Mental Health of Refugees: Etiology and Treatment [1st ed. 2023] 3031340779, 9783031340772

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Mental Health of Refugees Etiology and Treatment Paul M.G. Emmelkamp

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Mental Health of Refugees

Paul M. G. Emmelkamp

Mental Health of Refugees Etiology and Treatment

Paul M. G. Emmelkamp Department of Clinical Psychology University of Amsterdam Amsterdam, The Netherlands

ISBN 978-3-031-34077-2    ISBN 978-3-031-34078-9 (eBook) https://doi.org/10.1007/978-3-031-34078-9 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Acknowledgement

This book benefited from the FIAS fellowship at the Paris Institute for Advanced Study (France). It has received funding from the European Union’s Horizon 2020 research and innovation programme under the Marie Skłodowska-Curie grant agreement No. 945408 and from the French State programme “Investissements d’avenir,” managed by the Agence Nationale de la Recherche (ANR-11-­ LABX-0027-01 Labex RFIEA+).

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 Mental Health of Adult Refugees��������������������������������������������������������������   1 1.1 Introduction����������������������������������������������������������������������������������������   1 1.2 Host Countries of Refugees and Asylum Seekers������������������������������   2 1.3 Risk of Mental Disorders��������������������������������������������������������������������   3 1.4 Post-migration Stressors ��������������������������������������������������������������������   4 1.5 Detained Refugees and Asylum Seekers��������������������������������������������   5 1.6 Long-Term Effects������������������������������������������������������������������������������   5 1.7 Prevention of Mental Health Problems����������������������������������������������   6 1.8 COVID-19 Pandemic��������������������������������������������������������������������������   6 1.9 Summary of Risk and Protective Factors��������������������������������������������   7 1.10 Prevalence of Mental Disorders����������������������������������������������������������   8 1.11 Post-traumatic Stress Disorder������������������������������������������������������������   9 1.11.1 Prevalence ������������������������������������������������������������������������������  10 1.11.2 Cross-Cultural Factors������������������������������������������������������������  11 1.11.3 Complex Post-traumatic Stress Disorder��������������������������������  12 1.12 Anxiety and Depressive Disorder ������������������������������������������������������  13 1.13 Alcohol and Substance Abuse������������������������������������������������������������  14 1.14 Personality Disorders��������������������������������������������������������������������������  15 1.15 Psychosis��������������������������������������������������������������������������������������������  16 1.16 Other Mental Health Problems ����������������������������������������������������������  17 1.16.1 Suicidal Ideation and Suicide�������������������������������������������������  17 1.16.2 Grief����������������������������������������������������������������������������������������  19 1.16.3 Embitterment��������������������������������������������������������������������������  20 1.17 Intimate Partner Violence��������������������������������������������������������������������  21 1.17.1 Prevalence of Intimate Partner Violence in Refugees ������������  22 1.17.2 Cultural Values������������������������������������������������������������������������  22 1.17.3 Factors Influencing Intimate Partner Violence������������������������  24 1.17.4 Somatic Injuries����������������������������������������������������������������������  24 1.17.5 Risk of Mental Health Problems��������������������������������������������  24 1.17.6 Prevention ������������������������������������������������������������������������������  25 1.17.7 Poly-Victimization������������������������������������������������������������������  25 1.18 Health Status of Asylum Seekers and Refugees ��������������������������������  26 1.18.1 Somatization ��������������������������������������������������������������������������  26

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1.18.2 Noncommunicable Diseases ��������������������������������������������������  27 1.18.3 Mental Health Consequences��������������������������������������������������  28 1.18.4 Recent Developments ������������������������������������������������������������  29 1.19 Migrant Mental Health and Aging������������������������������������������������������  29 References����������������������������������������������������������������������������������������������������  30 2

 Mental Health of Refugee Minors������������������������������������������������������������  51 2.1 Introduction����������������������������������������������������������������������������������������  51 2.2 Prevalence of Mental Disorders����������������������������������������������������������  51 2.3 Unaccompanied Children��������������������������������������������������������������������  52 2.3.1 Chronic Trajectory of Mental Health Symptoms��������������������  53 2.4 Refugee Minors Living with Family��������������������������������������������������  54 2.5 Child Marriage������������������������������������������������������������������������������������  55 2.6 Resignation Syndrome������������������������������������������������������������������������  55 2.7 Executive Functioning������������������������������������������������������������������������  56 2.8 Substance Abuse ��������������������������������������������������������������������������������  56 2.9 Other Psychological Problems������������������������������������������������������������  57 2.10 Negative and Protective Factors����������������������������������������������������������  58 2.10.1 Parenting Behavior and Social Support����������������������������������  58 2.10.2 Attachment������������������������������������������������������������������������������  59 2.10.3 Violence in Host Country�������������������������������������������������������  60 References����������������������������������������������������������������������������������������������������  61

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 Social Support and Resilience: Impact on Mental Health ��������������������  69 3.1 Introduction����������������������������������������������������������������������������������������  69 3.2 Resilience��������������������������������������������������������������������������������������������  70 3.2.1 Social Identity ������������������������������������������������������������������������  70 3.2.2 Loss of Social Support������������������������������������������������������������  70 3.3 Post-traumatic Growth������������������������������������������������������������������������  71 3.3.1 Post-traumatic Growth in Refugees and Asylum Seekers������  72 3.4 Resilience in Children and Adolescents����������������������������������������������  73 3.4.1 Refugee Youth ������������������������������������������������������������������������  74 3.4.2 Family Stress Model and Resilience��������������������������������������  76 3.5 Mental Health Stigma ������������������������������������������������������������������������  76 3.5.1 Cultural Differences����������������������������������������������������������������  77 3.5.2 Screening for Mental Health and Cultural Differences����������  77 3.6 Social-Cultural Determinants of Mental Health Inequalities��������������  78 3.6.1 Discrimination������������������������������������������������������������������������  78 3.6.2 Integration Versus Acculturation��������������������������������������������  79 3.6.3 Differences Between Parents and Children����������������������������  79 3.7 Social Support������������������������������������������������������������������������������������  80 3.7.1 Social Support and (Mental) Health ��������������������������������������  80 3.7.2 Social Support in Refugee Children ��������������������������������������  81 3.8 Concluding Remarks��������������������������������������������������������������������������  82 References����������������������������������������������������������������������������������������������������  83

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 Cultural Adaptations of Mental Health Care������������������������������������������  95 4.1 Introduction����������������������������������������������������������������������������������������  95 4.2 Use of Mental Health Services ����������������������������������������������������������  95 4.2.1 Cross-Cultural Variation in Symptomatology������������������������  96 4.2.2 Mental Health Diagnosis��������������������������������������������������������  96 4.2.3 Use of Interpreters������������������������������������������������������������������  97 4.3 Cultural Identity����������������������������������������������������������������������������������  98 4.4 Culture and Mental Health������������������������������������������������������������������  99 4.5 Barriers to Mental Health Care ���������������������������������������������������������� 100 4.6 Stigma Reduction Intervention ���������������������������������������������������������� 101 4.7 Explanatory Models of Mental Illness������������������������������������������������ 102 4.8 Cultural Factors in Clinical Practice �������������������������������������������������� 103 4.8.1 Readiness of Psychotherapists to Work with Refugees���������� 104 4.8.2 Cultural Competence of Mental Health Workers�������������������� 105 4.8.3 The Role of Interpreters���������������������������������������������������������� 105 4.9 Adaptation of Psychotherapy in Lowand Middle-Income Countries������������������������������������������������������������ 106 4.10 Outcome of Interventions Across Different Racial/Ethnic Groups�������������������������������������������������������������������������� 107 4.10.1 Interventions for Young Refugees������������������������������������������ 109 4.10.2 Qualitative Research �������������������������������������������������������������� 109 4.11 Culturally Adapted Cognitive Behavior Therapy�������������������������������� 109 4.12 Guidelines for Cultural Adaptation���������������������������������������������������� 110 References���������������������������������������������������������������������������������������������������� 112

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 Assessment of Mental Health Problems�������������������������������������������������� 121 5.1 Introduction���������������������������������������������������������������������������������������� 121 5.2 Culture-Bound Values of Diagnosis���������������������������������������������������� 121 5.2.1 Lay Explanatory Models of Mental Illness���������������������������� 122 5.2.2 Impact of Patient Language Proficiency on the Quality of Assessment�������������������������������������������������� 122 5.2.3 Scoring of Questionnaires May Be Primed by Culture���������� 123 5.2.4 Concluding Remarks�������������������������������������������������������������� 124 5.3 Cultural Formulation Interview���������������������������������������������������������� 124 5.3.1 Research into the Usability of the Cultural Formulation Interview������������������������������������������������������������ 125 5.4 Questionnaires������������������������������������������������������������������������������������ 127 5.5 Assessment of Adults�������������������������������������������������������������������������� 128 5.5.1 Screeners to Assess Mental Health Problems ������������������������ 128 5.5.2 General Psychopathology ������������������������������������������������������ 129 5.5.3 Post-traumatic Stress�������������������������������������������������������������� 130 5.5.4 Depressive Symptoms������������������������������������������������������������ 132 5.5.5 Somatic Symptoms ���������������������������������������������������������������� 132 5.5.6 Symptoms of Insomnia ���������������������������������������������������������� 132 5.5.7 Grief���������������������������������������������������������������������������������������� 133

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5.5.8 Embitterment�������������������������������������������������������������������������� 133 5.5.9 Post-migration Living Difficulties������������������������������������������ 133 5.5.10 General Well-Being and Health Status ���������������������������������� 134 5.6 Assessment of Children and Adolescents ������������������������������������������ 134 5.6.1 General Psychopathology ������������������������������������������������������ 135 5.6.2 Depressive Symptoms������������������������������������������������������������ 135 5.6.3 Post-traumatic Stress�������������������������������������������������������������� 136 5.7 Other Issues Relevant for Assessment������������������������������������������������ 137 5.7.1 Assessing Partner Violence ���������������������������������������������������� 137 5.7.2 Internet-Based Tools for Screening of Refugee Mental Health�������������������������������������������������������������������������������������� 138 5.7.3 Hierarchical Screening Model������������������������������������������������ 138 5.8 Concluding Remarks�������������������������������������������������������������������������� 139 References���������������������������������������������������������������������������������������������������� 139 6

 Mental Health and Social Support Interventions ���������������������������������� 153 6.1 Introduction���������������������������������������������������������������������������������������� 153 6.2 Mental Health Gap Action Programme���������������������������������������������� 154 6.3 Problem Management Plus ���������������������������������������������������������������� 155 6.4 Problem Management Plus in Conflict-Affected Individuals ������������ 156 6.4.1 Gender-Based Violence���������������������������������������������������������� 157 6.5 Group Problem Management Plus������������������������������������������������������ 158 6.5.1 Concluding Remarks�������������������������������������������������������������� 160 6.6 Problem Management Plus: Refugees and Asylum Seekers�������������� 160 6.6.1 Adapted Problem Management Plus�������������������������������������� 163 6.6.2 Concluding Remarks�������������������������������������������������������������� 164 6.7 Common Elements Treatment Approach�������������������������������������������� 164 6.8 Skills-Training of Affect Regulation: A Culture-Sensitive Approach�������������������������������������������������������������������������������������������� 166 6.9 Integrative Adapt Therapy������������������������������������������������������������������ 167 6.10 Method for the Empowerment of Trauma Survivors�������������������������� 168 6.11 Self-Help Plus ������������������������������������������������������������������������������������ 168 6.12 Value Based Counseling �������������������������������������������������������������������� 170 6.13 Other Interventions ���������������������������������������������������������������������������� 171 6.13.1 Depression������������������������������������������������������������������������������ 171 6.14 Digital Mental Health ������������������������������������������������������������������������ 172 6.15 Stepped Care �������������������������������������������������������������������������������������� 173 References���������������������������������������������������������������������������������������������������� 173

