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 [email protected]

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 o Multi-modal approaches

o Emerging evidence for traumafocused 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) o Tested with Bosnian refugees in Boston (Weine et al., 1998)

oNET has demonstrated efficacy in o Multiple 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 o Psychoeducation 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 o Emotional processing o Integration of memories into autobiographical memory base o Redress?

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 4month follow up

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

Brief NET for PTSD in Iraqi Refugees PTSD Symptoms 3

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2.8 2.6 2.4 2.2 2 1.8 Baseline

2 months NET

WLC

4 months

Brief NET for PTSD in Iraqi Refugees Posttraumatic Growth *

60

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55 50 45

40 35 30 25 20 Baseline

2 months NET

WLC

4 months

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 o Self-report measures as follow-up assessment o No treatment control group

oImplications o Dosage of intervention likely to be important o Impact of post-migration environment o Utility 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 o No significant change during baseline, exploratory or follow-up periods in PTSD symptoms o Significant reduction in PTSD symptoms during treatment period (within-subjects effect size = 1.6) o Significant 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 traumarelated 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) o Maximum of 7 90 minute sessions o Delivered by Turkish psychologist with Syrian interpreters

EMDR for PTSD in Syrian refugees PTSD symptoms 70

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60 50 40 30 20 10 0 BL

Posttreatment EMDR

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1 month FU

EMDR for PTSD in Syrian refugees Depression symptoms *

25

20

15

10

5

0 BL

Posttreatment 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 o Prolonged, repeated trauma o Displacement o Post-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 o Active control groups o Blind assessments o Randomization o Manualized 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 [email protected]