According to the National Institute of Mental Health (2016), posttraumatic stress disorder (PTSD) can develop in individuals who have experienced a shocking, frightening, or dangerous event, making them continue to feel stressed or frightened even when not in danger. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has documented the many symptoms of PTSD: re-experiencing the event; aggressive, reckless, or self-destructive behavior; sleep disturbances; hypervigilance; avoidance of distressing memories or reminders; distorted blame; trauma-related emotions; and feelings of alienation (American Psychiatric Association, 2013).
Refugees' experiences before, during, and after migration can make them more vulnerable to developing PTSD. McGregor, Melvin, and Newman (2015) asserted that trauma from cumulative events—such as prolonged civil unrest and religious/political persecution, war violence, and involuntary displacement—contribute to PTSD in refugees. Schick et al. (2016) stated that after refugees experience the traumatic events of their homeland, they then face the challenges of adapting to their host country. They are expected to participate in the host society's activities, integrate socially, develop language proficiency, and become financially independent—all while facing possible language and communication barriers, difficulty finding work, family separation, and discrimination. In addition, refugees often experience cultural losses of their language, community network, and family support system (Refugee Health Technical Assistance Center [RHTAC], 2015) that can make finding help for PTSD problematic. Indeed, PTSD in refugees is a normal reaction to an abnormal situation (Harlem Brundtland, 2000).
Unfortunately, many refugees who come to the United States have existing mental health problems (RHTAC, 2015). In the United States, PTSD rates among refugees range from 10% to 40% (RHTAC, 2015). Addressing PTSD in refugees is a problem that will continue to grow as the global number of refugees continues to rise. In 2017, approximately 16.2 million refugees were displaced worldwide (United Nations High Commission for Refugees [UNHCR], 2018), with more than 85,000 settled in U.S. cities. As of 2015, 1,051,031 foreign individuals had been granted lawful permanent residence in the United States (U.S. Department of Homeland Security, 2015).
Texas has the second highest number of resettled refugees, with approximately 11,200 in 2017 (Office of Refugee Resettlement, 2017a). Although the Texas Office of Refugee Settlement (2017b) promotes mental health in refugee communities by conducting culturally competent screenings, facilitating strengths-based case management services, and promoting mental health education and resiliency factors, it does not advocate specific strategies and interventions.
The current pilot study was conducted at a federally funded, non-profit medical and mental health clinic located in central Texas that serves refugees who have experienced torture in their home countries. The clinic's nurse practitioner (NP) and physician manage medical and mental health medications. Two masters-prepared social workers screen low-income clinic clients for mental health concerns and provide individual, trauma-focused therapy as well as case management for housing and employment. Providers reported that the traditional Western approach of individual therapy and medication often is not culturally congruent for the refugee population, which is typically more receptive to informal peer-driven and group approaches to handling issues. Due to refugees' feelings of isolation and lack of social support, providers have reported decreased effectiveness and lack of symptom improvement with the usual treatment of individual therapy and medication. Although refugees may be from different geographical areas, they share many experiences, including their immediate predicament as refugees. The current study's researchers (M.A., S.M.) hypothesized that even though PTSD causes are different for Veterans and refugees, the symptoms are the same; hence treatment may be the same as well. Therefore, they wanted to determine how a program proven effective at addressing PTSD in Veterans would work for refugees with PTSD.
For the current mixed-methods study, the researchers implemented the evidence-based PTSD Recovery Program (developed by the U.S. Department of Veterans Affairs National Center for PTSD and hereafter referred to as “the program”) with low-income refugees diagnosed with PTSD. The purpose of the study was two-fold: (a) to determine if participants reported fewer PTSD–related symptoms after the 10 weekly group therapy sessions (in addition to the usual care of individual therapy and medication); and (b) to evaluate clinic providers' satisfaction with the program and the likelihood of their continuing to use it at the clinic.
A literature search was conducted using the CINAHL and ProQuest databases to find articles related to mental health in the refugee population and use of the program's group therapy with Veterans.
