Complex PTSD and phased treatment in refugees: a debate piece

Assessment tools for complex post traumatic stress disorder: a systematic review

Appropriate screening tools are required to accurately detect complex post traumatic stress disorder (CPTSD). This systematic review aimed to assess and compare measurement tools. A literature search using key words 'complex post traumatic stress disorder', 'PTSD', and 'assessment' was undertaken on Embase and PsychINFO during February 2022 by two reviewers. Inclusion criteria included full text papers between 2002-2022 which evaluated CPTSD using assessment tools. Exclusion criteria included reviews, editorials, meta-analyses, or conference abstracts. Twenty-two papers met selection criteria. Thirteen studies used the International Trauma Questionnaire (ITQ). Two studies each evaluated CPTSD with the International Trauma Interview (ITI) or Symptoms of Trauma Scale (SOTS). The Developmental Trauma Inventory (DTI), Cameron Complex Trauma Interview (CCTI), Complex PTSD Item Set additional to the Clinician Administered PTSD Scale (COPISAC), Complex Trauma Questionnaire (ComplexTQ), and Scale 8 of the Minnesota Multiphasic Personality Inventory Scale (MMPI) were used by a single study each. The ITQ was the most thoroughly investigated, validated across different populations, and is a convenient questionnaire for screening within the clinical setting. Where self-report measures are inappropriate, the ITI, SOTS, and COPISAC are interview tools which detect CPTSD. However, they require further validation and should be used alongside clinical history and examination.

Assessing meaning violations in Syrian refugees: A mixed-methods cross-cultural adaptation of the Global Meaning Violations Scale-ArabV

Refugees are disproportionately affected by extreme traumatic events that can violate core beliefs and life goals (i.e., global meaning) and cause significant distress. This mixed-methods study used an exploratory sequential design to assess meaning violations in a sample of Syrian refugees living in Portugal. For this purpose, we cross-culturally adapted the Global Meaning Violations Scale (GMVS) for use with Arabic-speaking refugees. In total, 43 war-affected Syrian adults participated in the two-phase study. Participants completed measures of trauma and narrated violations as they filled out the newly adapted GMVS-ArabV. GMVS-ArabV validity evidence based on response processes was investigated through Phase 1 focus groups (FGs; n = 2), whereas data from Phase 2 cognitive interviews (n = 38) were used to preliminarily explore the measure's internal structure through descriptive statistics as well as culture- and trauma-informed content evidence through thematic analysis. The results suggested highest goal (M = 3.51, SD = 1.46) and lowest belief (M = 2.38, SD = 1.59) violations of educational goals and religious beliefs, respectively. Themes related to stressors, item formulation, response scale, and the global meaning construct suggested that (a) beliefs and goals can be differentially violated by different stressors; (b) much like war trauma, including torture, daily stressors can additionally shatter pretrauma global meaning; and (c) refugees reappraise meaning and suffer violations anew throughout their migration journeys. The GMVS-ArabV offers a promising tool for exploring shattered cognitions in refugees and informs evidence-based approaches to trauma recovery and psychological adjustment in postmigration settings (the Arabic abstract and keywords are available in the Supplementary Materials).

“Same same or adapted?” Therapists’ feedback on the implementation of trauma-focused cognitive behavioral therapy with unaccompanied young refugees

Background

Rates of trauma exposure and posttraumatic stress disorder (PTSD) are high among refugee youth. Although there is a vast evidence base on effective trauma-focused interventions for children and adolescents, there is only limited understanding of how to adapt these interventions for oftentimes severely traumatized young refugees. This study aims to investigate adaptations undertaken during trauma-focused cognitive behavioral therapy (TF-CBT) in a pilot study with unaccompanied refugee minors (URMs).

Method

Written answers on five questions given by N = 9 therapists on N = 16 TF-CBT cases were analysed qualitatively using Mayring’s content analysis. The questions were on (1) additional techniques used in the sessions, (2) obstacles to TF-CBT treatment, (3) cultural factors considered and most helpful components for (4) patient and (5) therapist. The categories were built inductively and analysed descriptively.

Results

In addition to the regular TF-CBT components, added content mostly concerned the so-called “crisis of the week”, meaning a more lengthy discussion of struggles and concerns in their daily lives. Few obstacles in treatment were reported, and little cultural factors had to be considered. The implementation of a trauma narrative and the agenda provided by the manual were frequently reported as helpful.

