Lecture 8: Problems and treatment of traumatized refugees in Western countries 

ARQ: organization helping people after traumas.

Who are refugees? Because conflict or persecution they have to flee their country. No longer in their own country, having to cross borders and it is not possible to go back home safely. Countries have a legal obligation to help refugees and are not allowed to send them back if it is not safe. When do you stop being a refugee: when they can go back? When they integrate in their new country?

2017: 14.716 new asylum application. Mostly from Syria (2.202) and Eritrea (1.095). 14.490 people reunited with their families in the Netherlands. 

Problems

Syrians are the largest group of refugees in the Netherlands. 40% of male and 45% of female recognised refugees have psychological complaints (anxiety, depression, PTSD).  

The refugee (mental) burden:

• War, organized crime, persecution 
• Leaving everything behind
• Fleeing
• Asylum procedure: very stressful
• Integration 
• Loss of status: for example, when you were a doctor in your home country and have to be a cleaner in the new country. 
• Takes a long time to be reunited with your family 
• Conflict in the home country is ongoing, they keep checking the news, very stressful. 

Posttraumatic stress disorder 

1. Exposure to actual or threatened death, serious injury, or sexual violence
2. Intrusion symptoms(need 1 for diagnosis) 
   1. Intrusive memories: the memory keeps the same vividness. 
   2. Destressing dreams
   3. Dissociative reactions 
   4. Cued psychological distress
   5. Cued physiological reactions
3. Avoidance symptoms(need 1 for diagnosis) 
   1. Avoidance of memories, thoughts, feeling 
   2. Avoidance of external reminders
4.  Cognitions and mood symptoms(need 2 for diagnosis)
   1. Inability to recall important aspect of event
   2. Exaggerated negative beliefs or expectations
   3. Distorted cognitions leading to blame 
   4. Persistent negative emotional state
   5. Diminished interest or participation in activities
   6. Detachment or estrangement from others
   7. Persistent inability to experience positive emotions
5. Arousal and reactivity symptoms(need 2 for diagnosis) 
   1. Irritable behaviour and angry outburst
   2. Reckless or self-destructive behaviour
   3. Hypervigilance (extremely alert) 
   4. Exaggerated startle response
   5. Problems with concentration 
   6. Sleep disturbance
6. Dissociative symptoms
   1. Depersonalization
   2. Derealization 

Complicated grief (persistent complicated bereavement disorder)

Complicated grief is unusually severe and prolonged, and it impairs function in important domains. Characteristic symptoms include intense yearning, longing, or emotional pain, frequent preoccupying thoughts and memories of the deceased person, a feeling of disbelief or an inability to accept the loss, and difficulty imagining a meaningful future without the deceased. Complicated grief affects about 2 to 3% of the population worldwide and is more likely after the loss of a child or a life partner and after a sudden death by violent means. 

PTSD prevalence

• Dutch general population: 7,4% 
• Displaced people worldwide: 30,6%
• Refugees in Western countries: 9%, 5% major depression 
• Treatment seeking refugees: 14-95%

Predicting PTSD in refugees

Elements that predict PTSD: 

• 23,6% torture
• 10% cumulative number of traumatic experiences
• 10% time since conflict 
• 3,5% level of political terror in country of origin 
• I.e. 1/3 predicted by traumatic experiences 

Prediction depression in refugees

• 22% cumulative number of traumatic experiences
• 21.9% time since conflict
• 11.4% torture
• 5.0% residency status

Treatment

Guideline for PTSD treatment in adults

• Trauma-focused cognitive-behavioural treatment (TF-CBT)
• Eye Movement Desensitization and Reprocessing (EMDR)

Discussion in refugees: should we follow the treatment guidelines in refugees? We have to stabilise them instead of focusing on the PTSD, but now a lot of research is done, and we know it is not true. There is no reason to wait.  

TFT in refugees

• Narrative Exposure Therapy (NET) is effective 
• Culturally-Adapted Cognitive Behavioural Therapy (CA-CBT) is effective 
• TFT is more effective than multimodal treatment
• TFT reduces PTSD severity and depression

Narrative Exposure Therapy: 

• Protocol with 10-12 sessions 
• Laying a lifeline (rope) on the floor, for different memories they put a rock or a flower down. 
• The other sessions are used for narrative (imaginary) exposure, reliving the memories. 
• The narrative is also written document, in this way they can give it to someone (children, lawyers). 

EMDR - helps to lose information and boil it down. 

1. Activating memory, putting it in the working memory
2. Focus on the event 
3. Rapidly moving the fingers across the eyes (burden the working memory)
4. A lot of information has to be processed by the working memory
5. The memory will become blurry, fewer emotions

If the memory is in the working memory, then it can be changed. 

EMDR study - Discussion: 

Acceptability 

Acceptability of EMDR significantly lower than of stabilisation → For a subgroup of refugees, acceptability needs to be a focus of treatment.  

Safety 

EMDR and stabilisation equally safe → EMDR may be offered earlier in treatment and to a broader range of refugee patients. 

Efficacy 

EMDR and stabilisation equally efficacious → Efficacy of EMDR with refugees needs to be increased. 

• With a subgroup of refugee patients?
• Greater number of sessions?
• More attention to match in explanatory models? 
• Phased or multimodal treatment?  

Explanatory model: culturally adapted psychotherapy is more effective than unadapted, bona fide psychotherapy for primary measures of psychological functioning. Adaptation of the illness myth was the sole moderator of superior outcomes via culturally adapted psychotherapy.