Refugees and Mental Health Care
Refugees can experience psychological disturbances due to their preflight, flight, and resettlement experiences. Historically, most studies have focused on how preflight trauma experiences affect PTSD symptoms. However, current research has begun to focus on the effects of refugees' resettlement experiences. Murray, Davidson, and Schweitzer (2010) reviewed current research to suggest best practices for resettlement interventions for refugees. Cognitive-behavioral therapy (CBT) and pharmacology were found to be four times more effective for culturally homogeneous groups than culturally heterogeneous groups. Their findings also indicated that psychosocial models promoting positive personal change are more beneficial than models focused on trauma- and stress-related experiences (Murray et al., 2010). Such positive personal change models have been found to help clients develop a sense of control, safety, and trust (Murray et al., 2010).
The World Health Organization (WHO; 2012) advised that teams assessing mental health and psychosocial needs in humanitarian settings be trained in ethical principles and basic interviewing skills. In addition, teams assessing a refugee sector should be knowledgeable about refugees' culture and available community resources, and balanced in gender. If possible, some members should be part of or familiar with the identified population (WHO, 2012).
In response to the increasing incidence of mental health problems among Iraqi refugee children from their exposure to trauma and violence prior to U.S. resettlement, Vermette, Shetgiri, Al Zuheiri, and Flores (2015) examined these children's health care access. In 2011, four focus groups (N = 24) were conducted in Dallas, Texas using interpreters. The parents explained that, due to extreme violence in Iraq, PTSD was present but not recognized or understood prior to resettlement. Parents also explained that acknowledging mental health difficulties was unacceptable in Iraqi culture. Several system-related and sociocultural issues emerged in the focus groups. The system-related issues focused on insurance-related barriers such as coverage lapses due to miscommunication, misunderstanding the renewal process, long waits for appointments, and difficulties communicating through interpreters. Interpreters frequently were not available in smaller clinics. Reported sociocultural barriers included acculturation stress, prejudice, and the necessity of restarting the health care process after resettling in another state. Researchers offered several recommendations to address these barriers: extending case management services from 8 months to 2 years, providing transportation to health care visits, improving interpretation services, and educating refugees about the U.S. health care system and how to navigate Medicaid (Vermette et al., 2015).
Asgary and Segar (2011) documented health care barriers experienced by refugee asylum seekers. They found three types of barriers: internal (i.e., mental illness, fatalism, mistrust, and perceived discrimination); structural (i.e., affordability, limited services, inadequate interpretation, resettlement challenges, health care for urgent care only, and poor cultural competency); and social assimilation (i.e., difficulty navigating a complex system and inadequate community support) (Asgary & Segar, 2011). Although refugees and asylum seekers can be treated effectively in standard psychiatric settings, several factors can affect treatment efficacy for these populations: cultural barriers, diverse health care beliefs and practices, biases, and client and provider cultural differences (Stenmark, Catani, Neuner, Elbert, & Holen, 2013).
Whitsett and Sherman (2017) urged providers to use well-validated screening instruments to assess not only patients' mental health needs, but also their social needs, such as housing and health screening. Such screening could help providers understand how trauma exposure negatively affects refugees' and asylum seekers' psychological functioning. Although the researchers concluded that individuals who survived torture likely would benefit from psychiatric treatment, they also emphasized that safe living conditions also improve treatment effectiveness (Whitsett & Sherman, 2017).
Group Therapy Guidelines for Veterans with PTSD
Although the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DoD) (2017) identify group therapy as an effective adjunctive treatment for Veterans with PTSD, they emphasized the need for individual therapy, as group therapy alone might not manage PTSD symptoms effectively. The VA and DoD endorse three types of group therapy: supportive group therapy, psychodynamic group therapy, and CBT groups.