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Psychological Interventions for Post-­traumatic Stress Disorder in Adults�������������������������������������������������������������������������������������� 181 7.1 Introduction���������������������������������������������������������������������������������������� 181 7.2 Prolonged Exposure for Post-traumatic Stress Disorder�������������������� 181 7.2.1 Dissociation and Depersonalization���������������������������������������� 182 7.2.2 Cultural Factors���������������������������������������������������������������������� 183

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7.3 Imagery Rescripting���������������������������������������������������������������������������� 183 7.3.1 Refugees���������������������������������������������������������������������������������� 184 7.4 Cognitive Processing Therapy������������������������������������������������������������ 184 7.4.1 Refugees���������������������������������������������������������������������������������� 185 7.4.2 Cognitive Therapy������������������������������������������������������������������ 186 7.4.3 Refugees���������������������������������������������������������������������������������� 187 7.5 Mindfulness-Based Cognitive Therapy���������������������������������������������� 187 7.5.1 Refugees���������������������������������������������������������������������������������� 188 7.6 Stress Management ���������������������������������������������������������������������������� 189 7.7 Eye Movement Desensitization and Reprocessing Therapy (EMDR)189 7.7.1 Refugees���������������������������������������������������������������������������������� 190 7.8 Narrative Exposure Therapy �������������������������������������������������������������� 192 7.8.1 Refugees���������������������������������������������������������������������������������� 193 7.8.2 Brief Version of Narrative Exposure Therapy������������������������ 195 7.8.3 Lay Counselors ���������������������������������������������������������������������� 195 7.8.4 Trauma-Informed Community-Based Intervention (NETfacts)������������������������������������������������������������������������������ 196 7.8.5 Concluding Remarks�������������������������������������������������������������� 196 7.9 Skills Training in Affect and Interpersonal Regulation (STAIR)�������� 197 7.10 Pharmacotherapy�������������������������������������������������������������������������������� 197 7.11 Concluding Remarks�������������������������������������������������������������������������� 198 7.11.1 Predictors of Treatment Outcome ������������������������������������������ 198 7.11.2 Treatment Through the Internet���������������������������������������������� 199 7.11.3 Post-migration Stressors �������������������������������������������������������� 200 References���������������������������������������������������������������������������������������������������� 200 8

 Psychological Interventions for Refugee Minors������������������������������������ 209 8.1 Introduction���������������������������������������������������������������������������������������� 209 8.2 Unaccompanied Refugee Minors�������������������������������������������������������� 210 8.3 Treatment for Post-traumatic Stress in Children and Youth���������������� 211 8.3.1 Clinical Guidelines����������������������������������������������������������������� 212 8.4 Eye Movement Desensitization and Reprocessing (EMDR)�������������� 212 8.4.1 EMDR in Refugee Youngsters������������������������������������������������ 213 8.5 Cognitive Behavioral Writing Therapy���������������������������������������������� 214 8.5.1 Writing for Recovery�������������������������������������������������������������� 215 8.6 Narrative Exposure Therapy and KIDNET���������������������������������������� 215 8.6.1 War-Affected and Refugee Children and Adolescents������������ 215 8.7 Trauma-Focused Cognitive Behavioral Therapy�������������������������������� 216 8.7.1 Refugee Minors���������������������������������������������������������������������� 218 8.8 START: Stress-Traumasymptoms-Arousal-Regulation Treatment�������������������������������������������������������������������������������������������� 219 8.9 Integrated Treatment for Complex Trauma (ITCT)���������������������������� 220 8.10 Common Elements in Various Therapies�������������������������������������������� 221 8.11 School-Based Interventions���������������������������������������������������������������� 222 8.11.1 Teaching Recovery Techniques���������������������������������������������� 222

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Contents

8.11.2 Early Childhood Education Program for Refugee Children�������������������������������������������������������������� 223 8.12 Family Interventions �������������������������������������������������������������������������� 223 8.13 Art Therapy/Music Therapy���������������������������������������������������������������� 223 8.13.1 Externalizing Problems���������������������������������������������������������� 224 8.14 Anxiety and Depression���������������������������������������������������������������������� 224 8.14.1 Early Adolescent Skills for Emotions (EASE) ���������������������� 224 8.14.2 Internet-Based Interventions�������������������������������������������������� 225 8.15 Concluding Remarks�������������������������������������������������������������������������� 225 References���������������������������������������������������������������������������������������������������� 226 9

Substance Abuse, Personality Disorders, and Severe Mental Illness�������������������������������������������������������������������������� 233 9.1 Introduction���������������������������������������������������������������������������������������� 233 9.1.1 Psychosis�������������������������������������������������������������������������������� 233 9.1.2 Asylum Seekers���������������������������������������������������������������������� 234 9.2 Use of Mental Health Service ������������������������������������������������������������ 235 9.3 Alcohol and Substance Abuse������������������������������������������������������������ 236 9.4 Substance Abuse and Intimate Partner Violence�������������������������������� 237 9.5 Substance Abuse and Comorbid Post-traumatic Stress Disorder������� 239 9.6 Psychological Interventions for Comorbid Post-­traumatic Stress and Substance Use Disorders �������������������������������������������������� 239 9.7 Practical Recommendations���������������������������������������������������������������� 241 9.7.1 Screening for Substance Abuse���������������������������������������������� 241 9.7.2 Which Intervention?���������������������������������������������������������������� 242 9.8 Personality Disorder���������������������������������������������������������������������������� 242 9.9 Personality Traits�������������������������������������������������������������������������������� 243 9.10 Treatment of Personality Pathology���������������������������������������������������� 244 9.10.1 Cognitive Therapy������������������������������������������������������������������ 245 9.10.2 Dialectical Behavior Therapy ������������������������������������������������ 245 9.10.3 Schema-Focused Therapy ������������������������������������������������������ 246 9.10.4 Transference-Focused Therapy ���������������������������������������������� 246 9.10.5 Mentalization-Based Treatment���������������������������������������������� 247 9.10.6 Which Intervention Is the Most Effective? ���������������������������� 247 9.11 Treatment of Personality Pathology in Non-Western Cultures���������� 248 9.12 Interventions for Adolescents with Personality Pathology ���������������� 249 9.13 Personality Disorder and Substance Abuse���������������������������������������� 251 9.14 Psychosis�������������������������������������������������������������������������������������������� 251 9.14.1 Differential Diagnosis ������������������������������������������������������������ 252 9.14.2 Young People�������������������������������������������������������������������������� 253 9.15 Prevention of Mental Disorders���������������������������������������������������������� 254 9.16 Concluding Remarks�������������������������������������������������������������������������� 255 References���������������������������������������������������������������������������������������������������� 255

1

Mental Health of Adult Refugees

1.1 Introduction Globally, the number of individuals displaced from their homeland due to war, conflict, political unrest, and related risks is increasing. According to the United Nations High Commissioner for Refugees (UNHCR, 2021) in 2021, over 84 million people have been forcibly displaced through persecution, violence, and/or human rights violations, including over 26 million refugees and nearly 4.5 million asylum seekers. However, just 1 year later, the number of forcibly displaced people reached even 100 million, which exceeds 1% of the global population (UNHCR, 2022). Displaced people can be categorized as internally displaced persons, refugees, asylum seekers, or immigrants. There are now more than 48 million internally displaced people worldwide who have been displaced by conflict and violence, most of them living in Africa (IDMC, 2021). Refugees and asylum seekers represent a subset of migrants who have experienced forced displacement, without the option of returning to their homeland (UNHCR, 2021). Forced migrants can broadly be divided into two categories: those who have been granted asylum in their new countries according to the 1951 Refugee Convention, commonly referred to as refugees, and the asylum seekers who live with the uncertainty of having their applications rejected and thus may be forced to return to their home countries. Thus, an asylum seeker is a person who has already left their country and is seeking legal protection in another country, but who has not yet been legally documented as a refugee. According to the 1951 Refugee Convention, a refugee is defined as someone who is unable or unwilling to return to their country of origin owing to a well-­ founded fear of persecution (e.g., based on race, religion, nationality, social group, or political opinion) in the country of his/her nationality and who therefore is not protected there (UN General Assembly, 1951). Thus, individuals may become refugees not only because of war but also because of having experienced sexual violence, having been persecuted for their religion, or because they were political activist in the country of origin. © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 P. M. G. Emmelkamp, Mental Health of Refugees, https://doi.org/10.1007/978-3-031-34078-9_1

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1  Mental Health of Adult Refugees

Many children are refugees as well, often accompanied by their parent(s), but in a number of instances by a relative. When they are not accompanied by an adult family member, they are considered “unaccompanied child refugees.” Each day, nearly 5000 children become refugees, and most of them grow up in refugee camps. Unaccompanied children and adolescents often experience greater time in refugee camps awaiting decisions about placement and are at greater risk for developing mental health problems (Pieloch et al., 2016). In contrast to refugees and asylum seekers, migrants are those who leave their country for a better job, living conditions, and study or to join a family abroad. There are important and distinct differences between these three groups, which have implications with respect to access to education, employment, health care, and social welfare. Research tends to group different categories of migrants together, which results in simplification of the often rather terrible experiences of people seeking asylum and of refugees.

1.2 Host Countries of Refugees and Asylum Seekers Most refugees seek asylum in developing countries (UNHCR, 2021). About a third of people who have acquired refugee status live in Western high-income countries. In such countries, refugees usually live in either camps or cities, often in close proximity to individuals of the host community. The United States is the country with the highest recipient of arrivals of new refugees, followed by Canada, the United Kingdom, Sweden, Germany, France, and Australia. Refugee migration to Germany increased substantially between 2013 and 2016 (DESTATIS, 2020): Individuals seeking asylum in Germany rose from around 600,000 to 1.6 million. However, Lebanon hosts the highest number of refugees per capita (over 1.5 million Syrian refugees, in addition to large numbers of Palestinian refugees) in a total national population of less than six million (Government of Lebanon and United Nations, 2019). The steep increase in refugees over the past few years carries clear public health implications (Priebe et al., 2016). In 2019, about 19 million African-born migrants were residing outside of Africa, and over 21 million African-born migrants resided in an African region outside their home country (International Organization for Migration, 2019). The Eastern Mediterranean Region is the origin of an increasing number of forcibly displaced people, mainly due to conflicts. Overall, 66% of the world’s refugees originate from the Eastern Mediterranean Region (Al-Mandhari et al., 2021). Humanitarian crises in Afghanistan, Iraq, Libya, Somalia, Sudan, Syrian Arab Republic, and Yemen led to complex migration pathways: more than 11.5 million stay in the Eastern Mediterranean Region, while about eight million searched outside this region for asylum. In 2019, about 67% of the world’s refugees originated from just five countries, three of which are in the Eastern Mediterranean Region: Syrian Arab Republic (6.7 million), Afghanistan (2.7 million), and Somalia (0.9 million) (UNHCR, 2019). The

1.3  Risk of Mental Disorders

3

past 10 years led to a great increase of Syrian refugees, Syria now being the country leading to most refugees and asylum seekers worldwide (UNCHR, 2021). Most of the Syrians have sought refuge in neighboring countries such as Jordan, Lebanon, and Turkey, but a substantial number of refugees and asylum seekers have fled to Europe. Syrian refugees residing in Turkey (over 3.6 million) are given the status of “under temporary protection” and are not considered as formal refugees by the government of the Republic of Turkey. Currently, most refugees and asylum seekers are coming from Syria, Afghanistan, Venezuela, South Sudan, Ukraine, and Myanmar. Since 2015, more than four million Venezuelans have fled their country, most of them to Colombia (UNHCR, 2019). In recent years, most asylum seekers in the United States have been coming from Venezuela (USCIS, 2019). A number of European countries have been attractive destination for asylum seekers/refugees who are in need of international protection, especially since the refugee crisis, which started in 2013. The majority of these immigrants came from Middle East countries such as Syria, Afghanistan, and Iraq, because of armed conflict, persecution, and human rights violations. Most recently, Russia’s invasion of Ukraine has created an unprecedented humanitarian crisis in Europe, classified by the UNHCR at the highest level available. Over four million refugees—mostly women, children, and students—have fled Ukraine in April 2022.