Conclusion

The results of this study indicate that the manualized evidence-based treatment TF-CBT can be used in the culturally heterogeneous population of URMs with minor adaptations. These findings can contribute to future research as well as clinical practice with URMs.

TF-CBT is a promising treatment for PTSD in traumatized refugee minors.

Necessary adaptations for this target group have not been analysed so far.

Therapists reported only a few “on the fly” adaptations during a pilot study on TF-CBT.

Prevalence of complex post-traumatic stress disorder in refugees and asylum seekers: systematic review

BACKGROUND

Refugees and asylum seekers often report having experienced numerous complex traumas. It is important to understand the prevalence of complex post-traumatic stress disorder (CPTSD), which can follow complex traumas.

AIMS

This systematic review aims to summarise the available literature reporting the prevalence in refugees and asylum seekers of three operationalised definitions of CPTSD: the ICD-11 diagnostic criteria, the ICD-10 criteria (for enduring personality change after catastrophic experience) and the DSM-IV criteria (for disorders of extreme stress not otherwise specified).

METHOD

Six electronic databases were searched for studies reporting the prevalence of CPTSD in adult refugee and/or asylum-seeking samples. Owing to heterogeneity between the studies, a narrative synthesis approach was used to summarise studies. Methodological quality was assessed using the Joanna Briggs Critical Appraisal Checklist for Prevalence Studies. This systematic review has been registered with PROSPERO (registration number CRD42020188422, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=188422).

RESULTS

Systematic searches identified 15 eligible studies, with 10 examining treatment-seeking samples and five using population samples. CPTSD prevalence in treatment-seeking samples was between 16 and 38%. Prevalence in population samples ranged from 2.2 to 9.3% in four studies, with the fifth reporting a much higher estimate (50.9%).

CONCLUSIONS

This review highlights both the high prevalence of CPTSD in treatment samples and the lack of research aiming to establish prevalence of CPTSD in refugee and asylum-seeking populations. Understanding the prevalence of these disabling disorders has implications for policy and healthcare services for the appropriate promotion, planning and provision of suitable treatment and interventions for this highly traumatised population.

Pilot evaluation of a group stabilisation intervention for refugees and asylum seekers with PTSD

BACKGROUND

Post-traumatic stress disorder (PTSD) is commonly experienced by asylum seekers and refugees (ASR). Evidence supports the use of cognitive behavioural therapy-based treatments, but not in group format for this population. However, group-based treatments are frequently used as a first-line intervention in the UK.

AIMS

This study investigated the feasibility of delivering a group-based, manualised stabilisation course specifically developed for ASR. The second aim was to evaluate the use of routine outcome measures (ROMs) to capture psychological change in this population.

METHOD

Eighty-two participants from 22 countries attended the 8-session Moving On After Trauma (MOAT) group-based stabilisation treatment. PHQ-9, GAD-7, IES-R and idiosyncratic outcomes were administered pre- and post-intervention.

RESULTS

Seventy-one per cent of participants (n = 58) attended five or more of the treatment sessions. While completion rates of the ROMs were poor - measures were completed at pre- and post-intervention for 46% participants (n = 38) - a repeated-measures MANOVA indicated significant improvements in depression (p = .001, ηp2 = .262), anxiety (p = .000, ηp2 = .390), PTSD (p = .001, ηp2 = .393) and idiosyncratic measures (p = .000, ηp2 = .593) following the intervention.

CONCLUSIONS

Preliminary evidence indicates that ASR who attended a low-intensity, group-based stabilisation group for PTSD experienced lower mental health scores post-group, although the lack of a comparison group means these results should be interpreted with caution. There are significant challenges in administering ROMs to individuals who speak many different languages, in a group setting. Nonetheless, groups have benefits including efficiency of treatment delivery which should also be considered.

Interleukin-6 secretion upon acute psychosocial stress as a potential predictor of psychotherapy outcome in posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) is a severe mental disorder that can develop after a traumatic event. PTSD has been reported to be associated with activation of the innate immune system, as measured by increased levels of pro-inflammatory cytokines. While it is well known that PTSD patients display increased levels of interleukin 6 (IL-6) when compared with healthy controls, the relationship between cytokine secretion and treatment outcome has been hardly investigated yet. The aim of this study was to assess the potential association of inflammatory activation and therapy outcome in PTSD. Before therapeutic intervention, we applied the Trier Social Stress Test (TSST) as a method to elicit psychosocial stress and an acute inflammatory response. IL-6 levels were measured in blood plasma of PTSD patients at different time points before and after the TSST. Severity of depressive, trauma-related, and somatic symptoms was assessed before and 8 weeks after trauma-focused treatment in a multimodal day clinic setting. We showed that high reactivity of IL-6 to psychosocial stress at the beginning of the therapy was associated with a negative therapy outcome in PTSD, especially regarding depressive symptoms. This study suggests plasma IL-6 reactivity as a potential molecular marker to predict treatment outcome in PTSD.