Current VA/DoD (2017) guidelines note the need to plan group participation carefully to achieve optimal results. This planning can include excluding clients likely to disrupt the group due to cognitive impairment, active psychosis, and suicidal or homicidal ideations. In addition, groups should be planned to include homogenous members with an emphasis on gender compatibility, similar traumatic experiences, and sexual orientation (VA/DoD, 2017). Yalom and Leszcz (2005) also noted that group member selection affects a group's effectiveness. Group therapy goals include providing treatment efficiently and helping members develop supportive relationships with each other, which can decrease the feelings of alienation and isolation common in individuals with PTSD (VA/DoD, 2017).
Group Treatment Effectiveness
According to the VA's Mental Illness Research Education Clinical Center (MIRECC; 2015), the VA–developed program of group therapy helps decrease reported PTSD symptoms while promoting positive patient outcomes (Fala, Coleman, & Lynch, 2016). Data collected from combat Veterans enrolled in the program were evaluated using the PTSD Checklist-Military (PCL-M) to determine the program's effectiveness at improving symptoms. Following participation in the 10-week program, participants had decreases in scaled and total PTSD checklist scores (p < 0.001) for the symptoms of hyperarousal, re-experiencing, and avoidance/numbing. Participants also experienced considerable improvement in psychosocial adjustment, such as psychosocial adaptive behaviors and self-efficacy (p < 0.001) (Fala et al., 2016). The VA reported that combat Veterans diagnosed with PTSD responded favorably to the program after it was implemented in several facilities (MIRECC, 2015).
Fala et al. (2016) used the program to address anticipatory anxiety in combat pilots by helping them focus on the present moment instead of the troubling experience. A paired-samples t test demonstrated a significant improvement in Veterans' PTSD symptoms (p < 0.001), adaptive behaviors (p < 0.001), and general self-efficacy (p < 0.001) using the McGuire Adaptive PTSD Scale Revised and General Self-Efficacy Scale (Schwarzer & Jerusalem, 1995).
Group treatment has been shown to be effective when used as an adjunctive treatment to individual therapy (Sloan, Bovin, & Schnurr, 2012). Campanini et al. (2010) adapted depression treatment into an interpersonal therapy group (IT-G) for PTSD. The study's results showed considerable symptom improvement in PTSD, depression, and anxiety as well as improved quality of life and social adjustment among clients in the IT-G compared to control groups (Campanini et al., 2010).
Lewin's (1951) force field analysis—a change model for reshaping behaviors and values despite forces restraining these efforts—helped guide the current study. The theory defines three change stages: unfreezing, changing, and refreezing. Unfreezing involves identifying the problem and dismantling the mindset and structures supporting it. Changing is transitioning from current practice standards to new ones. In refreezing, new behaviors and values are set (Lewin, 1951).
Application to Therapists. For the current study's unfreezing phase, researchers partnered with multidisciplinary clinic staff to help recognize the need to change to deliver optimal mental health care to the refugee population. In the changing stage, therapists received the VA's PTSD Recovery Program Therapist Manual and learned how to lead group therapy sessions. Therapists worked with researchers to conduct the group therapy sessions. The freezing stage was the decision to use group therapy sessions for all clients with PTSD.
Levine's (1973) conservation model focuses on each client's individuality, viewing the client as an autonomous whole. The model's major concepts are wholeness, adaptation, and conservation. In this model, health care providers use four conservation principles—conservation of energy, structural integrity, personal integrity, and social integrity—to guide their interactions and interventions to keep a client's wholeness intact. This model also focuses on adaptation, as individuals continuously experience change and adapt to their environment (Alligood, 2014).
Application to Refugees. As part of the education process, Levine's (1973) conservation model was explained to clinic providers and they were encouraged to view each individual as a whole to enhance the care they provide to refugees experiencing PTSD. By using group therapy to promote collective empowerment and community support access, providers can support these individuals as they adapt to their new communities. Such efforts also support the conservation of social integrity by encouraging social interactions among peers with similar experiences and promoting social well-being. Conservation of personal integrity can be achieved by addressing all clients' needs: physical, emotional, cultural, and social. Throughout the group therapy sessions, participants were encouraged to use coping skills and calming strategies to counteract PTSD symptoms. These skills helped participants regain a sense of emotional control, allowing them to conserve their emotional energy and personal integrity.
