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Psychological screening and treatment of post-trauma symptoms for Middle Eastern adolescent refugees: a pilot study
thesisposted on 26.02.2017, 22:50 by Locarnini, Ann
Adolescent refugees present with increased levels of PTSD and depression as a result of their refugee experiences. At present, research and clinical practice with this population are hampered by a lack of validated assessment measures to identify cases, as well as clinical guidelines for psychological treatment. The rapid growth in ethnic minority populations in western countries means that interventions that adapt universal principles for different cultural groups are required (Muñoz & Mendelson, 2005; Wilson, 2013). This study aims to assist any future large-scale research by piloting the process and procedures involved in such research. Study 1 consisted of an evaluation of a self-report measure, the Trauma Symptom Checklist for Children (TSCC) for psychometric equivalence in adolescents from an Australasian and Middle Eastern refugee background (N=83). Linguistic, construct, convergent and divergent validities were assessed and found to be in the good-to-excellent range. Metric equivalence was demonstrated between refugee and non-refugee participants, and reliability indices ranged from good to high for both Afghan and Australian participants (Cronbach’s alpha = .97 for refugees and non-refugees). Receiver Operating Curve (ROC) analysis revealed that the area under the curve (AUC) was equal to .95 for refugees and .91 for non-refugees TSCC (95% CI. [Refugees; .89-1, non-refugees; .83-1]). The sensitivity of the TSCC against PTSD diagnosis was 93.8% with a specificity of 81%, with a cut-off of 34.5 for refugees; it was 91% sensitive and 83.3% specific with a cut off of 46.5 for non-refugees. Factor analysis, detailed in Study 2, was possible in this small sample, owing to wide and high communalities between the factors; it revealed a three-factor solution with Low self-worth, Intrusive avoidance and Externalised anger identified. The Intrusive avoidance scale was found to be equally high in both Middle Eastern and Australasian participants, whereas scales representing Low self-worth and Externalised anger were lower in the Middle Eastern sample. This offered some support for the hypothesis that re-experiencing should be constant across cultures as part of a neurobiological response to trauma. The reduced levels of Low self-worth and Externalised anger may have been due to more social support, specific cultural factors, or the relativity phenomenon, which makes the current life in Australia appear safe and calm, compared to the Middle East. Study 3 investigated the techniques and adaptations considered essential by clinicians when administering treatment to adolescent refugees of varied cultural backgrounds. The aims were to determine how clinicians were adapting treatment for these cross-cultural populations. A mixed methods approach utilised quantitative survey data (n= 32), which provided demographic information about clinicians, demonstrating that clinicians were predominantly female, Australian-born, and working in areas of high refugee settlement in diverse roles – mostly as refugee nurses, psychologists and social workers. The most common techniques used were the microskills of empathic listening and a humanistic, or client-centred therapy. The client information revealed that most clients were aged above 14 years, were from Afghanistan or Sudan, and suffered from a range of disorders, with anxiety, depression and PTSD predominating. Clinicians estimated the clinical improvement of adolescent refugees equal to that of non-refugees. A qualitative interview with a subset of nine participants led to the Interpretive Phenomenological Analysis (IPA) of treatment components presented by these participants. The clinician reports stressed the importance of attending to the relationship, developing trust, listening to the client’s explanatory model of illness and, if necessary, working alongside cultural leaders. The overarching theme was connection to others, with subthemes regarding the therapeutic relationship – namely, learning about each other, addressing immediate needs, being alongside, and recognition of strengths. There was evidence of cultural competence in the use of dynamic sizing and hypothesis testing in the transcripts from the interview participants, adding validity to the findings. Study 4 presented the design and implementation of an adapted Trauma-Focused Cognitive Behaviour Therapy (TF-CBT). The New Steps program utilised Herman’s principles of recovery from trauma as well as the findings from the clinician interviews and survey. The resultant treatment has an emphasis on creating a safe environment, utilising strengths and helping to rebuild identity. These elements were integrated with TF-CBT components of psychoeducation, affective regulation, cognitive processing, optional trauma narrative and future planning. The clinical effectiveness and acceptance of treatment were critical outcomes, and were found to show high positive effect sizes for the adolescent Afghan refugees, with increases in wellbeing and decreases in PTSD and depression symptoms. In conclusion, the structure of universal re-experiencing and avoidance, with varying levels of low self-worth or anger, presents a compelling and useful clinical conception of cross-cultural PTSD. Hopefully, future research may provide the answers needed so that clinicians can prioritise treatment goals. The New Steps treatment program uses the concepts of Herman’s trauma theory, TF-CBT and Feedback Informed Treatment principles to provide a cross-cultural therapy. Theoretically this treatment approach should be useful for diverse clients, as it works at an individual level and encourages the therapist to look for a range of cultural barriers to effective alliance and treatment.