Readiness of Allied Professionals to Join the Mental Health Workforce: A Qualitative Evaluation of Trained Lay Trauma Counsellors' Experiences When Refugee Youth Disclose Suicidal Ideation

The recent refugee crisis presented a huge challenge for the Swedish mental health workforce. Hence, innovative mental health workforce solutions were needed. Unaccompanied refugee minors (URM) are a particularly vulnerable refugee group. Teaching Recovery Techniques (TRT) was introduced as a community-based intervention utilising trained lay counsellors in a stepped model of care for refugee youth experiencing trauma symptoms. Professionals (e.g., teachers, social workers) can deliver the Cognitive Behavioural Therapy-based intervention after a brief training. A point of debate in this workforce solution is the readiness of trained lay counsellors to deal with potentially demanding situations like disclosure of suicidal ideation. This study aimed to explore the TRT trained lay counsellors’ experiences of procedures upon URM’s disclosure of suicidal ideation. Individual semi-structured interviews with TRT trained lay counsellors were conducted, then analysed using systemic text condensation. The analysis revealed four themes: “Importance of safety structures”, “Collaboration is key”, “Let sleeping dogs lie” and “Going the extra mile”. Dealing with suicidal ideation is challenging and feelings of helplessness occur. Adding adequate supervision and specific training on suicidal ideation using role play is recommended. Collaboration between agencies and key stakeholders is essential when targeting refugee mental health in a stepped care model.

A participatory study of patient views on psychotherapy for complex post-traumatic stress disorder, CPTSD

BACKGROUND

A new diagnosis of Complex Post-traumatic Stress Disorder, CPTSD, is included in ICD-11 which was adopted in May 2019 by the World Health Organisation, WHO. In addition to the symptoms of PTSD, CPTSD includes emotional dysregulation, negative self-concept, and disturbances in relationships. It may be a helpful diagnosis for trauma survivors with experiences of human mistreatment such as torture and abuse.

AIMS

This study explores the views of patients in the community on psychotherapy for the diagnosis of CPTSD, taking a qualitative, participatory approach.

METHOD

Twenty-four former patients from an NHS secondary mental health service in London interviewed each other about their treatment. Participants also collaborated in data analysis. All had a diagnosis of PTSD, with additional symptoms of CPTSD identified at assessment.

RESULTS

The key factor in recovery was rebuilding relationships, beginning with the therapist. Groupwork was helpful in promoting relationships with others, as it may result in shame reduction. Involvement in the wider community through peer support groups was also valuable.

CONCLUSIONS

The rebuilding of relationships based on trust was an active mechanism of change and recovery from CPTSD. Participants felt that sufficient time, at least one year of psychotherapy with weekly sessions, was needed.

A brief transdiagnostic psychological intervention for Afghan asylum seekers and refugees in Austria: a randomized controlled trial

BACKGROUND

Asylum seekers and refugees are at great risk for developing mental disorders. Afghan refugees are a particularly vulnerable group with a low average education and mental health literacy level. Traumatic experiences and hardship before and during migration are predictive of mental health problems. However, post-migration living difficulties (PMLDs) also account for a large proportion of mental distress in such populations, which, critically, are not sufficiently considered in treatment protocols and research investigations. Indeed, the evidence base for the treatment of refugees and asylum seekers is sparse and limited mainly to trauma-specific treatments, where refugees may likely suffer from other mental health problems such as depression or anxiety.