The population for this mixed-methods study was a convenience sample (N = 20) of adult clinic clients with refugee status who were diagnosed by the physician, NP, or therapist with PTSD based on DSM-5 criteria. Inclusion criteria were patients at the clinic with a current diagnosis of PTSD, refugee status, and compliance with individual therapy and medications. Participants originated from Iraq, Nepal, and Myanmar, as the clinic was able to provide volunteer translators for these languages. Exclusion criteria were having cognitive impairment, active psychosis, and current suicidal or homicidal ideations. All clients meeting the inclusion criteria were invited to participate. All participants received the usual care provided at the clinic: monthly individual therapy with a social worker and medications for depression and/or anxiety from the NP or physician. During the first and tenth sessions, participants completed a self-report preintervention survey (PTSD Checklist for DSM-5 [PCL-5], Table A [available in the online version of this article]) that assessed 20 PTSD symptoms (Weathers et al., 2013). This survey has a rating scale of 0 to 4 for each symptom, with 0 indicating not at all and 4 indicating extremely (Weathers, Litz, Herman, Huska, & Keane, 1993). The PCL-5 has been used extensively and validated in numerous studies. Reliability of the PCL-5 also has been documented on three measures: Cron-bach's alpha = 0.90, sensitivity = 0.86, and specificity = 0.63 (Gelaye et al., 2017). In addition, participants' anecdotal comments were collected during each session and their feedback was gathered at the end of the project.
Ethics and Human Subject Protection
The current study was approved by the requisite Institutional Review Board. Participants were informed (in their own language with the help of translators) that study participation was strictly voluntary, and standard consent forms were obtained from each participant. Participants did not receive any monetary compensation.
Intervention—The PTSD Recovery Program
This program's sessions are designed to include five to 14 clients in 10 weekly sessions. The program's aim is to educate clients about PTSD and teach them coping skills for improving symptom management, reducing PTSD symptom severity, and improving psychosocial adjustment (VA, 2015). The program includes elements from psychoeducation, CBT, stress management, mindfulness, and interpersonal skills. Symptoms addressed in the weekly sessions included anxiety, nightmares, irritability, anger, feelings of isolation, flashbacks, loss of interest, feelings of numbness, sleeplessness, and loss of social support. The agendas for each of the 10 group sessions are provided in the program manual as well as in the Therapist Tips for each session (VA, 2015; access https://www.mirecc.va.gov/docs/visn6/PTSD_Recovery_Group-Client_Manual_3rd_edition.pdf). Prior to start of the group sessions, each provider received a copy of the manual and researchers provided training on the program. Each group was led by a social worker and a student researcher.
Provider satisfaction was evaluated with a survey (Table B, available in the online version of this article) completed 1-week postintervention. Researchers also asked providers to comment on their level of satisfaction with the program and the efficacy and sustainability of providing group therapy at the clinic.
Provider Satisfaction Survey
After two of the initial 20 participants dropped out after the first session, 18 participants (three women and 15 men) completed the study. Participants were divided into two nine-person therapy groups, with all three women placed in the same group. Data from both groups were combined for analysis. Quantitative data were analyzed using parametric and nonparametric statistics to measure changes in PCL-5 results from pre- to postintervention. A Wilcoxon signed-rank test was used to compare each PCL-5 item for changes from pre- to postintervention.
The 20 PCL-5 items were matched and compared using the Wilcoxon matched pairs for all 18 participants and again for those who participated in at least 80% of the sessions (n = 14). All participants (regardless of the number of sessions attended) showed statistically significant improvements on three items: item 11 (Are you having strong negative feelings such as fear, horror, anger, guilt, or shame?) (z = −3.697, p < 0.001); item 12 (Have you had a loss of interest in activities that you used to enjoy?) (z = −3.580, p < 0.001); and item 20 (Are you having trouble falling or staying asleep?) (z = −3.404, p = 0.001). Participants who attended at least 80% of the group therapy sessions (n = 14) reported postintervention symptom improvement on the same three items as the total group: item 11 (Are you having strong negative feelings such as fear, horror, anger, guilt, or shame?) (z = −3.247, p = 0.001), item 12 (Have you had a loss of interest in activities that you used to enjoy?) (z = −3.225, p = 0.001), and item 20 (Are you having trouble falling or staying asleep?) (z = −3.168, p = 0.002).