1.3 Risk of Mental Disorders Many refugees have experienced a wide spectrum of adverse traumatic events before, during, and/or after their flight and are considered a high-risk population for developing mental disorders. Refugees are typically exposed to numerous traumatic events such as exposure to armed conflict; witnessing atrocities; genocide; imprisonment; death of loved ones, partner, children, or other family members; physical or sexual violence; torture and losing one’s home; stressful escape and rather negative transit experiences; life-threatening journeys; lack of food, water, or shelter; ethnic or racial discrimination; cultural and language barriers; and restricted access to (mental) health care, education, or work (e.g., Alemi et al., 2014; Kirmayer et al., 2011; Kiselev et al., 2020; Schlaudt et al., 2020). Trauma in refugees and asylum seekers is not only the result of armed conflict, and forcible displacement, but in a number of cases also associated with (childhood) abuse as well. There is considerable evidence that refugees and asylum seekers, especially children and women, become victims of human trafficking for sexual exploitation and are vulnerable to gender-based violence or forced early marriage (Boswall & Akash, 2015; Slobodin & de Jong, 2015; Wells et al., 2016). The likelihood of developing post-traumatic stress disorder and comorbid disorders such as depression and anxiety disorders is dependent on the severity of the traumatic event, and the number of times these events occur. Generally, the greater the number of traumatic experiences, the more severe mental health problems (Bogic et al., 2015; Li et al., 2016; Steel et al., 2009).

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1.4 Post-migration Stressors As discussed above, refugees and asylum seekers are exposed to extreme life conditions that affect their mental health and well-being, and many of them have experienced life-threatening situations and a number of traumatic experiences prior to and during the process of flight from their home country to the host country (e.g., Priebe et al., 2016). Many of them are still confronted with the mental consequences of exposures to the ongoing war when they arrive in the host country. In addition, it has been recognized that stressors and living conditions in the host country can affect their mental health as well. In studies in Denmark (Hallas et al., 2007) and in Ireland (Ryan et  al., 2008), refugees and asylum seekers associated their mental health problems with stressors during the post-migration period in the host countries rather than with traumatic experiences in the past. In a study investigating the needs of asylum seekers in the Netherlands, mental health problems were also more frequently associated with stressors in the host country (e.g., uncertainty, helplessness, identity) than with traumatic experiences in the past (Slobodin et al., 2018). A number of studies have shown that post-migration stressors in the host countries have an impact on the onset and maintenance of psychological disorders (e.g., Chu et al., 2013; Müller et al., 2018; Newnham et al., 2019). Post-migration stressors influencing mental health problems include financial problems, worrying about family members left in the country of origin, cultural integration issues, resettlement in unfamiliar environments, “homesickness,” loss of social identity, feelings of isolation and loneliness, prohibition to work, disruption of education for children, problems with language or prolonged uncertainty regarding residency status, and possibility of having to go back to their country of origin (Gleeson et  al., 2020; Kirmayer et al., 2011; Miller & Rasmussen, 2010; Morgan et al., 2017; Sangalang et al., 2019; Schiess-Jokanovic et al., 2022; Tinghög et al., 2017). Actually, postmigratory resettlement conditions may be as important for the mental health problems of asylum seekers and refugees as experienced traumatic conditions prior to and during the process of migration (Chen et al., 2017; Heeren et al., 2014; Jannesari et al., 2020; Li et al., 2016; Nosè et al., 2020). In addition, refugees have great problems in obtaining employment that is in line with their education and experience in their home country, due to unrecognized work experience and discrimination (Udayar et al., 2021). Often, they have to accept employment for which they are overqualified in order to earn money to support their family. Low economic status is strongly associated with higher post-traumatic stress disorder, depression, and anxiety symptoms (Aysazci-Cakar et al., 2022). Further, refugees and asylum seekers are often judged based on the social and religious groups they represent (e.g., Arabic Muslim), which may lead to exclusion because of their cultural, social, or religious background (Hynie, 2018). Daily stressors such as lack of access to basic resources, lack of security, communal tensions, and family violence are associated with common mental health problems (Miller & Rasmussen, 2014). Of note, the lengthy asylum-seeking process and complicated immigration policies enhance chronic mental health problems in refugees after resettlement (Boetcher

1.6  Long-Term Effects

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& Neuner, 2022; Georgiadou et al., 2018; Giacco et al., 2018; Knipscheer et al., 2015; Li et  al., 2016). Nevertheless, a lot of countries are rather restrictive with respect to asylum seekers and require not only adults but also children and adolescents to live in mandatory immigration detention (Zwi et al., 2018, 2020) despite international law clearly stating that it should only be used as a last resort and that children should never be detained (Weiler et al., 2022). An insecure asylum status is one of the main stressors with which forcibly displaced people must cope. Actually, post-migration stressors may have greater impact on long-term (mental) health and well-being than premigration factors (Byrow et al., 2022; Chen et al., 2017; Hynie, 2018; Li et al., 2016; ). Refugees and asylum seekers with an insecure visa status have increased not only post-migration living problems but also higher rates of psychopathology (e.g., depression, suicidality, and post-traumatic stress disorder), compared to those with a secure visa status (e.g., Nickerson et al., 2019; Steel et al., 2006). In a study in the Netherlands, Iraqi asylum seekers who stayed longer than 2  years in the asylum seekers’ center suffered from higher levels of anxiety, depression, and somatoform disorders than those who stayed for less than 6 months (Laban et al., 2004). These findings posit that prolonged periods of uncertainty, fear, and boredom during the post-migration period may have a rather extreme effect on asylum seekers’ well-being.

1.5 Detained Refugees and Asylum Seekers A number of studies have investigated the impact of immigration detention on the mental health of refugees and asylum seekers. Generally, detained refugees and migrants experience more severe symptoms of post-traumatic stress disorder, depression, and anxiety compared with non-detained refugees and migrants (see Baggio et al., 2020; Filges et al., 2018; Von Werthern et al., 2018). In a recent metaanalysis (Verhülsdonk et al., 2021), results revealed that the prevalence of depression, post-traumatic stress disorder, and anxiety was twice as high in detained refugees compared with non-­detained refugees. Three out of four detained refugees experienced depression, and about half of them experienced post-traumatic stress disorder and/or anxiety. Other studies revealed that personality disorders and psychosis are also more prevalent among detained refugees than non-detained refugees (Graf et al., 2013; Sen et al., 2018).

1.6 Long-Term Effects Refugees show a low level of quality of life (e.g., Beza et al., 2022; Leiler et al., 2019a; Tinghög et al., 2017). In the first year of resettlement in the host country, post-traumatic stress disorder and depression rates are clearly higher in asylum seekers and refugees than in host countries’ populations due to exposure to traumatic events compared to the population of the hosting countries (Blackmore et al., 2020a; Hoell et al., 2021). Five years after resettlement, however, rates of anxiety

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disorders and depression even increased (e.g., Giacco et al., 2018), which may be due to lack of social support, insecure asylum status, and lack of mental care in the host country. In a study of Walker et al. (2021), the effects of the transition period among refugees in the United Kingdom were investigated with respect to improvement in mental health as a result of the stability of being granted leave to remain in the United Kingdom. Thus, the aim of this study was to investigate the impact of the transition period on the mental health of newly recognized refugees. The scores for anxiety, depression, distress, and post-migration living difficulties showed linear improvement overall during 12 months, supporting the results of a review of previous studies that finding a job and stability of accommodation is associated with improvement in mood and anxiety symptoms (Roberts & Browne, 2011). Only a small number of studies have followed up refugees for 10 years or longer to assess mental health problems. Results reveal that most refugees have no or limited mental health problems, but a minority still has chronic mental health problems (Silove et al., 2017).

1.7 Prevention of Mental Health Problems It has been suggested that self-efficacy—the ability to deal with upcoming challenges and stressors—may prevent post-migratory stress and mental health problems. One study among refugees found self-efficacy associated with less mental health problems and employment in the host country (Sulaiman-Hill & Thompson, 2013), suggesting that the experiences that refugees go through after their flight may affect self-efficacy beliefs. In another study (Tip et al., 2020), higher levels of self-efficacy predicted better positive affect 2 years later among refugees living in the United Kingdom. Other studies among refugees, however, found negative results. In a study among Syrian refugees resettled in Sweden and Turkey, self-efficacy was found to be associated with psychological distress (Chung et al., 2021). Contrary to the hypothesis, self-efficacy was positively correlated with emotional suppression, which was positively correlated with psychiatric comorbidity, but not with post-traumatic stress disorder. Also, results of a study among refugees living in the Netherlands as a host country were negative (van Heemstra et al., 2021). Contrary to expectations, no impact of self-efficacy on mental health was found, and self-efficacy did not moderate the relationship between daily stressors and mental health.

1.8 COVID-19 Pandemic The COVID-19 pandemic has had a disproportionately hard impact on refugees and asylum seekers (e.g. Benjamen et al., 2021). Public health measures, such as social distancing and self-isolation, are hard to implement in situations where many people live in large groups, such as in refugee camps. In a large survey conducted in the

1.9  Summary of Risk and Protective Factors

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second half of 2020, European data from 46 different countries were used (Marchi et al., 2022). Refugees and asylum seekers who had more difficulties in accessing health care and preventive measures against COVID-19 experienced worse mental health and increased discrimination by the host population for “spreading the disease” in Europe. Generally, most refugees live in crowded living conditions, which enhances the risk of getting COVID (e.g., Brickhill-Atkinson & Hauck, 2021; Salmani et  al., 2020) and increases health inequalities (Mahmoodi et  al., 2023; Lupieri, 2021).