METHODS/DESIGN

This trial is the first evaluation of a short-term, transdiagnostic treatment protocol for treatment-seeking Afghan refugees which addresses mental health problems and PMLDs while using an adapted version of the Problem Management Plus (PM+) protocol. Here, we will investigate the efficacy of an intervention manual with a prospective, single-center, randomized, assessor-blind, two-group trial among refugees who are on a waiting list for professional mental health treatment. Furthermore, we will investigate participants' subjective experiences with the intervention manual via in-depth interviews. One hundred twenty people will be assessed and randomly allocated to either the intervention arm or a treatment-as-usual arm. Clinical psychologists will conduct the treatment, and the sessions will take place with a Dari interpreter. The protocol consists of six 90-min sessions. The primary endpoint is the general symptom distress measure, assessed with the General Health Questionnaire 28 (GHQ-28). Secondary endpoints are the Post-Migration Living Difficulties Checklist (PMLDC), the International Trauma Questionnaire (ITQ), the World Health Organization Quality of Life Questionnaire (WHOQOL-BREF), the Psychological Outcome Profile (PSYCHLOPS), service and health care use (assessed with several items), and the Immigrant Integration Index (IPL-12).

DISCUSSION

This trial may provide substantial evidence for a brief transdiagnostic psychological intervention. Here, we intend to contribute to the treatment of mental health problems among Afghan refugees. The assessment of subjective experience with this treatment manual, as well as the evaluation of its clinical applicability, may optimize treatment acceptance and outcomes across a wide range of mental health problems among refugees.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS) registration number: DRKS00016538. Universal Trial Number: U1111-1226-3285. Registered on January 7, 2019. https://www.drks.de/drks_web/setLocale_EN.do.

Implementing Narrative Exposure Therapy for unaccompanied asylum-seeking minors with post-traumatic stress disorder: A pilot feasibility report

There are high rates of post-traumatic stress disorder (PTSD) in unaccompanied asylum-seeking minors (UAM) and there is a requirement for feasible, acceptable and evidence-based treatments. Narrative Exposure Therapy (NET) is a short-term treatment for PTSD following multiple traumatic events. This article aims to examine the applicability of NET for UAM in routine clinical practice and to provide preliminary feasibility, acceptability and effectiveness data. The participants were four UAM receiving NET within a dedicated child and adolescent mental health service for refugee children. Semi-structured interviews were conducted to understand the acceptability of this approach and standardised measures of PTSD were used to provide preliminary data regarding the effectiveness of NET for these clients. The clients attended NET consistently with few missed appointments. At post-treatment, two clients' symptom scores were below the clinical cut-off for PTSD and all three clients who completed NET met reliable improvement criteria. The clients reported improvements in functional outcomes and mentioned that they would encourage other young people with similar difficulties to engage in NET. This study was limited by the small sample size and naturalistic time limitations in clinicians' contracts. This article highlights that it is possible to implement NET within routine clinical practice and observed improvements in PTSD symptoms and functional outcomes for UAM.

Dropout from psychological therapies for post-traumatic stress disorder (PTSD) in adults: systematic review and meta-analysis

Background: Despite the established efficacy of psychological therapies for post-traumatic stress disorder (PTSD) there has been little systematic exploration of dropout rates. Objective: To ascertain rates of dropout across different modalities of psychological therapy for PTSD and to explore potential sources of heterogeneity. Method: A systematic review of dropout rates from randomized controlled trials (RCTs) of psychological therapies was conducted. The pooled rate of dropout from psychological therapies was estimated and reasons for heterogeneity explored using meta-regression. Results:: The pooled rate of dropout from RCTs of psychological therapies for PTSD was 16% (95% CI 14-18%). There was evidence of substantial heterogeneity across studies. We found evidence that psychological therapies with a trauma-focus were significantly associated with greater dropout. There was no evidence of greater dropout from therapies delivered in a group format; from studies that recruited participants from clinical services rather than via advertisements; that included only military personnel/veterans; that were limited to participants traumatized by sexual traumas; that included a higher proportion of female participants; or from studies with a lower proportion of participants who were university educated. Conclusions: Dropout rates from recommended psychological therapies for PTSD are high and this appears to be particularly true of interventions with a trauma focus. There is a need to further explore the reasons for dropout and to look at ways of increasing treatment retention.

The Current Status of EMDR Therapy Involving the Treatment of Complex Posttraumatic Stress Disorder

Complex posttraumatic stress disorder (CPTSD) is a diagnostic entity that will be included in the forthcoming edition of the International Classification of Diseases, 11th Revision (ICD-11). It denotes a severe form of PTSD, comprising not only the symptom clusters of PTSD (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition [DSM-IV-TR]), but also clusters reflecting difficulties in regulating emotions, disturbances in relational capacities, and adversely affected belief systems about oneself, others, or the world. Evidence is mounting suggesting that first-line trauma-focused treatments, including eye movement desensitization and reprocessing (EMDR) therapy, are effective not only for the treatment of PTSD, but also for the treatment of patients with a history of early childhood interpersonal trauma who are suffering from symptoms characteristic of CPTSD. However, controversy exists as to when EMDR therapy should be offered to people with CPTSD. This article reviews the evidence in support of EMDR therapy as a first-line treatment for CPTSD and addresses the fact that there appears to be little empirical evidence supporting the view that there should be a stabilization phase prior to trauma processing in working with CPTSD.