A paired t test was used to compare the total value variable for PCL-5 scores from pre- and postintervention responses. The results showed that participants reported a decrease in total value scores postintervention (mean = 19.67, SD = 15.878) compared to preintervention (mean = 44.11, SD = 10.527) (t = 10.367, p < 0.001).
Provider Satisfaction. Providers' comments indicated their overall satisfaction with group therapy as an adjunctive PTSD treatment for refugees. They also described the intervention as reliable, reproducible, and valuable for their refugee clients, endorsing it for use with all refugees. Providers identified several program aspects that were beneficial for participants: structured session outlines, the fact that the program is evidence based and has been implemented in other populations, and the relevance and relatability of session content to their refugee clients. Providers did not identify any disadvantageous program aspects.
These results support Lewin's Force Field Analysis as the providers identified the problem (PTSD in the clinic's refugee population) and were receptive to the new approach of group therapy as an adjunct treatment. Based on positive client feedback, providers reported that they plan to continue using the program, demonstrating a refreezing of new behaviors.
Participant Feedback. Participants' feedback about their group therapy experiences was positive, with many reporting improvements in daily functioning. One participant began group therapy reporting high anxiety levels that caused significant sleep disturbances. After attending group therapy sessions, he reported that using the relaxation and breathing techniques taught in group therapy relieved his insomnia and helped him control his anxiety, both of which had been significantly affecting his daily life.
One participant reported having high levels of anxiety (with sweating, shaking, and a racing heart) whenever he was approached by customers in military or police uniforms at the convenience store where he worked. He reported this experience served as a trigger, reminding him of negative experiences he had with hostile factions in his country and the trauma sustained from these factions. After learning relaxation techniques and healthy ways to confront triggers during group therapy, he reported approaching these customers little by little to get to know them and minimize his unfounded fears. He is now on a first-name basis with many of these regular customers and enjoys conversing with them.
A female participant reported having sought medical care several times for heartburn and nausea experienced during times of anxiety and high stress. Her primary care provider could not identify a medical cause for these symptoms, suggesting they may be associated with anxiety. After identifying her PTSD triggers during group therapy, she reported using her newly learned relaxation exercises when faced with a trigger. She stated that using these techniques in times of moderate anxiety has improved her heartburn and nausea and she hopes that continuing to use them will result in increased symptom improvement.
One male participant who worked as a taxi driver reported feeling disrespected by customers who used loud voices he perceived as confrontational. He reported that these individuals made him angry and irritable, sometimes causing the situation to escalate verbally. Through group therapy, this participant gained an understanding of this trigger by determining that males with loud voices reminded him of aggressive refugee camp guards. This participant now uses the de-escalation techniques he learned in group therapy to navigate these situations successfully.
Many participants newer to the United States reported the benefits of spending time with fellow participants who had been in the country longer and therefore were more established. Most newcomers had anxieties about learning English, finding employment, and establishing lives in this new and foreign country. Established participants were able to provide hope and guidance to fellow group members who were fearful and anxious about the changes they were experiencing.
Most of the newly placed participants reported feelings of isolation in addition to their PTSD symptoms. They spoke about feeling lonely and “cut-off” from their family, language, country, and support system. More established participants assured them that this was how they felt in the beginning, and said these feelings are a natural part of the immigration process. During the group therapy sessions, providers encouraged participants to continue their dialogues outside of the group, and by the end of this intervention, many had formed support systems with each other.