1.9 Summary of Risk and Protective Factors Giacco (2020) reviewed the available evidence with respect to risk factors and protective factors associated with the development of mental health problems in asylum seekers and refugees and identified five time points at different stages of the migration process in which these risk factors may occur: (a) Before travel: Not surprisingly, traumatic events witnessed or experienced, and being subjected to torture, are all associated with a high likelihood of developing post-­ traumatic stress disorder and common mental disorders. The risk of developing a mental disorder becomes higher if the refugee/asylum seeker is exposed to multiple traumatic events and has experienced intense anger and fears. Having had mental problems and/or poverty before migration predicts mental disorders after migration. (b) During travel: Exposure to violent events during refugees’ travel and separation from family members has been found to have negative consequences on mental health after resettlement in the host country. (c) Settlement in the host country: The risk factors encountered in the first period after settlement, often in refugee camps, are lack of food and lack of satisfactory accommodation. The longer the duration of the process of requiring asylum status and no access to health care, the more the likelihood of getting mental health problems. (d) Integration in the host country: Prevalence studies show higher rates of common mental disorders in refugees with a longer length of displacement. Risk factors for mental health problems are unemployment, discrimination, social isolation problems, and acculturation issues. Having a resident status, a broad social network including people from other than their own ethnic culture, and improved living arrangements are associated with less mental health problems. (e) Challenges to immigration status: Not only threats of deportation, and detention in immigration centers, but also losing satisfactory accommodation and unemployment enhance the risk of having mental disorders.

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1.10 Prevalence of Mental Disorders A number of studies have investigated the prevalence of mental disorders among refugees and asylum seekers, but as you will see below, there is considerable heterogeneity in prevalence rates across studies. One key limitation of the evidence in these studies is that some psychopathology data may be underreported due to the sensitive and highly stigmatizing nature of mental health issues among refugee populations. One in three refugees or asylum seekers experiences high rates of psychiatric morbidities such as post-traumatic stress disorders, anxiety, or depression, but the prevalence estimates of mental disorders for refugees vary widely ranging between 20% and 80% (Henkelmann et al., 2020; Turrini et al., 2017), which will be discussed below. Epidemiological studies in these groups are often hampered not only by language barriers and lack of well-trained interpreters, but also by lack of culturally validated assessment instruments (Lewis-Fernández & Aggarwal, 2013; Brisset et al., 2014; see Chap. 5), and different social situations not only in home countries but in host countries as well (Giacco et al., 2018). Nevertheless, there is considerable evidence that the prevalence of mental disorders in refugees is still high many years after resettlement in the host country (e.g., Bogic et al., 2015), being impacted by stressors in the early resettlement period (Stuart & Nowosad, 2020). Since the beginning of the civil war in Syria, at least 13 million Syrians have been displaced. In a review of 17 studies, the prevalence of post-traumatic stress disorder, depression, and anxiety of Syrian refugees and asylum seekers in host countries was investigated (Aysazci-Cakar et al., 2022). The studies included the following resettlement countries: Germany, Greece, Iraq, Jordan, Kurdistan, Lebanon, Sweden, Turkey, and the United States. The prevalence of mental health problems was between 23% and 43% for post-traumatic stress disorder, between 30% and 51% for depression, and between 18% and 49% for anxiety, indicating that the mental health problems of refugees and asylum seekers are 7–8 times higher than in the general population. The number of traumatic events predicted (severity of) mental health problems. The comorbidity of post-traumatic stress disorder with other mental disorders is not typical for refugees and asylum seekers. Also, in studies in the general population, there is considerable comorbidity associated with post-traumatic stress disorder (e.g., Spinhoven et al., 2014; Rytwinski et al., 2013). The most common comorbid disorders include depression, anxiety disorders, and substance use disorders. In another study (Nguyen et al., 2022) on the prevalence rates of common mental disorders (i.e., post-traumatic stress disorder, depression, and generalized anxiety disorder) in adult Syrian refugees resettled in high-income Western countries, nine studies which had a low-moderate risk of bias were included in a meta-analysis. Of the nearly 5000 refugees included in this meta-analysis, the mean prevalence rate for having generalized anxiety disorder was 40%, for depression 31%, and for post-­ traumatic stress disorder 31%. However, the reported prevalence rates for the studies included in the meta-analysis ranged from 32% to 54% for anxiety, 29% to 54% for depression, and 9% to 62% for post-traumatic stress disorder. This heterogeneity

1.11  Post-traumatic Stress Disorder

9

may be due to differences in assessment tools used, severity of exposure to traumatic events, and varying lengths since resettlement in host country. The prevalence rates of these common mental disorders in refugees resettled in high-income Western countries were significantly higher than reported rates in the general population. Compared to residential populations, refugee populations may have different explanation models for mental health problems, which may affect the formal assessment of mental disorders and the usage of mental health care (Hassan et al., 2016b; Lewis-Fernández & Kirmayer, 2019). Mental health problems in war survivors were higher in refugees who fled from Balkan countries to countries in western Europe compared to war survivors who stayed in the area of conflict (Schlechter et  al., 2021). Further, epidemiological studies of survivors of war who stay in the afflicted regions reveal that about 10% of them also suffer from comorbid depression and post-traumatic stress disorder (Morina et al., 2018b). However, higher prevalence rates have been reported for survivors of war who have lost a first-degree relative due to war violence. Nearly all mothers in Kosovo who lost their husband during the war in Kosovo met the criteria for post-traumatic-stress disorder, major depressive disorder, anxiety disorder, and/or substance use disorder (Morina & Emmelkamp, 2012). Widowed mothers who were living alone had a higher prevalence of mental disorders than non-bereaved mothers: post-traumatic stress disorder (82% vs. 18%), major depressive disorder (71% vs. 30%), and generalized anxiety disorder (48% vs. 10%). Furthermore, 45% of widowed mothers living alone reported current suicide risk.

1.11 Post-traumatic Stress Disorder Repeated exposure to trauma increases the risk of post-traumatic stress disorder and other common forms of mental distress. The likelihood of developing post-­traumatic stress disorder and comorbid disorders such as anxiety and depression is associated with the severity of the traumatic events and the number of times these events occur. Since most refugees and asylum seekers have been exposed to a number of severe traumatic experiences, post-traumatic stress disorder and depression and anxiety are observed at higher frequencies in this population (Heeren et al., 2014). The more types of traumas to which refugees were exposed, the greater the post-traumatic stress disorder, anxiety, and depression symptoms they exhibited (Nickerson et al., 2015). Post-traumatic stress disorder in refugees and asylum seekers is often associated with medically unexplained somatic symptoms (e.g., Gupta, 2013). Further, there are gender differences in trauma exposure and in the way traumatic events are processed. Rates of post-traumatic stress disorder are higher in female trauma-affected refugees due to higher likelihood of having experienced childhood trauma, sexual violence, or witnessing the death of their child or spouse. In a study in a specialized mental health clinic for trauma-affected refugees in Denmark (Mundy et al., 2020), results revealed that twice as many females reported exposure to family violence and sexual abuse

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than men. Men, on the other hand, were at least three times as likely to report exposure to combat and torture. The severity of the traumatic events was significantly associated with post-traumatic stress disorder for women, but not for men. However, in men, severe trauma exposure led to enduring personality change.

1.11.1 Prevalence As discussed above, there is considerable evidence that post-traumatic stress disorder is much more prevalent among refugees and asylum seekers than among the general population in the host country. For example, in the Netherlands, the lifetime prevalence of post-traumatic stress disorder is about 7% for the general population, whereas this is about 20% for refugees and asylum seekers from three different ethnic groups (Afghanistan, Iran, and Somalia) (Gerritsen et al., 2006b; Gerritsen et al., 2006a). In half of the refugees, the post-traumatic stress disorder developed after their arrival in the Netherlands (Lamkaddem et al., 2014). A large-scale meta-analysis, including samples of nearly 65,000 refugees from 40 countries, estimated the overall prevalence of post-traumatic stress disorder to be around 15.5% and around 17.5% for depression; the prevalence of torture was estimated to be 21% (Steel et al., 2009). The high prevalence of post-traumatic stress disorder, anxiety, and depression in refugees and asylum seekers was confirmed in a more recent meta-analysis of Henkelmann et al. (2020) among refugees in high-­ income countries. In the meta-analysis of Henkelmann et al. (2020), most refugees came from Asia (40.9%), followed by Europe (10.6%) and Africa (9.1%). The most frequently reported host continents were Europe (39.4%), North America (30.3%), and Australia (24.3%). Nearly two-thirds of the studies applied self-report measures to estimate prevalence rates; slightly more than one-third used clinical diagnostic interviews. Prevalence estimates of post-traumatic stress disorder were high in both child/adolescents (52%) and adults (29%). The diagnosis of post-traumatic stress disorder based on interviews was generally slightly lower (29%) than when the diagnosis was based on self-report (37%), but this difference was not significant. The main difference between self-report and interviews is that self-report assesses at best “possible caseness” of post-traumatic stress disorder, while a (structured) interview results in a formal diagnosis, when the core symptoms of post-traumatic stress disorder and clinically significant interference with everyday life are present. In a study (Acarturk et al., 2021) on 1678 Syrian refugees in Turkey, the prevalence of post-traumatic stress disorder in adult refugees was slightly lower (19.6%). The diagnosis was based on the Post-Traumatic Stress Disorder Checklist (PCL-5), which contains the four DSM-5 symptom clusters (intrusion, avoidance, negative cognition, and hyperarousal). The interviews with the refugees were conducted by trained interviewers who were fluent in Arabic. The slightly lower prevalence of post-traumatic stress disorder in this study compared to the prevalence in the large meta-analyses of Steel et al. (2009) and Henkelmann et al. (2020) may be due to different living conditions in the home countries and/or to the use of DSM-5 rather than DSM-IV or ICD diagnoses of post-traumatic stress disorder.

1.11  Post-traumatic Stress Disorder

11

In a study conducted in Sweden (Solberg et  al., 2020), asylum seekers from Afghanistan, Eritrea, Iraq, Somalia, and Syria who had been exposed to traumatic events prior to or during flight were approximately 2–4 times more likely to experience symptom levels above the cutoff for post-traumatic stress disorder, with “forced separation from family and friends,” “torture,” and “physical violence” emerging as especially strong indicators. In addition, post-migratory stressors emerged as strong indicators of post-traumatic stress disorder and common mental health disorders as well. The following two stressors, “often felt disrespected due to my national background” and “often felt excluded or isolated in the Swedish society,” emerged as the strongest indicators for post-traumatic stress disorder caseness. Eiset et al. (2022) investigated whether the distance traveled as a refugee was associated with the prevalence of post-traumatic stress disorder. This study compared Syrian refugees who traveled to either Lebanon or Denmark. The prevalence estimates of post-traumatic stress disorder were high in both Lebanon (55%) and Denmark (60%). Traveling to Denmark instead of Lebanon was associated with an increase in post-traumatic stress disorder prevalence. The authors conclude that long-distance migration may be associated with an increase in post-traumatic stress disorder prevalence in refugees. Results are difficult to interpret, however, given that the “diagnosis” was based on self-report rather than based on a structured interview. Post-traumatic stress disorder is not only prevalent among refugees and asylum seekers, but also among internally displaced people. Studies investigating the prevalence of post-traumatic stress disorder among internally displaced persons in Africa found the prevalence ranging from 42% in Nigeria (Sheikh et al., 2014) to 67% in Ethiopia (Makango et al., 2023), due to the impact of war and ethnic and political conflict. Taken together the data of the epidemiological studies on post-traumatic stress disorder in asylum seekers and refugees, nearly one out of three refugees suffers from post-traumatic stress disorder, compared to general-population prevalence rates of post-traumatic stress disorder in Europe of less than 7% (Burri & Maercker, 2014). There is a clear dose-effect relationship of trauma to symptoms of post-­ traumatic stress disorder in survivors of mass violence, war trauma, and torture (e.g., Johnson & Thompson, 2008; Mollica et al., 1998a; Mollica et al., 1998b). About 50% of refugees and asylum seekers are children, but children younger than 18 years have been underrepresented in studies on the mental health problems of these children (Uphoff et al., 2020). The prevalence of post-traumatic stress disorder in child refugees varied from 19% to 54% (Bronstein & Montgomery, 2011; Gandham et al., 2023; Kien et al., 2019) (see Chap. 2).