Trauma and Public Mental Health: A Focused Review

Psychological trauma has developed into a very common concept in the scientific community, in mental health care, as well as in popular language and mass media. The purpose of this article is to show the relevance of the discipline of traumatic stress studies to the field of public mental health by examining central concepts and findings concerning trauma and its aftermath and examining implications for public mental health. Attention is paid to the diagnosis of posttraumatic stress disorder (PTSD) and the construct of resilience as well as to specific areas of public mental health activities. A public mental health perspective will help to develop preventive approaches to trauma and extend the impact of various forms of interventions. It will also make clear that trauma care will have to consider the community and the society at large.

Dynamics of self-dialogue in the aftermath of trauma: A “fictional dissociation”

In light of the newly developed approach of “Virtual Fictional/Factual Positioning” (VFP), I introduce “fictional dissociation” as a new concept for evaluating “fictional positioning” and the role of storytelling as a coping strategy in the aftermath of trauma. Traumatic changes can interrupt one’s story and harm or even disconnect self-dialogue. The particular direction that survivors may take after a painful event is one of the most delicate concerns regarding trauma. This article especially examines the dynamics of self-dialogue following a fatal traumatic experience and the ways in which “fictional dissociation” as an artistic endeavour can help the self cope with psychological problems. A fictional case study from a Paul Auster novel, Oracle Night (2003/2011), displaying symptoms of complex post-traumatic stress disorder (complex PTSD) is examined to establish whether the protagonist can develop a functional dialogical self through storytelling in the act of “fictional dissociation.”

Creative arts in psychotherapy for traumatized children in South Africa: An evaluation study

Aim

To evaluate the feasibility and effect of a 10-session creative arts in psychotherapy group programme on posttraumatic stress symptoms, behavioural problems, and posttraumatic growth, in children who experienced a traumatic event.

Design

A multicentre non-randomized controlled trial with a treatment and a control condition conducted in South Africa (4 sites).

Methods

125 children aged 7 to 13 years were assigned either to the treatment condition receiving creative arts in psychotherapy or a control condition with a low-level supportive programme without treatment. Attrition rates were 63.4% and in total 47 children completed the programme and questionnaires assessing posttraumatic stress, posttraumatic growth and behaviour problems both at baseline and follow-up; 23 in the treatment group and 24 in the control group. Adjusted mean differences were analysed using ANCOVA with bootstrapping.

Results

Results showed that both hyperarousal symptoms (d = 0.61) and avoidance symptoms (d = 0.41) decreased more in the treatment group compared to the control group. There was no significant effect of the intervention found for reported levels of behavioural problems and posttraumatic growth.

Conclusion

In spite of severe challenges implementing and executing this pioneering study in underprivileged areas of South Africa, support was found for creative arts in psychotherapy reducing hyperarousal and avoidance symptoms, but not for other symptoms. Valuable lessons were learned on feasibility of implementing this intervention in a developing context.

Complex Posttraumatic Stress Disorder in Patients Exposed to Emotional Neglect and Traumatic Events: Latent Class Analysis

The inclusion of a complex posttraumatic stress disorder (CPTSD) diagnosis in the 11th revision of the International Classification of Diseases reflects growing evidence that a subgroup of individuals with PTSD also suffer from disturbances in emotion regulation, interpersonal skills, and self-concept, which together are termed "disturbances in self-organization" (DSO). Although CPTSD is assumed to result from exposure to complex traumatic events, emotional neglect may be an important contributor. This study investigated the presence of CPTSD, defined by endorsement of PTSD and DSO symptoms in a clinical postwar generation sample. The sample consisted of 218 patients who had been exposed to emotional neglect in childhood, a subgroup of whom had also been exposed to potentially traumatic events. Using items from the Harvard Trauma Questionnaire and the Brief Symptom Inventory, a latent class analysis revealed two classes: high endorsement of almost all CPTSD symptoms (n = 83; 38.1%) and low endorsement of all CPTSD symptoms (n = 135; 61.9%). Contrary to our hypothesis, no DSO-only class was found. The R3step method showed gender and number of traumatic events to be significant predictors of class membership. Compared to the low endorsement class, individuals in the CPTSD class were more likely to be female, p = .013, and to report a higher number of traumatic experiences, p < .001. The potential intermediary role of emotional neglect in the development of DSO and CPTSD is discussed.

