Health professionals' experiences of and attitudes towards mental healthcare for migrants and refugees in Europe: A qualitative systematic review

Sociodemographic and psychosocial risk factors of railway suicide a mixed-methods study combining data of all suicide decedents in the Netherlands with data from a psychosocial autopsy study

BACKGROUND

Railway suicide has profound implications for the victims and their family, and affects train drivers, railway personnel, emergency services and witnesses. To inform a multilevel prevention strategy, more knowledge is required about psychosocial and precipitating risk factors of railway suicide.

METHODS

Data from Statistics Netherlands of all suicides between 2017 and 2021 (n = 9.241) of whom 986 died by railway suicide and interview data from a psychosocial autopsy of railway suicide decedents (n = 39) were integrated. We performed logistic regression analyses to identify sociodemographic predictors of railway suicide compared to other methods of suicide. The Constant Comparative Method was subsequently employed on interview data from the psychosocial autopsy to identify patterns in psychosocial risk factors for railway suicide.

RESULTS

The strongest predictors of railway suicide compared to other suicide methods were young age (< 30 years old), native Dutch, a high educational level, living in a multi-person household (especially living with parents or in an institution), living in a rural area and a high annual household income of > 150.000 euros. Several subgroups emerged in the psychosocial autopsy interviews, which specifically reflect populations at risk of railway suicide. These subgroups were [1] young adult males with autism spectrum disorder who strived for more autonomy and an independent life, [2] young adult females with persistent suicidal thoughts and behaviours, [3] middle-aged males with a persistent mood disorder who lived with family and who faced stressors proximal to the suicide in personal and professional settings, [4] male out-of-the-blue suicides and [5] persons with psychotic symptoms and a rapid deterioration.

CONCLUSIONS

based on our findings we propose and discuss several recommendations to prevent railway suicide. We must continue to invest in a safe railway environment by training personnel and installing barriers. Additionally, we should adopt prevention strategies that align the needs of subgroups at increased risk, including young females who have attempted other methods of suicide and young males with autism spectrum disorder. Future research should determine the cost-effectiveness and feasibility of low-maintenance, automated interventions near crossings and psychiatric facilities.

Psychological adaptation among health care workers who work with trauma-exposed refugees in Greece

Greek health care workers (HCWs) working with refugee and asylum-seeker populations may be at risk of trauma exposure and related distress. The current study sought to further understand the factors that may promote or hinder psychological adaptation among HCWs working with trauma-exposed refugee populations in Greece. Participants were HCWs (N = 20) who completed semistructured interviews. Thematic analysis procedures identified three main themes: vicarious traumatization, (b) mismatch of expectations, and (c) difficulty coping. Our study findings highlight the need to provide adequate training, supervision, and mental health support for HCWs to prevent mental health issues in this population. Additional studies are necessary to understand the long-term consequences of working with refugee populations and explore ways to assist HCWs with self-care.

Low access and inadequate treatment in mental health care for asylum seekers and refugees in Germany-A prospective follow-up study over 12 months and a nationwide cross-sectional study

Refugees experience elevated rates of mental health problems, but little is known about mental health service utilization and quality among asylum seekers and refugees in Europe. In a 12-month follow-up study of newly arrived refugees (N = 166, Mage  = 32.38 years, 30.7% female) and a nationwide cross-sectional study (N = 579, Mage  = 33.89 years, 36.2% female) of refugees who had been living in Germany for an average of 6 years, we examined objective need for mental health treatment, perceived need, access to treatment services, and adequacy of treatment. We defined minimally adequate mental health treatment according to the WHO World Mental Health Survey as ≥8 sessions of psychotherapy (minimally adequate psychotherapy) or pharmacotherapy plus ≥4 medical visits (minimally adequate pharmacotherapy). In both studies, two in three individuals screened for mental health symptoms and additionally perceived a need for professional treatment. Of those, less than half had contact to any service provider, with only 1 in 14 receiving minimally adequate psychotherapy. Overall, no more than one in seven of refugees in need received minimally adequate treatment. Despite a comprehensive mental health-care system, refugees' access to mental health care and the treatment provided are inadequate. Health policies are urgently needed to provide equitable mental health care for all.