1.11.2 Cross-Cultural Factors Although there is some evidence that post-traumatic stress disorder has universal features that are cross-culturally valid (e.g., Lewis-Fernández et al., 2014; Yehuda et  al., 2015), research has also shown that there are important sociocultural

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differences in the expression and function of avoidance and nightmares following traumatic stress and bereavement (e.g., Hinton et  al., 2013; Hinton et  al., 2009; Michalopoulos et al., 2015; Yuval & Bernstein, 2017). Yuval et al. (2020) investigated the functional network of post-traumatic stress symptoms among East African refugees from Sudan and Eritrea living in the host country Israel. According to network theory, mental disorders may be better conceptualized as a causal system of functionally interacting symptoms that constitute the mental disorder. Causal functional interrelations between the observed symptoms may be understood as nodes of a network that produce a syndrome such as posttraumatic stress disorder (McNally et al., 2015). In the study of Yuval et al. (2020), the nature and function of post-traumatic symptoms—assessed with the Harvard Trauma Questionnaire—were investigated. Analyses revealed a functional symptom circuitry that shares some features with the Western model of post-­traumatic stress disorder. However, the network analysis revealed also a distinct functional cluster of symptoms not typically found in studies of Western populations. There is some evidence that in some cultures, trauma may result in high rates of experiencing ghost visitation. Hinton et al. (2020) developed a model based on their experience with Cambodian refugees in which key aspects of post-traumatic stress disorder—including a sense of threat, imminent assault, and catastrophe—may be considered to be spirit visitation and assault. According to this model, trauma leads in some cultures to multiple symptoms such as nightmare, sleep paralysis, waking-­ state hallucination, hallucinations when falling asleep or awakening, and somatic sensations like sudden chills that can be interpreted as a spirit attack: “... The experience of being visited by a ghost may then result in concerns (e.g., that the ghost is calling one’s soul) and to trauma recall (e.g., evoked by fear itself or by trauma associations to the ghost: the ghost being thought to be a relative killed by the Khmer Rouge) that gives rise to fear and arousal ... with that fear and arousal looping back to worsen the biology of post-traumatic stress disorder that results in more symptoms that may be considered a ghost visitation, which perpetuates a vicious cycle of worsening” (p. 336). In their study, ghost encounters were found to play an important role among Cambodian refugees at a psychiatric clinic. More than half of the patients had been bothered by ghost encounters in the last month, which was highly related to post-traumatic stress disorder severity. Most patients (85%) who were bothered by ghosts in the last month had post-traumatic stress disorder, whereas only 15% of the patients who were not bothered by ghosts had post-­ traumatic stress disorder.

1.11.3 Complex Post-traumatic Stress Disorder The research discussed above is limited to “classic” post-traumatic stress disorder. However, individuals with experiences of complex trauma may experience symptoms more varied and severe than the intrusion, avoidance, and hyperarousal symptoms classically associated with post-traumatic stress disorder. The diagnostic category of complex post-traumatic stress disorder has been incorporated into the

1.12  Anxiety and Depressive Disorder

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ICD-11 as a separate disorder to post-traumatic stress disorder (see Brewin et al., 2017). Complex post-traumatic stress disorder is characterized by affective dysregulation, disturbances in relational function, and negative self-concept in addition to the classical clusters of intrusion, avoidance, and hyperarousal and results in greater functional impairment than post-traumatic stress disorder. Complex posttraumatic stress disorder is more frequently associated with multiple and more severe traumas, higher levels of concurrent mental disorders, and greater functional impairment (e.g., Brewin et al., 2017; Cloitre et al., 2019). Results of a study of Hyland et  al. (2018) show that complex post-traumatic stress disorder assessed according to ICD-11 criteria is associated with higher levels of dissociation, depression, suicidal ideation, self-harm, and borderline personality disorder compared to DSM-5 post-traumatic stress disorder. Presumably, a number of refugees with post-traumatic stress disorder will fulfill the criteria of complex post-traumatic stress disorder, but few studies have this investigated (for review, see de Silva et al., 2021; Mellor et al., 2021). In half of these studies, there was a higher prevalence of complex post-traumatic stress disorder in refugees, indeed suggesting that the diagnostic criteria for post-traumatic stress disorder may not capture the complex psychological responses that follow complex trauma in refugees and asylum seekers. There is also some evidence that post-migration living difficulties (e.g., discrimination, socioeconomical life conditions, language barriers, uncertain visa status) are associated with higher levels of complex post-traumatic stress disorder (Liddell et al., 2019; Schiess-Jokanovic et al., 2022).

1.12 Anxiety and Depressive Disorder Many of these refugees and asylum seekers have comorbid mental disorders including depression and anxiety disorders, substance abuse disorder, and personality disorder as well. A cocurrent disorder may be a predictor of poor treatment response for post-traumatic stress disorder (e.g., Haagen et al., 2017). In a study among Syrian refugees, the prevalence rates of symptoms of anxiety and depression were 36.1% and 34.7%, respectively (Acarturk et al., 2021). In the study of Bogic et  al. (2015), 21 studies reported depression in refugees after a medium of 9 years post-resettlement. Over three-quarters of the studies reported a prevalence of depression in more than 20% of the refugees. The largest prevalence of depression (55%) was reported in Cambodian survivors of mass violence (Mollica et al., 1998b). In a recent systematic review and meta-analysis of displaced persons, 81 studies with an overall sample size of 53,458 were included (Bedaso & Duko, 2022). The pooled prevalence estimate of depression among displaced persons was 26.4%. The authors conclude that three in five internally displaced persons, one in three refugees and asylum seekers, and one in four migrants suffer from depression globally. These figures exceed the prevalence of depression reported by community samples in different nations substantially. Refugee and asylum-seeking women who are pregnant or postpartum may constitute an especially vulnerable group due to the particular health and social needs

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during this period. Perinatal depression is a major problem among refugee and asylum-­seeking women, and females may have an increased risk of psychosis when they are pregnant or postpartum (Fellmeth et al., 2017). Previous depression and poor social support enhanced the risk of perinatal depression. Another especially vulnerable group is lesbian, gay, bisexual, transgender, and queer (LGBTQ) refugees and asylum seekers who are highly likely to experience mental distress caused by specific social factors related to (nonacceptance of) sexual orientation, including barriers to social integration (Fox et  al., 2020; Pelters et al., 2022).

1.13 Alcohol and Substance Abuse Many recent epidemiological studies did not investigate the prevalence of alcohol and substance abuse among asylum seekers and refugees, which might give the wrong impression that it hardly occurs (e.g., Steel et al., 1999; Weaver & Roberts, 2010). Ezard (2012) published a review of studies investigating alcohol and substance abuse among individuals who had been exposed to conflict (such as by combatants) and refugees who were resettled in host countries. The review was based on studies which provided information from ten distinct displaced populations in Africa, Asia, Europe, and South America from 1971 to 2007. Alcohol dependence was more prevalent among men than women. Post-traumatic stress disorder was associated with alcohol dependence for men but less so for women. High alcohol consumption led to gender-based violence in Ethiopia and Kenya, and drinking alcohol was associated with transmission of sexually transmitted infections. In drug users in Afghanistan, nearly all participants were men rather than women. Results of this review suggest that substance use problems can develop not only in the country of origin, or during transit, but also in resettled refugees, which was confirmed in other studies (e.g., Douglass et al., 2022; Hertner et al., 2023; Horyniak et al., 2016b; Greene et al., 2018). There is some evidence that being an active Muslim is a protective factor for substance use (Dupont et al., 2005). Further, the longer the time spent in hostile conditions in the host country after migrating, the more the drug use. Prevalence rates of substance abuse among refugees vary widely. In a review of Morina et al. (2018a), alcohol use disorders were the most common type of substance abuse reported, particularly among male refugees (2–60%). Drug abuse generally did not exceed 2%. Relatively low prevalence of substance abuse (12–15%) was reported in former Iraqi and Yugoslavian refugees, living in Europe and the United States (Arfken et al., 2011; Bogic et al., 2012). In refugees who lived in refugee camps, however, the prevalence rate of substance abuse is substantially higher, ranging from 17% to 66% (Bapolisi et al., 2020; Horyniak et al., 2016b; Horyniak et al., 2016a; Lo et al., 2017). Lo et al. (2017) found in a systematic review of studies among conflict-affected populations in low- and middle-income countries that harmful alcohol use was associated with cumulative trauma event exposure in the past, depression, and primarily older males.

1.14  Personality Disorders

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Taken the results of these studies together, refugees and asylum seekers with an ethnic minority background drink less alcohol than the majority population. Interestingly, although refugees from ethnic minorities have substantially more mental disorders, they are less likely than native-born refugees to develop substance abuse problems (Salas-Wright & Vaughn, 2014). Findings from a very large study among refugees in Sweden (Harris et al., 2019) suggest that lower rates of substance use disorders in refugees may be associated with cultural aspects of substance use in refugees’ countries of origin. However, living in Sweden led to an increase in substance use among refugees, eventually becoming equivalent with substance use morbidity in the Swedish-born population. Stress experienced by refugees and asylum seekers often leads to self-­medication and addiction, which causes lower self-esteem and lower quality of life, which in turn may increase substance abuse. Refugees and asylum seekers are vulnerable to alcohol and substance use not only because traumatic experiences and post-­ migration stressors may lead to alcohol and/or substance abuse as a coping mechanism to deal with the experienced stress and anxiety (Emmelkamp & Vedel, 2006), but also in order to deal with the negative feelings about unemployment and poverty in the host country. In addition, refugees may be particularly vulnerable to alcohol and substance use due to the stress associated with acculturating to the norms and values of their host country. Of note, in a large study conducted in France, migration status increased the risk of alcohol abuse and drug dependence, and this risk was maintained in the second and third generations (Guardia et al., 2017). Last but not least, as refugees are acculturated in their host country, they are inclined to adapt to the norms of the host country with respect to the consumption of alcohol and other substances such as hashish and cocaine.

1.14 Personality Disorders There is a clear lack of studies on the full spectrum of mental disorders including personality disorders in asylum seekers and refugees (Blackmore et  al., 2020a; Morina et al., 2018a). Hardly any study has addressed the prevalence of personality disorders in refugees and asylum seekers. In a study in the United Kingdom, however, the most prevalent screened mental disorder in a refugee and asylum seeker detention center was depression (53%), followed by personality disorder (35%) and post-traumatic stress disorder (21%) (Sen et al., 2018). Personality disorders are among the most severe mental disorders, leading to poor psychosocial functioning and increased mental health comorbidity (Emmelkamp & Meyerbröker, 2020). Traumatic experience is an important etiological factor in the development of a number of personality disorders, but research in refugees is scarce. Callous and unemotional personality traits are related to severe antisocial behaviors (Kahn et  al., 2013). A study on callous and unemotional traits and Big Five personality traits (Latzman et al., 2016) among refugees revealed that non-Western adolescents who had lived in a refugee camp reported higher uncaring personality

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trait levels and lower levels of agreeableness and openness compared with migrants who had not lived in a refugee camp. In a recent study among refugees (n = 120) and migrants (n = 281) in Germany (Zettl et al., 2022), refugees reported higher overall expression of maladaptive personality traits than migrants. In addition, refugees displayed higher levels of antagonism (e.g., manipulativeness, callousness, deceitfulness, and hostility) and disinhibition (e.g., risk taking, impulsivity, and irresponsibility), which are traits of antisocial personality disorder. In a study of Mundy et al. (2020) among refugees in a specialized mental health clinic for trauma-affected refugees in Denmark, conflict-related trauma led to enduring personality change according to ICD-10 in men. Refugee men were more hostile or distrustful; felt empty, hopelessness, or chronically threatened; and were often characterized by social withdrawal as a result of previous exposure to combat or torture. The lack of assessment of personality pathology and the reluctance of some clinicians to use this diagnosis in refugees and asylum seekers may deprive these persons from potentially effective treatment (Emmelkamp & Meyerbröker, 2020). These treatments may be helpful in a proportion of asylum seekers and refugees, especially in young adolescents with severe traumatization (Chanen et  al., 2017; Schuppert et  al., 2017). There is a clear need of studies investigating “evidence-­ based” psychological treatments in refugees and asylum seekers.

