What should we be offering people who are refugees or seeking asylum?

Dr Kerry Young and Dr Nick Grey

News reports of the evacuation of Afghan nationals fleeing Kabul earlier this year forced us to confront the reality of what it means to be displaced due to persecution and war.

Thousands of these families were evacuated to the UK. Some are British Citizens who were working in Afghanistan and many others have sought asylum. Reports suggest that there are a large number of family groups, as well as lone individuals.

Adult asylum seekers and refugees present with depression and post-traumatic stress disorder (PTSD) at fourteen and fifteen times the rate of the general population respectively. Child asylum seekers and refugees show rates of PTSD five times greater, and depression two times greater than in the general population. 

Nevertheless, many asylum seekers and refugees do not experience mental health problems, and not all emotional difficulties experienced are well captured by existing diagnostic categories.

The greatest risk factor for mental health problems in asylum seekers and refugees is the number of traumatic events the person has experienced and how closely involved they were in these events. While the traumas generally occur in the country of origin, they can also take place during the refugee’s flight to the UK.

Post-migration factors are also very important and are the areas in which we can intervene once people are asylum seekers and refugees in a safe country.

In 2019, Dr Kerry Young and Dr Nick Grey produced a briefing paper for the Home Office about what mental health services should be offered to refugees. In this, they reviewed available evidence and interviewed UK experts . To date, statutory support across the UK has not been co-ordinated, with many refugees and asylum seekers receiving help from a range of charities local to where they are living.

The recommendations which follow are based up on the findings in that briefing paper.

Recommendations for Adults

For adult asylum seekers and refugees, it is important that we help them if necessary to:

1. Access primary care – we might need to educate providers about legal entitlements to care, the need to provide interpreters to help them register with and talk to GPs, the need to extend appointment times to account for interpreting

2. Ensure that their physical health needs are properly investigated alongside any mental health problems

3. Ensure adults seen in secondary mental health services are given a comprehensive needs assessment

4. Access safe and suitable housing

5. Access English language classes and opportunities to enter employment, education or training

6. Access early evidence-based treatment of identified mental health problems – particularly PTSD, but also depression, anxiety, traumatic bereavement, anger, self-harm, suicidality.

For child asylum seekers and refugees, it is important that we help them if necessary to:

1. Access comprehensive assessment in the context of their family, school and community environment. These assessments should also include physical and neurodevelopmental factors.

2. Receive a stepped care model of intervention, with low intensity interventions offered in schools by Education Mental Health Practitioners (EMHPs) and high intensity therapies out of schools. These interventions must follow NICE guidance.

3. Ensure that the mental health needs of their parent(s)/carers are met

PTSD

There is clear evidence for the effectiveness of treatments for PTSD and comorbid conditions, in both adult and child asylum seekers and refugees. Various meta-analyses ^1-3 and systematic reviews ^4-8 have reached similar conclusions. First line treatments are psychological therapies with a trauma focus – that is, where the traumatic events are discussed in detail.

The trauma-focused therapies that are recommended for adults with PTSD in NICE guidelines⁹, are trauma-focused cognitive behavioural therapy (TF-CBT)¹⁰ and Eye Movement Desensitisation and Reprocessing (EMDR)¹¹ . NICE guidance describes Narrative Exposure Therapy (NET) as a form of TF-CBT. NET should be considered separately from other TF-CBTs for the treatment of PTSD in asylum seekers and refugees, as it was developed for this population. It was developed originally as a treatment to be used in refugee camps in low income countries. In recent years, it has been evaluated in middle- and high-income countries. Of recommended treatments for PTSD in asylum seekers and asylum seekers and refugees, NET is considered to be the most culturally appropriate.^12,13 Currently, NET is accepted as the treatment with the most evidence for effectiveness in treating PTSD in adult asylum seekers and asylum seekers and refugees who have experienced multiple traumatic events.

In cases where the psychological treatments have not been helpful or where the adult refugee is also suffering from depression alongside PTSD, NICE recommend a particular category of anti-depressant medication known as SSRIs (Selective Serotonin Reuptake Inhibitors).

For treating PTSD in children and young people, NICE recommends that TF-CBT should be offered first. This is similar to the treatment for adults but also encompasses greater involvement of the wider system, including caregivers/parents, other family, schools etc. There is a form of NET that has been developed specifically for use with children called KidNET.¹⁴ There are not yet studies examining its use in high income countries but it has been successfully trialled in low income countries. KidNET can be considered to be part of the broader family of TF-CBTs and as such may be of benefit to refugee children with PTSD.

Evidence-based treatments for PTSD in adult and child asylum seekers and refugees

Experts agree that timely treatment of PTSD in refugee adults and children allows wider social benefits. Once their PTSD has been treated, asylum seekers and refugees will be better able to concentrate to learn English, to engage in meaningful activity and to be well enough to consider work if appropriate.

Depression

The systematic reviews and meta-analyses find that when asylum seekers and refugees are suffering from both PTSD and depression (which is commonly the case), treating the PTSD with a trauma-focused therapy also improves levels of depression. Otherwise, there is no available evidence for the treatment of depression alone in adult or child asylum seekers and refugees. Experts agree that, in such cases, clinicians should follow NICE guidance for the treatment of depression and culturally modify on a case-by-case basis.¹⁵

Experts agree that existing psycho-educational materials for anxiety and depression will work well with refugee populations, although they may need to be culturally adapted on a case-by-case basis. These materials may need to focus more on the effects of multiple traumatic events (if appropriate.) In addition, if they have been through many traumatic events, asylum seekers and refugees are also more likely to experience dissociation. Please see Chessell et al. (2019)¹⁶ for a practical guide to working with dissociation in this population.