Refugees and asylum seekers who have experienced trauma: Thematic synthesis of therapeutic boundary considerations

OBJECTIVE

Therapeutic boundaries are limits to appropriate behaviours within a therapist-client relationship (e.g. related to accepting gifts, self-disclosures, therapist neutrality and advocacy). Therapeutic boundary considerations are fundamental in the care of refugees and asylum seekers. Research on the experiences of therapists navigating such boundaries is sparse and warrants further exploration. The aim of this qualitative systematic review was to thematically synthesise literature regarding therapists' (psychologists, psychotherapists, counsellors) experiences of implementing flexible therapeutic boundaries with refugee and asylum seeker clients and determine how such applications have been helpful for therapeutic interventions.

METHOD

Six databases were searched. Following full-text screening, 21 papers were included in the analysis. Boundary theory underpinned the analysis.

RESULTS

Three major themes were developed: (i) Changes to Therapeutic Practice & Therapeutic Intervention, (ii) Re-Conceptualisation of Therapy as 'Clinical Political' and Re-Conceptualisation of Therapist Identity and (iii) Careful Monitoring of Personal Boundaries-Not becoming 'Hardened' or 'Haunted'. Papers described how, when used in a reflective, considerate way, flexible therapeutic boundaries can strengthen the therapist-client alliance and positively impact therapeutic interventions. Many therapists acknowledged making conscious efforts to re-conceptualise therapeutic work with refugee and asylum seeker clients from advocacy standpoints. However, systemic constraints, and lack of guidance, made this difficult to navigate and contributed to therapist burn-out.

CONCLUSIONS

Boundary considerations manifested as interpersonal, structural and cultural changes to practice. These have implications for clinical practice and developing guidelines on boundary practices with refugees and asylum seekers. Future research should explore promoting therapist well-being and training needs for therapists supporting this population.

The role of psychotherapists' perceived barriers in providing psychotherapy to refugee patients

Access to psychotherapy is critical to improving mental health, but only a small proportion of refugees receive treatment in the regular psychotherapeutic care system in high-income countries. In previous research, outpatient psychotherapists reported several barriers to more frequent treatment of refugee patients. However, it is unclear to what extent these perceived barriers contribute to the poor provision of services to refugees. In a survey of N = 2002 outpatient psychotherapists in Germany, we collected data on perceived treatment barriers and on the integration of refugees into regular psychotherapeutic practice. Half of the psychotherapists reported that they do not treat refugee patients. In addition, therapies provided for refugees were, on average, 20% shorter than for other patients. Regression analyses showed direct negative associations between psychotherapists' overall perception of barriers with the number of refugees treated and the number of sessions offered to refugee patients, even when controlling for sociodemographic and workload-related characteristics. Correlation analyses on the level of specific types of barriers further revealed that particularly language-related barriers and lack of contact with the refugee population are negatively correlated with the number of refugees treated and the number of sessions for refugees. Our findings indicate that the integration of refugees into regular psychotherapeutic care could be improved by measures to connect psychotherapists with refugee patients as well as professional interpreters and to ensure coverage of costs for therapy, interpreters and related administrative tasks.

School-based Psychosocial Interventions' Effectiveness in Strengthening Refugee and Migrant Adolescents' Mental Health, Resilience, and Social Relations: A Four-country Cluster Randomized Study

School-based psychosocial interventions are increasingly put forward as a way to support young refugees' and migrants' well-being and mental health in resettlement. However, the evidence on these interventions' effectiveness remains scarce and scholars denounce particular gaps in the evidence to date, pointing to a lack of large-scale, controlled studies and studies including social outcome measures. This cluster randomized study aims to strengthen the evidence base on school-based psychosocial interventions for refugee and migrant youth by assessing the effect of two interventions, Classroom Drama and Welcome to School, on youth's mental health, resilience, and social relations in Belgium, Denmark, Norway, and the United Kingdom. Multilevel analyses were conducted separately for the two interventions (Classroom Drama, n = 307, ages 11-19; Welcome to School, n = 251, ages 11-23), using separate no-treatment control groups. Our analyses indicated a significant main, positive effect of Classroom Drama on perceived family support, and an effect on perceived support from friends that was moderated by country: in the United Kingdom, the intervention group reported an increase in perceived friend support, whereas the control group reported a decrease. Furthermore, baseline resilience moderated the effect of the Classroom Drama intervention on behavioral difficulties and well-being. No effects of Welcome to School on any of the outcome variables were found. Overall, this study provides novel, nuanced evidence on school-based psychosocial interventions for refugee and migrant adolescents.