Undocumented asylum seekers with posttraumatic stress disorder in the Netherlands

Background: To date, most studies on the mental health of refugees in Europe have focused on the prevalence and treatment of psychopathology. Little is known about those who illegally reside in the host country, referred to, in the Netherlands, as undocumented asylum seekers. There are indications that mental health and psychosocial problems are more prevalent in this group than among refugees in general, with unsatisfactory treatment outcomes. Objective: To describe characteristics and mental health and psychosocial problems of undocumented asylum seekers, and to establish the need for, and feasibility of, a tailored treatment approach. Method: Based on a literature review and extensive clinical experience, common mental health and psychosocial problems and accessibility of care for undocumented asylum seekers are established, as well as the common treatment approach in the Netherlands. A tailored treatment programme and experiences with its implementation are described. Results: Mental health and psychosocial problems are highly prevalent among undocumented asylum seekers, and access to care is limited. In addition, treatment in the Netherlands, if provided, is mostly insufficient yet prolonged. Given the specific psychosocial problems and living conditions of undocumented asylum seekers, a necessary criterion to enable adequate and evidence-based treatment provision is acknowledgement of their distinct needs. A tailored treatment programme as currently implemented in the Netherlands appears to meet this criterion and be feasible under certain conditions. Collaboration between mental health care providers and involved social service and governmental parties by regular meetings, though complicated, is a relevant element. Conclusions: Even though undocumented asylum seekers are illegally residing in a country, medical ethics and the human rights perspective necessitate for adequate and evidence-based treatment for those among them with mental health problems. The tailored treatment approach presented here suggests that, notwithstanding factors complicating care provision which require specific attention, this is feasible.

Complex trauma, PTSD and complex PTSD in African refugees

Background: The introduction of the diagnosis of complex posttraumatic stress disorder (CPTSD) by ICD-11 is a turning point in the field of traumatic stress studies. It's therefore important to examine the validity of CPTSD in refugee groups exposed to complex trauma (CT) defined as a repeated, prolonged, interpersonal traumatic event. Objective: The objective of this study was to compare DSM-5 and ICD-11 post-traumatic stress disorder diagnoses and to evaluate the discriminant validity of ICD-11 PTSD and CPTSD constructs in a sample of treatment-seeking refugees living in Italy. Method: The study sample included 120 treatment-seeking African refugees living in Italy. All participants were survivors of at least one CT. PTSD and CPTSD diagnoses were assessed according to both DSM-5 and ICD-11 criteria. Results: Findings revealed that 79% of the participants met the DSM-5 criteria for PTSD, 38% for ICD-11 PTSD and 30% for ICD-11 CPTSD. Generally, ICD-11 CPTSD items evidenced strong sensitivity and negative predictive power, low specificity and positive predictive power. Latent class analysis results identified two distinct groups: (1) a PTSD class, (2) a CPTSD class. None of the demographic and trauma-related variables analysed was significantly associated with diagnostic group. On the other hand, the months spent in Italy were significantly associated with PCL-5 score. Conclusions: Findings extend the current evidence base to support the discriminant validity of PTSD and CPTSD amongst refugees exposed to torture and other gross violations of human rights. The results suggest also that, in the post-traumatic phase, the time spent in a 'safe place' condition contributes to improve the severity of post-traumatic symptomatology, but neither this variable nor other socio-demographic factors seem to contribute to the emergence of complex PTSD. Further investigations are needed to clarify which specific vulnerability factors influence the development of PTSD or CPTSD in refugees exposed to complex trauma.

