By Glyn Hupalo
Introduction
Overview
A report by the United Nations High Commissioner for Refugees (UNHCR, 2023) estimated that the global number of forcibly displaced and stateless people will reach 117.2 million by the end of 2023, 25% (29.3 million) of whom will be refugees from some 27 different countries. To gain refugee status in various countries, an individual must need to leave their home country due to fear of persecution or harm (Australian Government, 2020; GOV.UK, n.d.; Government of Canada, 2023). Before leaving their homeland and during their journey to the country which grants them asylum, refugees often experience extremely traumatic events (Australian Institute of Family Studies, 2022). It is these traumatic events which can often later be the source of a range of mental health conditions such as depression, post traumatic stress disorder (PTSD) and anxiety (Li et al., 2016). A recent meta-analysis conducted by Patanè et al. (2022) looking into the global prevalence of mental disorders in refugees found that 31% of refugees globally experienced PTSD. When the authors compared their findings with the prevalence of PTSD experienced by the general global population (Koenen et al., 2017; World Health Organization, 2017), they discovered that refugees were 4 to 5 times more likely to experience PTSD. With the growing number of refugees each year and statistics indicating that refugees are more likely to suffer PTSD, it seems likely that in the future a large percentage of people receiving treatment for PTSD will be refugees. In order to best assist these individuals, it is vital to gain a greater understanding of the current treatments available for PTSD that are specific to refugees.
Current Treatment
Despite historical evidence indicating that people have experienced mental distress as a result of exposure to traumatic events dating back hundreds of years, it was not until 1980 that the disorder we now call PTSD became a diagnosable condition (Crocq & Crocq, 2022). Since its inclusion in the third edition of the Diagnostic and Statistical Manual (DSM), PTSD as a disorder has become more widely recognised, and through empirical support assisted in the creation of a new chapter about trauma and stressor-related disorders in the fifth edition of the DSM (Friedman, 2013). As opposed to the era before the inclusion of PTSD in the DSM-III, there are now a whole host of treatment and intervention options that claim to be successful in the treatment of PTSD. These treatments can be divided into two groups: medication and psychotherapy.
Sonis & Cook (2019) claimed that there is insufficient evidence to determine whether medication or psychotherapy is a more effective treatment for PTSD. However, various sources such as American Psychological Association (2020), Forbes et al. (2020), Martin et al. (2021), and World Health Organization (2017) recommend the use of psychotherapeutic treatments such as Cognitive Behavioural Therapy (CBT), Cognitive Processing Therapy (CPT), Narrative Exposure Therapy (NET), and Eye Movement Desensitisation Reprocessing Therapy (EMDR), all of which are evidenced-based treatments, before the use of medications such as selective serotonin reuptake inhibitors sertraline (SSRIs) and antidepressants. When considering the treatment of PTSD in refugees, McDonald (2010) highlighted that if cultural aspects relevant to the individual are not considered, even the most effective treatments will fail to be successful. Therefore, many of the aforementioned psychotherapeutic treatments and medications may not be suitable for all refugee groups or require cultural modification. With this in mind, this paper will present research findings to outline the most common treatments and interventions currently used to address PTSD in refugees.
Research Findings
In order to determine the most relevant treatment methods and interventions for further research, six meta-analyses evaluating the efficacy of various PTSD treatments in refugees were analysed (Cloitre, 2009; Ehntholt & Yule, 2006; Lies et al., 2019; Nosè et al., 2017; Turrini et al., 2019, 2021). The common treatments which emerged were CBT, NET, EMDR, and medication. While these treatments were consistently referenced across all meta-analyses, inconsistencies in the effectiveness of NET and EMDR, as well as the use of medication, began to emerge in more recent studies. These inconsistencies will be explored in greater detail below.
Cognitive Behavioural Therapy (CBT)
As a treatment for PTSD, CBT aims to identify, challenge, and develop alternative interpretations of intrusive thoughts about traumatic events (McDonald, 2010). While extensive research exists on CBT as a treatment for PTSD, only a small number of studies specifically relate to the treatment of PTSD in refugees. Of this research, the majority focused on altered versions of CBT, namely Trauma Focused Cognitive Behavioural Therapy (TF-CBT) and Culturally Adapted Cognitive Behavioural Therapy (CA-CBT). Research on TF-CBT (e.g., Chipalo, 2021; Unterhitzenberger et al.,2019) tended to focus on PTSD in refugee children as the subject of the study, whereas research on CA-CBT (e.g., Bahu, 2019; Hinton et al.,2004, 2005) focused more on PTSD in adult refugees within a particular ethnic group. While each study listed found that CBT was successful in reducing the effects of PTSD, it is important to highlight the limitations of this research data. Firstly, all studies presented drew findings from extremely small sample sizes, with no evidence available to indicate success with a larger sample size. Secondly, both Chipalo (2021) and Unterhitzenberger et al. (2019) acknowledged that the data supporting their studies came solely from pilot studies, with a need for further research to support the validity of their findings.
Narrative Exposure Therapy (NET)
Based on the cognitive behavioral framework, NET is an evidence-based, short-term trauma treatment developed to assist those affected by war and torture in a culturally inclusive manner (Gwozdziewycz & Mehl-Madrona, 2013; NET The Institute, n.d.). Its underpinning philosophy states that through the process of writing down the events of one’s life, with specific focus on traumatic events, it is possible to reauthor the experience of traumatic memories through an alternative lens (Raghuraman et al., 2021). As exposing people to traumatic memories risks retraumatising them, this treatment may not be appropriate for all individuals (PTSD UK, n.d.). This aligns with the American Psychological Association (2020)'s rating of NET as a conditional recommended treatment as opposed to CBT which is rated as strongly recommended.
