Dr Glenn Melvin
Professor Louise Newman
Dr Meredith Levi
Ms Ann Locarnini
beyondblue Victorian Centre of Excellence
Project completion year
Aim and objectives
- To conduct a pilot study of Trauma Focused Cognitive Behavioural Therapy (TF-CBT) for adolescents with refugee backgrounds with PTSD or trauma symptoms.\
- To examine the cultural relevance of a CBT approach in refugee youth.
To overcome some of the negative perceptions within refugee cultures about treatment of mental illness (talking to strangers about personal problems, stigma, mistrust of authority figures), the researchers accurately presented the program to the families as a skills-based program that may help adolescents who have been through very difficult times to cope with strong feelings and solve problems.
Fifteen young people were referred to the program. Of these, 10 (mean age = 15.8 years; male = 5) met selection criteria and were recruited. This group comprised young people from Sudan, Afghanistan and Burma. Given the range of presentations that can follow a trauma history, participants were enrolled on the basis of the presence of symptoms of depression, anxiety or trauma. As this was an exploratory study, there were minimal exclusions to participation in the study. Exclusion criteria included bipolar disorder, organic brain syndrome, severe intellectual disability, psychotic disorder, substance abuse disorder, active suicidal risk or other severe psychiatric disturbances that require acute hospital admission.
Nine out of 10 young people had risk factors capable of exacerbating their trauma symptoms. These included imminent expulsion (n=2), failure to enter a desired course (n=1), family violence (n=2), parental psychopathology (n=4), poverty (n=4), grief due to loss of parent (n=4) and social isolation (n=4). Six young people had a history of severe trauma as described by parents or referrer yet only four were able to articulate at baseline.
Clinicians employed a semi-structured interview (ADIS) to obtain DSM-IV diagnoses, a Global Assessment of Functioning (GAF) and self-report measures before treatment. After treatment, a clinical review of baseline diagnosis was undertaken, along with self-report measures and GAF estimation.
Treatment sessions were conducted in English at the participant’s school. The early part of therapy involved rapport building, orienting to treatment, building an emotional vocabulary and psycho-education about the role of post-traumatic stress on attention, memory, concentration and sleep. When the participant had little English, a common vocabulary was used to make communication and therapy easier.
Creative expression, including games and activities, was used to establish rapport. Relaxation training, modulation of emotional reactions and discussion of traumatic experiences assisted with overcoming post trauma symptoms. Constructing a trauma narrative about the young person’s life in book form provided a coherent integration of experiences for suitable applicants (this stage of treatment was only done when clinically indicated – that is, it was not done when young people were unable to recall traumatic events or when it was thought that discussion of specific traumatic events could re-traumatise the client).
Incorporating a family visit helped address communication problems and any parental misunderstandings about the young person’s symptoms or behaviour. It also offered an opportunity to discuss other behavioural problems that may have endangered the young person’s ability to grow and develop normally, such as getting into fights, parental violence or school refusal.
The final stage of treatment included planning for managing future difficulties with an emphasis on early recognition of symptoms and identifying means of gaining support.
Clinicians were called on to offer advocacy for the young people, either in dealing with schools and disciplinary matters, providing links to financial assistance, assisting parents to get the psychosocial support that they needed, helping one boy to be included in soccer training and assisting another socially isolated girl to join a homework club, through to taking a girl to the doctor to learn about sexual health.
The mean number of sessions attended was 15 sessions (sd=6.8, range 8-28). Two young people dropped out of treatment, one because his depression was resolved and another because she had no significant symptoms. Two other participants have missing data for the post-treatment assessment.
Modifications to standard TF-CBT were necessary to engage the youth and increase satisfaction with treatment. The modifications were informed by past research with refugee youth and clinical experience. They are set out below and are consistent with the adaptable nature of TF-CBT.
All young people improved following treatment. Four young people were found to have Major Depressive Disorder prior to commencing treatment. After treatment, all depressed young people had made symptomatic improvement according to clinician review. There was a reduction of symptoms in all measures tested. There was significant change in self-reported depressive symptoms (CDI) and overall global functioning (GAF). Small numbers and different dose effects (weeks in treatment) reduced the chance of finding statistically significant findings in the self-report measures.
For some students and their families, there was reluctance to think about their difficult past. This made it harder to link current symptoms to past trauma and meant that the clinicians worked slowly to allow the young person to gain trust and feel comfortable discussing such issues. Most young people presented with complex needs. Many cases required cross referrals to medical or social supports, with psychological issues having to wait until more urgent issues were addressed.
The researchers expected the issue of stigma to be greater than it was. Surprisingly, the families welcomed the idea of their children attending a program such as this and did not see it as stigmatising. It is acknowledged that this sample may have been self-selecting.
- The study has demonstrated that the TF-CBT approach is feasible for traumatised adolescents of a refugee background. This finding points to the need for a randomised controlled trial of the treatment approach to demonstrate efficacy.
- An important practical outcome has been the establishment of the adolescent refugee clinic at Monash University. This has now become integrated with many of the local outreach services in the region, such as ERMHA, New Hope and the Centre for Multicultural Youth (CMY).
- The establishment of this project has provided opportunities for under-graduate and post-graduate psychology and medical student training. The clinic had a psychiatric registrar join the clinic in 2011 and another registrar was appointed in 2012. The registrars also work in the adult refugee clinic at Dandenong Hospital where relatives of clients were being seen for their psychiatric problems hence they are in a good position to appreciate the complexity of their clients’ lives.