Effectiveness of a Multimodal, Day Clinic Group-Based Treatment Program for Trauma-Related Disorders: Differential Therapy Outcome for Complex PTSD vs. Non-Complex Trauma-Related Disorders

Background: The effectiveness of the psychotherapeutic treatment of posttraumatic stress disorder is evidence-based and generally considered proven. However, the effectiveness of multimodal, group-based day clinic treatment programs has rarely been investigated. Moreover, there is no consensus in the literature concerning the question whether psychotherapeutic approaches for trauma-related disorders are also applicable for patients with complex PTSD (cPTSD). The aim of the study was to evaluate our multimodal group-based treatment program regarding a change of psychiatric burden, a change of protective factors, and possible differences in therapy outcome for patients with or without cPTSD. Methods: The group-based treatment for patients with trauma-related disorders was examined in 66 patients who filled out the following questionnaires in the first and in the last week of treatment: Essen Trauma Inventory (ETI), Screening for complex PTSD (SkPTBS), Patient Health Questionnaire-somatization module (PHQ-15), Beck Depression Inventory-Revised (BDI-II), Posttraumatic Growth Inventory (PTGI), and Questionnaire on social support (F-SozU). Results: The treatment was shown to significantly reduce depressive symptoms (p < 0.001, d = -0.536) and increase posttraumatic growth (New Possibilities: p = 0.004, d = 0.405; Personal Strength: p = 0.005, d = 0.414). For patients with cPTSD, depressive (p = 0.010, d = -0.63) as well as cPTSD symptoms (p = 0.020, d = -0.796) were significantly reduced; perceived social support was increased after day clinic treatment (p = 0.003, d = 0.61). Contrary to our expectations, somatoform symptoms were increased after therapy. Conclusions: The present work expands previous research by demonstrating that multimodal group-based, day clinic treatment is effective in the treatment of trauma-related disorders, also in their complex form.

Trauma-Focused Art Therapy in the Treatment of Posttraumatic Stress Disorder: A Pilot Study

Research showed that more than 30% of patients with Posttraumatic Stress Disorder (PTSD) do not benefit from evidence-based treatments: Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) or Eye Movement Desensitization and Reprocessing (EMDR). These are patients with prolonged and multiple traumatization, with poor verbal memory, and patients with emotional over-modulation. Retelling traumatic experiences in detail is poorly tolerated by these patients and might be a reason for not starting or not completing the recommended treatments. Due to lack of evidence, no alternative treatments are recommended yet. Art therapy may offer an alternative and suitable treatment, because the nonverbal and experiential character of art therapy appears to be an appropriate approach to the often wordless and visual nature of traumatic memories. The objective of this pilot study was to test the acceptability, feasibility, and applicability of trauma-focused art therapy for adults with PTSD due to multiple and prolonged traumatization (patients with early childhood traumatization and refugees from different cultures). Another objective was to identify the preliminary effectiveness of art therapy. Results showed willingness to participate and adherence to treatment of patients. Therapists considered trauma-focused art therapy feasible and applicable and patients reported beneficial effects, such as more relaxation, externalization of memories and emotions into artwork, less intrusive thoughts of traumatic experiences and more confidence in the future. The preliminary findings on PTSD symptom severity showed a decrease of symptoms in some participants, and an increase of symptoms in other participants. Further research into the effectiveness of art therapy and PTSD is needed.

Challenges of Combining Perspectives

Abstract.Background: Asylum seekers have increased risk of suicide and suicidal behavior, with differences related to origin, gender, and age. There are barriers to communication in clinical encounters between asylum seekers and clinicians. There is insufficient knowledge about how communication in the clinical encounter affects the suicide risk in female asylum seekers. Aims: To explore the documented communication between female asylum-seeking suicide attempters and clinicians and how it affects treatment. Method: The medical records of 18 asylum-seeking women who had attempted suicide were analyzed with content analysis. Results: Communication between patients and clinicians was affected by: the unbearable realities of the women; difficulties for clinicians in decoding languages of distress, and understanding trauma and subjective meanings of suicide; challenges of combining patients' and clinicians' perspectives; and a sense of shared powerlessness. Limitations: The medical records did not give direct access to the patient's experience, only to the patient as documented by the clinician. Conclusion: The results suggest that clinicians working with asylum seekers who have attempted suicide need to develop an understanding of social and cultural factors and of trauma issues. A question for further study is how an enhanced integration of context and subjectivity in psychiatric practice would equip clinicians for the specific challenges encountered.