1.15 Psychosis A number of studies have investigated the incidence of non-affective psychosis among refugees (e.g., Hollander et al., 2016). There is a growing body of evidence that the risk of developing psychotic disorders is higher for refugees than for non-­ refugee migrants (e.g., Brandt et  al., 2019; Dapunt et  al., 2017; Hollander et  al., 2016). In a systematic review and meta-analysis of nine studies (Brandt et al., 2019), refugees had a significantly higher risk of developing schizophrenia and non-­ affective psychoses compared with the native population. In the methodologically better designed studies included in Brandt et al. (2019), the relative risk increased statistically significantly to 1.39 for refugees compared with non-refugee migrants and to 2.41 for refugees compared with the native population. Only one study (Anderson et al., 2015) of the nine studies included in the meta-analysis of Brandt et al. (2019) revealed no association of refugee or migrant status with the risk of psychosis compared with the native group. In this study, Anderson and colleagues examined the incidence of schizophrenia and schizoaffective disorders in first-­ generation immigrants and refugees, relative to the general population in Canada. However, second-generation migrants were included in the general population, which may have confounded results, given that second-generation migrants have also a higher risk of psychosis (Henssler et al., 2020). In a recent large study in Sweden (Duggal et al., 2020) in over 50,000 refugees, the risk of non-affective psychosis was 41% higher among male refugees who had lived in refugee camps for prolonged periods of time compared to refugees who

1.16  Other Mental Health Problems

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have undergone resettlement with permanent residence status. Unfortunately, evidence is limited to Western host countries.

1.16 Other Mental Health Problems 1.16.1 Suicidal Ideation and Suicide In general, there is considerable evidence that trauma exposure is not only related to mental health problems, but to suicidal ideation as well. Suicidal ideation refers to having thoughts of ending one’s life. These thoughts can vary in intensity from incidental thoughts a few times a month to full preoccupation with wanting to die. Nock et al. (2008) found that the lifetime prevalence of suicidal ideation is 9.2% (range 3–16%) across 17 countries in Africa, Asia, Europe, the Middle East, North America, and the Pacific. Given the exposure to trauma and other vulnerabilities experienced during the flight and the stay in host country including uncertainty for their future resettlement, many refugees and asylum seekers have a heightened risk of suicidal ideation and suicide (Nickerson et  al., 2019; Premand et  al., 2018; Vijayakumar, 2016). Asylum seekers held in detention settings have an increased risk of psychological distress and suicide (Dudley, 2003; Filges et al., 2018) due to isolation, with increased risk of exposure to trauma, including physical and/or sexual abuse. In a recent study on suicidal ideation among recently arrived refugees in Germany (Nesterko et  al., 2022), 31% of the refugees had experienced suicidal ideation within the 2 weeks prior to being assessed. Refugees in the Nesterko et al.’s study came primarily from Venezuela, Cameroon, and Syria. Suicidal ideation was related to worse mental and physical health, symptoms of post-traumatic stress disorder and depression, and experiencing of sexual violence (sexual assault and/or unwanted sexual experiences). In a study among refugees in Sweden (Leiler et al., 2019b), 34% of refugees, most of whom were from Afghanistan and Syria, experienced suicidal ideation. Leiler et al. (2019b) and Nesterko et al. (2022) used only one item from the PHQ-9 to assess suicidal ideation, which limits the conclusions which can be drawn. In the Netherlands, the suicide rate among refugees and asylum seekers was compared to the Dutch population. In male asylum seekers, the risk of suicide was higher than in the general population of the Netherlands; no difference was found between suicide mortality in female asylum seekers and in the female general population of the Netherlands (Goosen et al., 2011). Suicidal behavior was related to a lower use of mental health services, negative outcomes of the asylum procedure, and loss of family members (Goosen et al., 2011). Björkenstam et  al. (2020) investigated associations between mental disorders and suicide attempt and suicide in refugees in Sweden. Only suicide attempts and mental disorders resulting in specialized patient care were registered in this study. In general populations, individuals suffering from mental disorders have a considerable higher risk for suicide attempt and suicide, and this was confirmed in this

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Swedish study: Swedish-born individuals with a mental disorder had a sixfold elevated risk for both suicide and suicide attempt compared with the general population of Sweden without a mental disorder. In refugees with a mental disorder, however, the risk of suicide attempt and suicide was lower in refugees than in Swedish-born individuals except for refugees with bipolar disorders, personality disorder, and schizophrenia; in these cases, the numbers of suicide attempt and suicide were equally high for refugees and Swedish-born individuals. In a follow-up study (Niederkrotenthaler et al., 2020), the risks for suicide and reattempt in refugees were lower compared to Swedish-born individuals, despite that mental health care was less prevalent among refugees compared to Swedish-born individuals. Presumably, refugees from many countries who fly to Sweden are less likely to act upon suicidal ideas, due to cultural and religious factors prevailing in their country of origin leading to stigma associated with suicidal behavior and suicide. The majority of refugees included in the studies of Björkenstam et  al. (2020) and Niederkrotenthaler et  al. (2020) were from Muslim-majority countries. Of note, among immigrants in Sweden, male suicide rates in rural areas were higher than in urban areas (Kanamori et al., 2022). In a review of studies investigating suicide in immigrants and refugees, the prevalence of suicidal ideation was 16% and for attempted suicide was 6%, most often in females; nearly 1% died as a result of suicide (Amiri, 2020). However, Amiri included in his review studies done with various immigrant groups and refugees without distinguishing between the refugees and immigrants. The increased risk of suicidal ideation and suicide in refugees is related to the high prevalence of depression in this group. In a recent meta-analysis of suicide (Haase et al., 2022), the prevalence of suicidal ideation and suicide attempts among refugees was investigated in nonclinical populations of refugees or asylum seekers (aged 16 years and older). The overall prevalence rates of suicidal ideation were 22.3% for women and 27.7% for men. Studies on refugees reported substantially higher prevalence rates of suicidal ideation compared to the general population. Suicide attempts had an overall prevalence of 0.57%, which prevalence is comparable to the prevalence of suicide attempts in non-refugee populations. Thus, in nonclinical populations of refugees, the prevalence of suicidal ideation is much higher than in non-refugees, but the prevalence of suicide attempts is similar to the non-refugee population. In another recent review on suicide rates, suicide attempts, or suicidal ideation among displaced persons, the prevalence of suicide attempts ranged from 0.14% to 15.1% across all studies (Cogo et al., 2022). Among refugees granted asylum, the risk of suicide was lower compared with the host population in most studies. In asylum seekers and refugees living in camps, however, the suicide risk and risk of suicidal ideation were higher compared to host populations. In sum, so far, research with respect to suicidal ideation among asylum seekers and refugees has been limited to relatively few studies. Unfortunately, possible cultural or ethnic differences between the participants in most studies discussed have not been taken into account, although there is some evidence that culture-specific features of suicidality among different groups of immigrants do exist (Chu et al.,

1.16  Other Mental Health Problems

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2010). There is a clear need of longitudinal studies on suicidal ideation in different refugee populations hosted in different countries (Nesterko et al., 2022).

1.16.2 Grief Relatively few studies have addressed persistent grief problems in refugees. Prolonged grief disorder has been recognized as a formal mental disorder in ICD-11 (WHO 2022). Prolonged grief disorder is diagnosed when acute grief stays distressing and disabling, beyond 1 year following bereavement, and is described as persistent yearning for the deceased and associated emotional pain, difficulty in accepting the death, a sense of meaninglessness, bitterness about the death, and difficulty in engaging in new activities (WHO, 2018). More recently, prolonged grief disorder has also been accepted as a formal disorder in the revision of DSM-5: DSM-5-TR (APA, 2022). The DSM-5-TR criteria for prolonged grief disorder require that distressing symptoms of grief continue for at least 12 months following the loss of a close attachment and that the grief response is characterized by intense longing/yearning for the deceased person and/or preoccupation with thoughts and memories of the lost person to a clinically significant (i.e., impairing) degree, nearly every day for at least the past month. The burden of these symptoms has to cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. There is much evidence that prolonged grief is associated with comorbid post-traumatic stress disorder, anxiety disorder, and depression (Simon et al., 2007), with an increased risk of suicidality (Latham & Prigerson, 2004), inferior quality of life (Boelen & Prigerson, 2007), and chronic physical illnesses (Prigerson et al., 1997), and may interfere with work and social functioning (e.g., Bonanno et al., 2007). The prevalence of prolonged grief disorder in bereaved people in the normal population is estimated between 3.7% and 7% (Maciejewski et al., 2016; Kersting et  al., 2011). A meta-analysis reported that the prevalence estimate of prolonged grief disorder is 9.8% for bereaved people after natural losses (Lundorff et  al., 2017). Previous studies among refugees (Craig et  al., 2008; Schaal et  al., 2010) found a higher prevalence of bereavement problems in refugees, but the samples were small and not representative, including patients who were recruited from mental health settings. More recent studies (Comtesse & Rosner, 2019; Steil et  al., 2019), however, found a rather high prevalence of prolonged grief disorder among refugees residing in Germany. Strong correlations between prolonged grief disorder on the one hand and anxiety, depression, and somatization on the other were found (Steil et al., 2019). In a nationally representative sample of refugees’ study (N = 1245) in Australia (Bryant et al., 2020), nearly 16% of refugees reported 2 years after admittance to Australia problematic grief reactions. Most refugees came from Afghanistan, Iraq, Bhutan, or Myanmar. Grief problems were associated with a greater likelihood of mental illness, including severe mental illness, disability, and currently unemployment. The development of problematic grief disorder was associated with exposure

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to a range of traumatic stressors, including murder or disappearance of family members. Children of refugees with problematic grief reactions had more psychological difficulties than those whose parents did not have problematic grief reactions. As noted by the authors, problematic grief reactions in refugees are associated with psychological and social challenges that are likely to interfere with refugees’ capacities to optimally adjust to their new settings. In another study, Bryant et al. (2021) reported the prevalence rate of prolonged grief disorder in a representative sample of Syrian refugees in Jordan. Among those experiencing bereavement, 15% met the criteria for prolonged grief disorder, which is about 9% of the entire sample. Refugees with prolonged grief disorder were more likely to have another mental disorder. The percentage of more than 15% of bereaved refugees who fulfill the criteria for prolonged grief disorder in two studies with refugees (Bryant et al., 2020, 2021) is substantially higher than that reported in non-­ refugee population-based studies. The prevalence of grief reactions is three times higher than the prevalence of individuals with prolonged grief disorder in Western countries (Rosner et al., 2021). In a study of Comtesse et al. (2022), the influence of the disappearance (ambiguous loss) versus the death of a loved person on prolonged grief disorder symptom severity was investigated among refugees living in the host country Germany. Ambiguous loss led to higher levels of prolonged grief disorder symptoms than the formally recognized death, which suggests that ambiguous loss may constitute a specific risk factor for prolonged grief disorder symptoms among refugees. As noted by the authors, uncertainty about the fate of the disappeared loved one and being unable to mourn and the inability to bury the body will enhance grief-related distress. In addition, post-traumatic stress symptoms and lack of social support were associated with prolonged grief disorder symptoms. Some studies revealed that there may be cultural differences in grief reactions (Xiu et al., 2017). In a study of Lechner-Meichsner and Comtesse et al. (2022), illness beliefs and treatment expectations regarding prolonged grief disorder were investigated among refugees from Arab countries and from sub-Saharan Africa. They found specific beliefs of refugees regarding causes and cures of prolonged grief disorder, culture-specific rituals, and religious beliefs. However, as noted by the authors, cultural differences should not be overstated, because beliefs about causes of grief also showed some similarities with Western conceptualizations of grief.