"It is worth hanging in there" - Psychotherapeutic experiences shaping future motivation for outpatient psychotherapy with refugee clients in Germany

BACKGROUND

A high prevalence of mental disorders in refugees contrasts with a low rate of treatment and limited access to health care services. In addition to pre-, peri- and post-migration stress, language, cultural barriers together with lack of information about cost reimbursement, and access to German (mental) health care institutions are discussed as barriers to use of available services. Such barriers together with insufficient experience of treating traumatized refugee clients may lower therapists' motivation and facilities to accept refugee clients. A model project called "Fearless" trained, and supervised therapists, translators, and peer counsellors to reduce these barriers and increase therapists' motivation and engagement in future treatment of refugees.

METHODS

From a total 14 therapists participating in the project N = 13 were available for semi-structured interviews. The interviews were scheduled during or after their outpatient psychotherapy of refugee clients and lasted one hour on average. Based on qualitative assessment strategies, open questions addressed the therapists' experience of challenges, enrichments, and motivation throughout the therapy. Therapists' responses were analyzed using content structuring qualitative content analysis.

RESULTS

Three major challenges modulated therapists' future motivation for treating refugee clients: specific bureaucratic efforts (e.g., therapy application), organizational difficulties (e.g., scheduling appointments), and clients' motivation (e.g., adherence, reliability). Still, most interviewed therapists (n = 12) evaluated the therapy as enriching and expressed their motivation to accept refugee clients in the future (n = 10).

CONCLUSION

Results recommend the reduction of bureaucratic effort (e.g., regular health insurance cover for all refugees) and implementation of organizational support (e.g., peer counsellors) in support of therapists' motivation for future treatment of refugee clients. Further structural support e.g., with organizing and financing professional translators and referring refugee clients to psychotherapists should be deployed nationwide. We recommend the training in, and supervision of, the treatment of refugee clients as helpful additional modules in psychotherapy training curricula to raise therapists' motivation to work with refugee clients.

Central and Eastern European migrants' experiences of mental health services in the UK: A qualitative study post-Brexit

OBJECTIVE

Central and Eastern European (CEE) migrants are a large minority group in the UK who are vulnerable to experiencing mental health problems. However, due to their shared 'whiteness' with the majority population, health service disparities may be overlooked. This is the first study exploring CEE-born people's experiences of mental health services post-Brexit.

METHOD

Thirteen CEE migrants who had received mental health services in the UK were interviewed and data was thematically analysed.

RESULTS

Barriers and facilitators to engagement reflected: 1) attitudes towards help-seeking; 2) cultural in/visibility; and 3) professional-service user communication. Some barriers were unique to the CEE community and not shared by other minority groups, such as the 'invisibility' of ethnic identity and this framed the way participants navigated interactions with services.

CONCLUSIONS

Cultural differences and mental health stigma were reported to influence understanding of mental health, attitudes to help-seeking, and experiences of services. Flexible ethnic identity and majority group "passing" could conceal inequalities in healthcare.

PRACTICE IMPLICATIONS

The need for culturally informed approaches, professional upskilling, strengthened inter-agency working, and collaboration with CEE communities. The need to build on pre-existing strengths, for self-directed and self-care activities, for appropriate pacing and confidentiality discussions, and the use of web-based resources.

Research group as helpers due to the war in Ukraine: Focus group experiences of women researchers

Introduction

World Health Organization studies have shown that one in every five people who have experienced war or other conflicts suffers from a mental health disorder, the most vulnerable groups being children and women. According to international guidelines, mental health care should be made available immediately in the event of disaster. With the first influx of Ukrainian refugees to Hungary at the outbreak of the war, the Research Group of Childhood Mental Health at Eötvös Loránd University and Semmelweis University in Budapest immediately decided to help by transforming itself into a support group for refugee families. The members of the support group are all women. The aim of the present study is to explore the motivation behind the transformation of the research group and the help it provided. A further aim was to compare the group's experiences with descriptions in the literature of impacts on helpers who work with refugees.

Methods

The current paper reflects on the transformation from researchers to helpers and the effects of that transformation at group and individual level using the focus group method and consensual text analysis. The transformation of the support group necessitated the involvement of students, whose experiences are also examined.

Results

We identified five main categories: context; the help recipients' perspective; the personal level; the professional level; and the level between the personal and professional.

Discussion

The analysis revealed the way in which the voluntary helping developed, the resulting difficulties, and coping options. Volunteering among Ukrainian refugees has both positive and negative psychological consequences. While stress and trauma threaten the psychological well-being of the helpers, positive aspects, such as flexibility and professional development, are also reported. Due to the strong motivation among group members and their experience in practical work, the all female research group was quickly able to transform itself into a support group.