Forced migrants involved in setting the agenda and designing research to reduce impacts of complex emergencies: combining Swarm with patient and public involvement

PLAIN ENGLISH SUMMARY

The UK's National Institute for Health Research (NIHR) Health Protection Research Unit in Emergency Preparedness and Response was asked to undertake research on how to reduce the impact of complex national/international emergencies on public health. How to focus the research and decide on priority topics was challenging, given the nature of complex events. Using a type of structured brain-storming, the researchers identified the ongoing UK, European and international migration crisis as both complex and worthy of deeper research. To further focus the research, two representatives of forced migrant communities were invited to join the project team as patient and public (PPI) representatives. They attended regular project meetings, insightfully contributed to and advised on practical aspects of potential research areas. The representatives identified cultural obstacles and community needs and helped choose the final research study design, which was to interview forced migrants about their strategies to build emotional resilience and prevent mental illness. The representatives also helped design recruitment documents, and undertake recruitment and interviewer training.

BACKGROUND

Many events with wide-ranging negative health impacts are notable for complexity: lack of predictability, non-linear feedback mechanisms and unexpected consequences. A multi-disciplinary research team was tasked with reducing the public health impacts from complex events, but without a pre-specified topic area or research design. This report describes using patient and public involvement within an adaptable but structured development process to set research objectives and aspects of implementation.

METHODS

An agile adaptive development approach, sometimes described as swarm, was used to identify possible research areas. Swarm is meant to quickly identify strengths and weaknesses of any candidate project, to accelerate early failure before resources are invested. When aspects of the European migration crisis were identified as a potential priority topic area, two representatives of forced migrant communities were recruited to explore possible research ideas. These representatives helped set the specific research objectives and advised on aspects of implementation, still within the swarm framework for project development.

RESULTS

Over ten months, many research ideas were considered by the collaborative working group in a series of six group meetings, supplemented by email contact in between. Up to four possible research ideas were scrutinised at any one meeting, with a focus on identifying practical or desirable aspects of each proposed project. Interest settled on a study to solicit original data about successful strategies that forced migrants use to adapt to life in the UK, with an emphasis on successfully promoting resilience and minimizing emotional distress. "Success in resettlement" was identified to be a more novel theme than "barriers to adaption" research. A success approach encourages participation when individuals may find discussion of mental illness stigmatising. The patient representatives helped with design of patient-facing and interview training materials, interviewer training (mock interviews), and aspects of the recruitment.

CONCLUSION

Using patient and public involvement (PPI) within an early failure development approach that itself arises from theory on complex adaptive systems, we successfully implemented a dynamic development process to determine research topic and study design. The PPI representatives were closely involved in setting research objectives and aspects of implementation.

Posttraumatic world assumptions among treatment-seeking refugees

The clinical relevance of negative changes in cognitions about oneself, others, and the world is reflected in the diagnostic criteria for posttraumatic stress disorder (PTSD) in the DSM-5 and complex posttraumatic stress disorder in the ICD-11. Although such changes in cognition have been posited to be especially relevant for traumatised refugees, few studies have examined this in refugee populations. The present study used a cross-sectional design to compare negative cognitions among 213 adult treatment-seeking refugees with those in previously published samples from the general population, veterans with combat-related PTSD, and whiplash victims. Measures included the World Assumptions Scale (WAS) and the Events and DSM-IV PTSD subscales of the Harvard Trauma Questionnaire (HTQ). Path models examined the relation of the WAS subscales to five demographic and trauma-related variables. Results showed that world assumptions were especially negative with regard to Benevolence of World, Benevolence of People, and Luck subscales, on which refugees scored lower than all reference samples. Differences between the refugee sample and the reference samples were smallest with regard to self-worth and self-controllability. World assumptions were associated with gender and PTSD symptom severity but not with age, length of residence in the Netherlands, and number of traumatic event types. The DSM-5 criterion of negative changes in belief about oneself, others, and the world appears more applicable to refugees than the more narrowly formulated ICD-11 criterion of diminished and defeated sense of self. Prevention and treatment efforts with refugees may need to be especially aimed at preventing a further decline of trust as well as restoration of trust in others and the world.

Traumatized refugees: identifying needs and facing challenges for mental health care

In the past few years the number of refugees worldwide has increased dramatically. Many of them were traumatized in their homelands due to violent conflict or persecution, as well as during their flight, and are confronted with ongoing stressors in the exile countries. In order to contribute to enhancing the clinical knowledge, this special issue of the European Journal of Psychotraumatology focuses on traumatized refugees. It includes three review articles as well as four original articles on the mental health burden, screening instruments and interventions in different groups of refugees. The articles published in this special issue focus on important aspects of better understanding the needs of traumatized refugees, as well as on identifying and offering appropriate mental health care for this population. Future research recommendations are provided in the hope to contribute to improving mental health care strategies of this still underserved population.