1.16.3 Embitterment A substantial number of refugees are characterized by embitterment as a response to unfairness and humiliation. Embitterment can be described as a strong feeling of moral injury, and disappointment, with the felt inability to defend oneself (Linden et al., 2006; Linden & Maercker, 2011). Embitterment can result in dysfunctional behavior including withdrawal from social contacts, negativism, and even acts of revenge. As a result of a number of negative experiences before, during, and after their flight, asylum seekers and refugees might have an increased risk to suffer from embitterment.

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Two recent studies revealed that traumatized refugees are particularly vulnerable for clinical embitterment (Linden & Teherani, 2020; Spaaij et al. 2021), which may be one of the factors involved in increasing the risk of developing mental health problems in asylum seekers and refugees. Linden and Teherani (2020) investigated the differences between nonpolitical motivated emigrants and refugees from Iran with regard to embitterment. Emigrants scored lower on embitterment than refugees, which supports the idea that embitterment is a reaction to injustice, which is experienced by many refugees. In a clinical sample of traumatized adult asylum seekers and refugees from a variety of countries who were treated for torture and war trauma in Switzerland, 65% of the individuals reported elevated levels of embitterment (Spaaij et al. 2021). More than 85% of the sample cases were males. Higher rated embitterment was associated with low self-efficacy and greater moral injury appraisals. Neither degree of exposure to trauma nor post-migration difficulties explained the higher rate of elevated embitterment. Embitterment not only leads to severe subjective suffering but may also hamper the integration process in the host country because refugees who experience embitterment may eventually socially withdraw and may not accept any (mental) support. As noted by Linden and Maercker (2011), embitterment can increase additional dysfunctional and harming feelings such as anger, shame, sadness, anxiety, aggression, helplessness, and hopelessness. Embitterment may eventually even lead to radicalization (Eleftheriadou, 2020), but this has not yet been investigated.

1.17 Intimate Partner Violence Family violence includes intimate partner violence and violence between a caregiver and a child (child maltreatment). According to the definition of the World Health Organization (WHO), intimate partner violence is “any behaviour within an intimate relationship that causes physical, psychological or sexual harm to those in the relationship” (World Health Organization, 2012, p. 1). More specifically, intimate partner violence has been described as “physical violence, sexual violence, stalking and psychological aggression … by a current or former intimate partner” such as a spouse, boyfriend, and regular sexual partner (Breiding et al., 2015, p. 11). In a recent study in the United Kingdom based on data from the 2014 Adult Psychiatric Morbidity Survey, the authors found a clear association between interpersonal violence and self-harm, suicidal ideation, and suicide attempts. One in three women who had attempted suicide in the past year was a recent victim of intimate partner violence, especially emotional and sexual violence (McManus et al., 2022). Generally, epidemiological studies worldwide revealed that females are more often victims of intimate partner violence than males (Benjet et al., 2016). Based on the data of the World Mental Health Survey Consortium, intimate partner violence or sexual violence accounted for 47% of years of post-traumatic stress morbidity (Kessler et al., 2017).

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1.17.1 Prevalence of Intimate Partner Violence in Refugees Family violence is rather prevalent among refugees (Timshel et al., 2017). Female refugees and women living in conflict-affected communities face exacerbated vulnerabilities and risk factors for intimate partner violence regardless of immigration status (El-Moslemany et  al., 2020; Keating et  al., 2021; Roupetz et  al., 2020), which confirms previous results of a meta-analysis (Porter & Haslam, 2005). In Syrian refugees, an increase in violence toward women perpetrated by their husband led to harsher discipline and violence toward their children (Al-Natour et al., 2022). Intimate partner violence is not limited to refugees in Arabian countries. In a study in Australia, prevalence of intimate partner violence was significantly higher among women born in conflict-affected countries compared to Australia-born women (Hicks et al., 2021). Approximately 70% of North Korean refugee women are victims of intimate partner violence (Kim, 2011, 2019), and in a study based on the Customized Support Plan for Victimized North Korean female refugees, many North Korean refugee women proved to be victims of intimate partner violence after their resettlement in South Korea (Korean Ministry of Gender Equality and Family, 2010; Nam et  al., 2021). The prevalence of intimate partner violence among Palestinian refugees and refugees in Bosnia-Herzegovina, Serbia, the Democratic Republic of Congo, and East Timor ranged from 22 to 76% (Khawaja & Barazi, 2005; Sipsma et  al., 2015; Wako et  al., 2015). Other studies found high rates of intimate partner violence among displaced couples from Palestine (Clark et  al., 2010), Uganda (Annan & Brier, 2010), Liberia (Vinck & Pham, 2013), and Syria (Parker, 2015). There are a number of studies which show that refugee women living in the United States are often victims of intimate partner violence as well (e.g., Asian refugees, Lee & Hadeed, 2009; Latino immigrant, Sabina et al., 2014). Foreign-born victims were significantly more likely to be victims of intimate partner homicide and for a perpetrator to commit homicide (Sabri et  al., 2018, 2021). Homicide reviews and analyses of reported homicide cases have consistently documented an overrepresentation of refugee women among victims (Runner et al., 2009).

1.17.2 Cultural Values Acculturation is the process of adaptation to the way of life, both culturally and psychologically, in a host country (Njie-Carr et  al., 2021). Among other factors, there is evidence that stress as a result of the acculturation process may be one of the risk factors for intimate partner violence (e.g., Capaldi et al., 2012). Being unemployed, social stressors, loss of property, fear of being detained, or fear of being killed leads to emotional distress in husbands (Rizkalla & Segal, 2019; Shafi, 2019) and may eventually result in intimate partner violence. Women’s flight from their home country and the displacement and migration that follow increase women’s risk for intimate partner violence (Mose & Gillum, 2016), but in a study

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among Bosnian refugee women living in the United States and non-refugee Bosnian women still living in Bosnia-Herzegovina, no differences in rates of experienced intimate partner violence were found (Muftić & Bouffard, 2008). For some refugee women, cultural values and norms over time increase gender inequality. In a study among over 400 women in conflict-affected northern Uganda, no association was found between attitudes accepting wife-beating and occurrence of intimate partner violence (Black et al., 2019). There is some evidence, however, that women who hold gender role values supportive of intimate partner violence are more likely to blame themselves for an assault. Khawaja et al. (2008) investigated the acceptance of wife-beating in married men and women living in Palestinian refugee camps in Jordan. Results reveal that the majority of males and females (over 60%) hold that wife-beating is justified with—surprisingly—no difference between men and women. Women, who had been victims of intimate partner violence, were more likely to report acceptance of wife-beating. Further, a man’s previous experience of abuse against his wife predicted justifying intimate partner violence. As noted by the authors, the occurrence of wife-beating in a community seems to legitimize this violence because both victims and perpetrators are more likely to report justifications for intimate partner violence: “... In communities where women who leave abusive relationships are further victimized by a society that ostracizes them for divorcing their husband, women may choose to justify and accept the occasional wife-beating as normal” (Khawaja et al., 2008, p. 216). In a study of Al-Badayneh (2012), nearly 30% of women living in Jordan believed in husband rights to control women and 93% believed that wives are obliged to obey their husbands. In a more recent study in Jordan, the prevalence of intimate partner violence was still rather high: physical violence 26% and sexual violence 13% (Damra & Abujilban, 2021). According to a review of Gausman et  al. (2021), over 60% of Syrian refugee females aged 15–19 years hold that a man is justified in hitting his wife, while about 46% of older women agree. A majority of Syrian refugee men in Jordanian camps believe that wife-beating is acceptable. Islam et al. (2021) investigated the attitudes toward physical abuse and experiences of intimate partner violence of Rohingya refugee women in the Rohingya refugee settlement in Bangladesh. Results revealed that Rohingya women’s attitudes toward and experiences of intimate partner violence were associated with their exposure to child marriage. Overall, 61% of the refugee women were married before 18 years of age (child marriage). Child marriage was strongly related with justification of wife-beating and experience of intimate partner violence in the past year. In sum, cultural beliefs about the role of males in many Arabic cultures including Jordan are based on an “inherited” structured patriarchal ideology, which prescribes the superiority of men over women, which gives men the right to control the lives and personal issues of their wives and families. Intimate partner violence is seen as a justified way to resolve marital conflict and control the family (Al-Natour & Gillespie, 2022). This is also reported in studies conducted in other Arabian countries including Egypt (Hassan et al., 2016a), Iraq (Mishkin et al., 2022), and Turkey (Adibelli & Yuksel, 2019), but intimate partner violence is not limited to Arabian countries.

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1.17.3 Factors Influencing Intimate Partner Violence How come that there is such a high prevalence of intimate partner violence in refugee settings? Some studies have attributed the prevalence of intimate partner violence in refugee communities to the role of refugee’s stressors such as mobility restrictions, unemployment, poverty, and separation from families (Akhter & Kusakabe, 2014), leading men to resort to intimate partner violence to compensate for their feelings of inferiority and enable them to regain power over their family (Wachter et al., 2018). In addition, the change in cultural prescriptions about gender roles, expectations, and behaviors are stressors for the male partners of female refugees, increasing tensions and confrontations between the couple, thus enhancing the chance of intimate partner violence (Daoud, 2021). On the other hand, cultural beliefs may also prevent victims of intimate partner violence to use adequate problem-­solving methods. Holding onto patriarchal beliefs, blaming oneself for not being able to preserve family integrity, and fear of being stigmatized by the community are just a few examples of sociocultural aspects that may hinder refugee women from requesting divorce or from looking for social or mental health services (Okeke-Ihejirika et al., 2020; Souto et al., 2016).

1.17.4 Somatic Injuries Many victims of intimate partner violence have physical injuries including arthritis, neck and back pain, headaches and migraines, hypertension, unexplained dizziness, sexually transmitted infections, chronic pelvic pain, gynecological symptoms, and gastrointestinal problems (Guruge et  al., 2010). Dadras et  al. (2021) investigated pregnancy complications in Afghan women living in Iran and found that adverse pregnancy outcomes were also associated with intimate partner violence.