Levine's (1973) Conservation Model allowed use of the concepts of wholeness, adaptation, and conservation to facilitate refugees' adaptation to their new environments. Group therapy provides a foundation of support and helped participants understand and learn new skills that strengthened not only their adaptation into communities, but also their individual confidence in their unique wholeness, and their own and others' personal integrity.
The UNHCR (2014) public health objectives include improving mental health care access for refugees by increasing the availability of psychiatric care referrals. In effect, these objectives make providing mental health care access as important as providing primary health care access. This objective also is endorsed by the WHO (2012) whose overall goals for refugees include promoting psychiatric and mental health well-being, preventing psychiatric disorders, providing mental health care, and enhancing recovery.
These global policies require practical application by providers treating this population. Most individuals in the health care community acknowledge the problems of providing effective mental health care to refugees. Research is needed to determine which interventions, strategies, and evaluations are effective and beneficial. Community-based psychosocial care should become an integral part of the public health care and social service system for refugees. The current study's positive quantitative results (from participants' PCL-5 surveys) and qualitative results (from provider and participant feedback) indicate that it was a beneficial intervention for this sample of refugees.
Another outcome of this intervention was its contribution to the development of a support system and strengthening of community relationships among participants. As participants spent time together in group therapy, they began to support each other in other aspects of their lives. For example, one participant brought job applications for another participant who was desperately seeking employment. Although these results cannot be measured quantitatively, the support proved to be vital for participants who felt isolated and lacked the support of their families and communities of origin. The program's effectiveness is also reflected in the fact that providers plan to implement it as standard care at the clinic.
Implications for Clinicians
The continuing increase in refugees entering the United States can place a great strain on the country's health care system. Moreover, caring for refugees from other countries introduces a unique set of challenges and requirements (Stenmark et al., 2013). Each culture is shaped through its history, traditional beliefs, social structure, and religion. Providers must remember that a wide range of cultural beliefs surround mental health, and that attitudes toward mental illness vary among individuals and families based on ethnicities, cultures, religions, and countries of origin (Unite for Sight, 2015). Providers who work with refugees should try to educate themselves on their clients' history and geographical and cultural beliefs. Another concern for therapists is awareness of their own biases or prejudices. A client who wrongly perceives provider insensitivity as racism could experience an exacerbation of the trauma they have already experienced (Cleek, Wofsy, Boyd-Franklin, Mundy, & Howell, 2012).
The program used for the current study provides education that can help normalize common reactions, improve coping, and enhance self-care (VA/DoD, 2010). The program also encourages the creation of support groups that can provide community-based care to refugees in much the same way it has been provided to Veterans, resulting in improved treatment delivery and health outcomes. This program can be adapted to and evaluated with other patient populations with PTSD aside from Veterans and refugees. Fortunately, many of the necessary resources are available online (VA, 2015; VA/DoD, 2010; WHO & Calouste Gulbenkian Foundation, 2017).
As the study progressed, some unexpected concerns arose that affected participation: transportation, childcare, and scheduling issues. Because many participants had difficulty finding transportation to and from group sessions, providers identified transportation aid as an important concern to address for future groups. In addition, many participants lacked resources to obtain childcare, resulting in some bringing their children to meetings. During this study, the clinic receptionist volunteered to serve as an on-site childcare provider to allow participants to attend group sessions. In the future, the need for planned childcare should be considered to facilitate participation. Although work conflicts were a known limitation of this intervention, providers reported this issue to be more problematic to attendance than expected. Another study limitation was the lack of participant demographic information to allow for comparison with other groups. Finally, having such a small number of participants made it impossible to assess for power and limits the generalizability of the study's findings.
As the number of refugees grows, so will concerns about addressing their mental health issues to help them become healthy members of society. The current study's quantitative and qualitative results show that the PTSD Recovery Program was an effective adjunctive PTSD treatment for this sample of refugees. Considering these results, the program should be evaluated further to confirm its efficacy with larger and more varied refugee populations. Future studies with larger populations could evaluate the effectiveness of the program by comparing results from a group receiving the intervention and usual care to a group receiving only usual care.
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