In line with expert recommendations, training has begun for IAPT services to enable them to provide evidence-based help to refugees and asylum seekers. Funded by Health Education England and run from the London CBT Training Centre, the programme began in June 2021. It is being delivered to services where refugees are settling around the country. High Intensity Therapists are invited to apply for the training package, which involves three days training to deliver evidence-based therapy, directed self-study and six, monthly supervision sessions from refugee experts.

Woodfield Trauma Service has produced a number of films for patients – in English, Arabic and Farsi - that can form part of low intensity interventions. These are available at the bottom of this page.

The Centre for Anxiety Stress and Trauma has also gathered translated materials for use with refugees and asylum seekers.

We also recommend that all psychological therapy services read and act on the IAPT Black, Asian and Minority Ethnic Service User Positive Practice Guide (Beck et al, 2019).¹⁷

For those working with Unaccompanied Asylum Seeking Minors, please read recent helpful guidance, ‘Practice guidelines for clinical psychologists for supporting appropriate care and treatment for Unaccompanied Asylum-Seeking Minors in the United Kingdom’ (Said and King, 2020) 

References

¹ Patel, N. (2014). Psychological, social and welfare interventions for psychological health and well-being of torture survivors. Cochrane Database of Systematic Reviews (11).

² Nocon, A., Eberle-Sejari, R., Unterhitzenberger, J. and Rosner, R.(2017).The effectiveness of psychosocial interventions in war-traumatized refugee and internally displaced minors: systematic review and meta-analysis European Journal Of Psychotraumatology, 8(2).

³ Nosè, M., Ballette, M., Bighelli,I., Turrini, G. et al. (2017b). Psychosocial interventions for post-traumatic stress disorder in asylum seekers and asylum seekers and refugees and asylum seekers resettled in high-income countries: Systematic review and meta-analysis. PLoS ONE 12(2), 1-16.

⁴ Crumlish, N. and O'Rourke, K. (2010). A systematic review of treatments for post-traumatic stress disorder among asylum seekers and asylum seekers and refugees and asylum-seekers. The Journal Of Nervous And Mental Disease 198(4), 237-251.

⁵Tyrer, R. A. and Fazel, M. (2014). School and Community-Based Interventions for Refugee and Asylum Seeking Children: A Systematic Review. PLoS ONE, 9, 89359.

⁶ Tribe, R. H., Sendt, K-V and Tracy, D. (2017). A systematic review of psychosocial interventions for adult asylum seekers and asylum seekers and refugees and asylum seekers. Journal Of Mental Health. https://doi.org/10.1080/09638237.2017.1322182.

⁷ Khan, K. (2017). Evidence on interventions that improve mental health of child asylum seekers and asylum seekers and refugees and child asylum seekers in Europe: A Rapid Systematic Review. 

⁸ Thompson, C.T., Vidgen, A. and Roberts, N.P. (2018). Psychological interventions for post-traumatic stress disorder in asylum seekers and asylum seekers and refugees and asylum seekers: A systematic review and meta-analysis. Clinical Psychology Review, 63, 66-79.

⁹ NICE (2018). Guidance for prevention and treatment of Posttraumatic Stress Disorder in Adults and Children. 

¹⁰ Ehlers, A. and Clark, D.M. (2000). A cognitive model of posttraumatic stress disorder. Behav Res Ther, 38(4), 319-45.

¹¹ Shapiro, F. (2001). Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures (2nd ed.). New York, NY, US: Guilford Press.

¹² Robjant, K. and Fazel, M. (2010).The emerging evidence for Narrative Exposure Therapy: a review. Clinical Psychology Review, 30(8), 1030-1039.

¹³ Slobodin, O. and de Jong, J. T. V. M. (2015). Family interventions in traumatized immigrants and asylum seekers and asylum seekers and refugees: A systematic review. Transcultural Psychiatry 52(6), 723-742.

¹⁴ Neuner, F., Catani, C., Ruf, M., Schauer, E., Schauer, M., Elbert, T. (2008). Narrative exposure therapy for the treatment of traumatized children and adolescents (KidNET): from neurocognitive theory to field intervention. Child Adolesc Psychiatr Clin N Am.17(3), 641-64.

¹⁵ Beck, A. (2016). Transcultural Cognitive Behaviour Therapy for Anxiety and Depression: A practical guide. Routlege.

¹⁶Chessell, Z. J., Brady, F., Akbar, S., Stevens, A., & Young, K. (2019). A protocol for managing dissociative symptoms in refugee populations. The Cognitive Behaviour Therapist, 12, E27. http://doi.org/10.1017/S1754470X19000114

¹⁷ Beck, A., Naz, S., Brooks, M, & Jankowska, M. (2019). IAPT Black, Asian and Minority Ethnic Service User Positive Practice Guide. 

Video resources

The following videos are made available by the Woodfield Trauma Service, and are available in English, Arabic and Farsi. Click the language under each video that you want to watch.

PTSD Psychoeducation – a film about PTSD symptoms and memory storage during trauma

English

Arabic

Farsi

Grounding and Dissociation – psycho-education about managing dissociation and flashbacks

English

Arabic 

Farsi

Sleep Psychoeducation – a film for patients about basic sleep hygiene

English

Arabic

Farsi

Behavioural Activation – telling patients about basic ways to increase their activity

English

Arabic

Farsi

This article was originally published in CBT Today magazine December 2021.

While we have checked the links in this article at the time of publication, BABCP is not responsible for any subsequent changes to these.