma-focused interventions

oBUT – methodological limitations prevent strong conclusions

Research Evidence: An Update oA number of new studies have been conducted in past four years

o Emphasis has been on trauma-focused therapy o Narrative Exposure Therapy

o Eye Movement Desensitization and Reprocessing

o Imagery Rescripting

oSeveral qualitative and theoretical papers detailing challenges associated with treating PTSD in refugees

Narrative Exposure Therapy oDeveloped by Schauer, Neuner & Elbert (2013)

oDerived from Testimony Psychotherapy o Lira and Weinstein (Cienfuegos and Minelli, 1983)

oTested with Bosnian refugees in Boston (Weine et al., 1998)

oNET has demonstrated efficacy in oMultiple settings (Sudanese, Somali and Rwandan refugees in

Uganda; asylum-seekers, former political prisoners)

o Across delivery modes (doctoral-level therapists from Europe, lay clinicians in refugee camps) o See Robjant & Fazel, 2010 and Morkved et al 2014 Clin Psych Rev

Narrative Exposure Therapy o Elements oPsychoeducation

o Derive timeline

o Imaginal exposure therapy

o Develop narrative

o Plan for use of narrative (if client wishes)

oMechanisms by which NET may work oEmotional processing

o Integration of memories into autobiographical memory base

oRedress?

Brief NET for PTSD in Iraqi Refugees o Participants were 63 Iraqi refugees resettled in Michigan, USA

oParticipants were randomly assigned to brief NET (3 sessions) or waitlist control condition (2:1 ratio) o60 to 90 minute sessions oArabic-speaking therapists

oAssessment at baseline, 2-month and 4- month follow up

oHigh participation (95%) and retention (98%) rates

1.8

2

2.2

2.4

2.6

2.8

3

Baseline 2 months 4 months

PTSD Symptoms

NET WLC

*

Brief NET for PTSD in Iraqi Refugees

20

25

30

35

40

45

50

55

60

Baseline 2 months 4 months

Posttraumatic Growth

NET WLC

Brief NET for PTSD in Iraqi Refugees

* *

Brief NET for PTSD in Iraqi Refugees o Key findings o PTSD symptoms -Medium between-groups effect

size (d = 0.32)

o NET results in significantly greater improvement in PTG

oLimitations oSelf-report measures as follow-up assessment

oNo treatment control group

oImplications oDosage of intervention likely to be important

o Impact of post-migration environment

oUtility of measuring positive outcomes as well as symptom reductions

Imagery rescripting oImagine traumatic experience and an intervention that changes course of events

o Evidence that decreases non-fear emotions such as shame, guilt and anger

o Has been previously added to imaginal exposure (Arntz et al., 2007; Kindt et al., 2007)

o Authors propose will increase tolerability of intervention and reduce drop-outs

oAdaptation in current study so intervention was before trauma took place (but after anticipation of trauma)

Imagery rescripting for PTSD in refugees o Participants were 10 refugees from a variety of backgrounds (e.g., Iraq, Turkey, Kosovo, Afghanistan)

o Concurrent multiple baseline design was employed oParticipants randomly assigned to 5

different baseline lengths (6 to 10 weeks), oNext, 5 weeks of supportive treatment

given to control for nonspecific effects

oTreatment o10 sessions of imagery rescripting

Imagery rescripting for PTSD in refugees o Results oNo significant change during baseline,

exploratory or follow-up periods in PTSD symptoms

oSignificant reduction in PTSD symptoms during treatment period (within-subjects effect size = 1.6)

oSignificant reduction in depression symptoms during treatment period (within-subjects effect size = 0.9)

Imagery rescripting for PTSD in refugees oFindings suggest imagery rescripting may be promising in reducing trauma-related symptoms in refugees

oHowever, limitations associated with study make it difficult to draw strong conclusions oAll participants already in treatment

oMeasures taken by treating therapist (with 1 day training)

oDiscussion of trauma during exploratory phase

Eye Movement Desensitization and Reprocessing

oDeveloped by Shapiro (2001)

o Client recalls traumatic memories while engaging in eye movements or bilateral stimulation (e.g., tapping)

o Has been previously piloted with refugees seeking asylum in Netherlands (Ter Heide et al., 2011)

o No systematic study in refugees

EMDR for PTSD in Syrian refugees oParticipants were randomly selected Syrian refugees with PTSD living in camp in Turkey (N = 29)

oRandomly assigned to EMDR or waitlist control group

oBlind outcome assessments

oEMDR intervention components o Formulation; rationale; cognitive therapy;

desensitization; body scan; closure (imagine holy light coming from heaven)

oMaximum of 7 90 minute sessions oDelivered by Turkish psychologist with Syrian

interpreters

EMDR for PTSD in Syrian refugees

0

10

20

30

40

50

60

70

BL Posttreatment 1 month FU

PTSD symptoms

EMDR WLC

*

EMDR for PTSD in Syrian refugees

0

5

10

15

20

25

BL Posttreatment

Depression symptoms

EMDR WLC

*

EMDR for PTSD in Syrian refugees o Findings o EMDR resulted in significant decreases in PTSD and

depression in Syrian refugees

oLimitations o No treatment control group

o Absence of long-term follow-up

o Not treatment-seeking sample

oCultural considerations o Stigma - treatment carried out in kindergarten

building – research team provided childcare

o Treatment fidelity – no participant agreed to audiotaping of session (supervisor observed at least 1 session with each therapist)

Methodological Challenges o Quality of studies o Control group important, but better to have active

control condition

o Small sample sizes

o Absence of long-term follow-up assessments

o Non-blind assessments

o Therapists

o PTSD measurement

oHowever…… o Challenges of conducting this research must be

acknowledged

o Studies are improving overall

Theoretical challenges o We still don’t have a good understanding of the unique psychological impact of the refugee experience oProlonged, repeated trauma

oDisplacement

oPost-migration stressors

oMore research needed on core mechanisms underlying refugee mental health

o Lead to development of tailored interventions for refugees and asylum-seekers in a variety of contexts

Emotion Regulation in Refugees o Studies investigating how refugees regulate their emotions following different types of traumatic experiences

o In collaboration with STARTTS, SSI and other refugee service providers in Sydney

o Evidence that o Torture profoundly affects the strategies that are used,

and how effective they are

o Cognitive reappraisal reduces intrusive memories and trauma-related distress in refugees with PTSD

oMechanistic studies form building-blocks for interventions

Where to from here? o High-quality randomized controlled trials oActive control groups

oBlind assessments

oRandomization

oManualized interventions

o Follow-up assessments

o Research into specific mechanisms underpinning refugee mental health o Translation of these findings to treatment

interventions that are tailored to the refugee experience

Treatment of Posttraumatic Stress Disorder

in Refugees: Latest Research Studies

Dr Angela Nickerson Senior Lecturer Director, Refugee Trauma and Recovery Program School of Psychology, UNSW Australia anickerson@psy.unsw.edu.au