When examining NET-specific research, it appears that over time, as more research was conducted, the evidence of NET’s effectiveness has declined. Earlier studies such as Hensel-Dittmann et al. (2011), Neuner et al. (2004), Neuner et al. (2009), and Stenmark et al. (2013) all concluded that NET was effective in reducing PTSD in refugees. However, more recent studies (e.g., Lies et al., 2019; Turrini et al., 2019, 2021) have indicated that NET was either less effective than other treatment options or there was not enough evidence of its effectiveness. While the effectiveness of NET in adults remains in question, studies such as Neuner et al. (2008) and Onyut et al. (2005) indicate that KIDNET, an adaptation of NET for children, is a suitable PTSD treatment for refugee children. It is worth noting that while garnering positive results, the aforementioned studies are by no means recent, and the overall body of research on KIDNET for PTSD has not increased greatly since the publication of these studies. More recent studies such as Velu et al. (2022) and Wittmann et al. (2022) are still ongoing due to disruptions caused by COVID-19, resulting in no conclusive new evidence that KIDNET has gained more evidence to suggest its effectiveness.
Eye Movement Desensitization Reprocessing (EMDR)
EMDR is an integrative, person-centred psychotherapy method that aims to reprocess disturbing and traumatic life experiences through working with images, cognitions, emotions, and other phenomena linked with distressing memories (Laliotis & Shapiro, 2022; Russell & Shapiro, 2021). To achieve this, an individual is exposed to distressing stimuli while, simultaneously, EMDR techniques such as eye movements, tapping or tones or employed (EMDR Institute, 2020). Despite the fact that hundreds of case studies and 44 randomised control studies have been conducted to evaluate the effectiveness of EMDR since 1989 (EMDR Institute, 2020), there is little research available with a specific focus on the use of EMDR with refugees. Of the research available it is important to note that some studies (e.g., Acarturk et al., 2015; Yurtsever et al., 2018) were conducted using subjects living in refugee camps as opposed to others which focused on subjects who had been permanently relocated to a new country (e.g., Castelli Gattinara & Pallini, 2017; Sykinioti, 2019). The difference in results noted between these types of studies was that the long-term efficacy of treatment in subjects treated in refugee camps was lower than those who experienced treatment after having been permanently relocated. Another notable recurring theme throughout the literature was that due to its technique-based nature, EMDR has proven effective in being adaptable to cultural needs and overcoming language and cultural barriers due to its focus on non-verbal techniques (Acarturk et al., 2015; Genç, 2022; Hurn & Barron, 2018; Nickerson, 2016). Finally, it is also worth mentioning that of the limited research available, there was as much work dedicated to the efficacy of EMDR in refugee children as there was for adults. Studies such as Genç (2022), Hurn & Barron (2018), and Lempertz et al. (2020) indicated positive preliminary findings but stressed the need for more research to be complete.
Medication
Medication or pharmacological treatment in the context of PTSD mainly focuses on ingesting selective serotonin reuptake inhibitors (SSRIs), a type of antidepressant which modulates neurological activity in the nervous system (American Psychological Association, 2020). While studies such as Friedman (2013) and Ipser & Stein (2012) have provided evidence that medication is an effective evidenced-based treatment for PTSD, it is often recommended as a secondary treatment to psychotherapy (Coventry et al., 2020). Furthermore, research indicates that medication may only be effective as a short-term treatment (e.g., Ipser & Stein, 2012; Kinzie, 2016). Very little research specific to the use of medication as a PTSD treatment for refugees appears to exist. From the research found, it seems that medication is used more to control psychotic episodes and sleeping issues which may occur as a result of PTSD than as a treatment for PTSD itself (Kinzie, 2016).
Conclusion
The growing global refugee crisis has underscored the urgent need for effective interventions to address the mental health challenges faced by this vulnerable population. This is highlighted by evidence that refugees are at a significantly higher risk of developing PTSD compared to the general population (Koenen et al., 2017; Patanè et al., 2022; World Health Organization, 2017). As discussed in this literature review, the most utilised treatments for PTSD in refugees are CBT, NET, EMDR, and medication (Cloitre, 2009; Ehntholt & Yule, 2006; Lies et al., 2019; Nosè et al., 2017; Turrini et al., 2019, 2021). After careful analysis of the literature specific to each treatment, there is no evidence that indicates that one treatment is more consistently effective than the others. As no single treatment has yet been evidenced as being more effective than the others, it brings about the opportunity for individuals to explore when seeking treatment, to find the option that best meets their needs. In addition, it shifts the metric for how success is measured to focus on how culturally adaptive and inclusive a treatment is, which Genç (2022), McDonald (2010), and Nickerson (2016) stress is essential to a treatment's success. It is also important to remember that while each treatment method demonstrated effectiveness in treating PTSD, further research into all treatments is required to further validate their individual effectiveness. Addressing PTSD in refugee populations is a complex and evolving field, and the pursuit of evidence-based, culturally sensitive interventions is crucial to improving the well-being of refugees suffering from PTSD. Future research should continue to explore and refine treatment options to meet the specific needs of this vulnerable population and provide them with the best possible care.
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