1.17.5 Risk of Mental Health Problems Not surprisingly, intimate partner violence is associated with increased risk of mental health problems (e.g., Falb et al., 2019; Hossain et al., 2021; Oram et al., 2017; Silove et al., 2014). Mental health problems include depression, acute and chronic symptoms of anxiety, post-traumatic stress disorder, substance use/dependence, and suicidal ideation. Brooks et al. (2022) found intimate partner violence in refugees to result in the largest increase for depression, anxiety, or post-traumatic stress disorder when compared to any other mental health risk factors. There is some evidence that low education level, having a nonresident legal status, alcohol use, relationship problems, rapid and forced marriage, financial dependence on a partner, or unemployment enhances the risk of intimate partner violence in refugees and asylum seekers (El-Moslemany et al., 2020; Khawaja et al., 2008; Wachter et al., 2018). Women from refugee backgrounds who experience intimate partner violence are particularly vulnerable to mental health problems during pregnancy (Rees et al., 2019).

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1.17.6 Prevention Taken these results together, there is a clear need for intimate partner violence prevention strategies for refugees and asylum seekers from conflict-affected countries (Hicks et al., 2021; Wong & Bouchard, 2021). Unfortunately, intimate partner prevention campaigns in high-income countries have not focused on attitudes toward gender roles and intimate partner violence among refugees and asylum seekers coming from conflict-affected countries. Further, it is also important for social and mental health workers to be aware of culturally shaped gender role attitudes that may enhance the use of intimate partner violence.

1.17.7 Poly-Victimization Refugee (and asylum-seeking) women have not only a higher risk of intimate partner violence, but there are also studies which reveal that a number of female refugees have a risk of poly-victimization. Females in refugee populations are at increased risk of sexual and physical violence. Female refugees are vulnerable to violence throughout their lives, whether in the country of origin during armed conflicts when their lives were disrupted due to persecution, in transit, or after resettlement in the host country (e.g., Freedman, 2016; Hynes & Cardozo, 2000). These may include the risk of sexual abuse from smugglers or traffickers who may force sexual relations in return for assisting women in escaping to a potential “safe” country. Most North Korean refugees travel through China, Cambodia, or Vietnam before entering South Korea, and almost one-third of North Korean refugee women were victims of sexual violence during their escape period (Nam et  al., 2021). Sexual violence and intimate partner violence were highly associated: North Korean refugee women with a history of sexual violence reported a much higher rate of intimate partner violence during the last year when compared to those without a history of sexual violence (Nam et al., 2021). Various studies have investigated intimate partner violence in war contexts, for example among displaced couples from Palestine, Lebanon, Uganda, Sri Lanka, Afghanistan, and Liberia. Yazidi women living in northern Iraq have experienced severe human rights violations through attacks by the so-called Islamic State group, including sexual violence and intimate partner violence as well as war-related attacks and enslavement. In a study of Goessmann et al. (2020), participating Yazidi females (99.7%) had experienced at least one war-related violent event, and 66.0% were victims of intimate partner violence in the past year. In addition, 16.6% of these participants were victims of abduction and/or sexual slavery. Rates of posttraumatic stress and depression symptoms were high, and women who experienced abduction reported even higher levels of psychopathology than those who did not. Several studies have shown that sexual violence is one of the most common problems among women in refugee camps and settings. A systematic review and meta-analysis of over 8000 female refugees reported a prevalence of sexual violence against women of 21.4% (Vu et al., 2014).

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1.18 Health Status of Asylum Seekers and Refugees There is considerable evidence that post-traumatic stress is associated with poor physical health including chronic fatigue, fibromyalgia, cardiovascular disease, irritable bowel syndrome, rheumatoid arthritis, and chronic pain (e.g., Edmondson et al., 2013; Häuser et al., 2013; Lee et al., 2016; Pacella et al., 2013; Siqveland et al., 2017). Generally, somatic symptoms improved as well after successful treatment for post-traumatic stress disorder (e.g., Holliday et  al., 2015; Sofko et  al., 2016; Song et al., 2020). However, results from the study of Song et al. revealed that patients who reported poorer physical functioning at the beginning of treatment experienced a slower rate of post-traumatic stress symptom improvement.

1.18.1 Somatization In refugees, emotional distress may present not only as mental symptoms but as physical symptoms as well, especially among Asian refugees (Hinton et al., 2012; Novick et al., 2013; Riley et al., 2017). Due to the stigma of mental disorders, psychological distress may present as somatic complaints (Bolton et al., 2012; Laban et al., 2008; Lin et al., 1985; Rohlof et al., 2014; Yanni et al., 2013). Many refugees and asylum seekers with primarily somatic symptoms expect to get treatment for their somatic complaints rather than for their mental health problems, which may impede the therapeutic process. Generally, higher levels of somatization are reported among Asian people than among native Western individuals. In a number of refugees and asylum seekers, medically unexplained symptoms can affect individuals in their daily life, since they influence the functioning of them. There is some evidence that somatization is a culturally specific sign of distress, which is socially and culturally acceptable (Ryder et  al., 2008; Hinton et  al., 2008). The number of medically unexplained physical symptoms among refugees is generally higher than among non-refugees, and somatization in refugees is associated with psychopathology and traumatization (e.g., Rohlof et  al., 2014). In a recent study (Renner et  al., 2021), nearly half of Syrian refugees in Germany who had post-traumatic stress disorder suffered from somatization as well, which emphasizes the importance of physical symptoms as the expression of mental distress in Syrian refugees. Chronic pain is a frequently exhibited health condition, affecting many traumatized refugees (e.g., Altun et al., 2022; Campeau, 2018; Kaur, 2017; McGrath et al., 2020; Teodorescu et al., 2015). In the study of Altun et al. (2022), severity of chronic pain among female refugees was primarily associated with post-migration experiences such as rurality of settlement and perceived discriminatory experiences. In a recent study among Syrian refugees resettled in Norway, 43% of refugees reported chronic pain (Nissen et al., 2022); higher levels of chronic pain were associated not only with post-traumatic stress disorder, but with anxiety and depression as well. Other studies found that traumatized and tortured refugees experienced much higher levels of pain compared to non-refugee individuals suffering from pain (Buhman et al., 2014; Harlacher et al., 2016).

1.18  Health Status of Asylum Seekers and Refugees

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Refugees often experience increased rates of ongoing physical health problems due to a lack of access to appropriate health care and adequate medication for chronic diseases, lack of immunization, and increased risk factors because of unhealthy lifestyles in countries of resettlement (Lebano et al., 2020). Regarding maternal and child health of refugees and asylum seekers, a few studies reveal a higher rate of preterm births and stillbirths (Wanigaratne et al., 2016), lower birth weight, and increased mortality (Bürgin et al., 2022). In a number of studies, female refugee or immigrant status was associated with late initiation of prenatal care (e.g., Kandasamy et al., 2014), but this was not replicated in a recent study (Ewesesan et al., 2022). Studies in the Eastern Mediterranean region found antenatal care coverage to be lower for refugees than for non-refugees and the maternal mortality ratio among Syrian refugee women in Lebanon to be much higher than that among Lebanese women (see Al-Mandhari et al., 2021). A number of studies among refugees and asylum seekers in Europe reported that respiratory diseases are relatively frequently reported (e.g., Olaru et al., 2018). In a large study in Italy (Manfredi et al., 2022) among adult refugees and asylum seekers, who fled from Africa, the Middle East, Bangladesh, Cambodia, and Nepal, medical records revealed that on arrival, skin (with a high prevalence of scabies), respiratory, digestive, and generic diseases were the most frequent. One-quarter arrived with at least one disease. During the stay, respiratory diseases were the most common. The majority of diseases diagnosed in this group of refugees and asylum seekers were mild (Manfredi et al., 2022). Infectious diseases, sensory impairments, and low immunization rates are common for refugee and asylum-seeking individuals (Victorian Foundation for Survivors of Torture, 2021). Refugees and asylum seekers may have a significant burden of communicable infectious diseases, such as tuberculosis, malaria, viral hepatitis, and parasitic infections, due to higher prevalence of such diseases in their country of origin and overcrowding in shelters and rural camps (Proença et al., 2020). In refugee settlements in Uganda, epidemic prone diseases were highly prevalent including malaria, typhoid, dysentery, measles, and cholera (Ario et al., 2022). Also, in host country Germany, nearly one-third of refugees and asylum seekers reported worse health status 1  year post-arrival compared to when they reached the host country Germany where they resettled (Biddle et al., 2019).

1.18.2 Noncommunicable Diseases Noncommunicable diseases are diseases that do not transmit from one person to another. According to the WHO definition, noncommunicable diseases known as chronic diseases tend to be of long duration and are the result of a combination of genetic, physiological, environmental, and behavioral factors. The four main types of noncommunicable diseases are cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes, which require long-term management. Many former refugees are at an increased risk of developing one or more chronic conditions that require multiple medications (polypharmacy), and this risk increases with age. Refugees and asylum seekers in host country often develop diabetes type 1, due to

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less physical activity, overweight, and mental stress (van den Muijsenbergh, 2019). Results of a study based on data from Dutch Community Health Services for asylum seekers revealed that asylum seekers with post-traumatic stress disorder had a 1.5 times higher prevalence of diabetes type 2 compared with refugees without post-­ traumatic stress disorder. The association between diabetes type 2 and post-­traumatic stress disorder was stronger in asylum seekers without comorbid depression compared with those with comorbid depression (Agyemang et al., 2011). Asylum seekers from the majority of countries of origin were at higher risk of diabetes compared with the general population in the Netherlands (Goosen et al., 2014). Chronic disease (co-)morbidities such as hypertension, diabetes mellitus type 2, and obesity account for a large burden of disease among refugees (Kubiak et al., 2021; Kumar et al., 2020; Yanni et al., 2013). Refugee status was associated with higher prevalence of cardiovascular disease as compared to non-refugee counterparts in a number of studies (see Ngaruiya et al., 2022). Compared with individuals in host countries, higher prevalence rates of chronic diseases were found in refugees (e.g., Amara & Aljunid, 2014; Doocy et al., 2016; Yun et al., 2012). A number of studies have investigated the prevalence of noncommunicable diseases among Syrian refugees in Syria’s neighboring host countries (Turkey, Lebanon, or Jordan). In a systematic review and meta-analysis (Al-Oraibi et  al., 2022) of the data of 237,723 Syrian refugees, the prevalence rates of hypertension, diabetes mellitus type 2, cardiovascular diseases, chronic respiratory diseases, and arthritis were 24%, 12%, 5%, 4%, and 11%, respectively, in community care centers. The prevalence of hypertension and diabetes mellitus type 2 was much higher in primary care settings than in community settings. This study found that almost half of Syrian refugees visiting primary care clinics had diabetes mellitus type 2 (48%) and approximately one-third had hypertension (35%).

1.18.3 Mental Health Consequences The health consequences are not limited to physical health. A study of Gammouh et al. (2015) reported that 35% of Syrian refugees suffering from chronic diseases had comorbid depression. In a study of Sharp et al. (2021b); Sharp et al. (2021a), the prevalence of depression among female Syrian refugees with chronic disease living in Jordan was compared with Jordanians with chronic disease. This study revealed that about half of the total study population reported moderate to high depression. The comorbidity between chronic disease and depression was less than half of the Jordanians; nearly three-quarters of the Syrian refugees had comorbid depression and chronic disease (Sharp et al., 2021b). Most Syrian and many Jordanian women endorsed a bidirectional relationship between their chronic disease and depression. Depression may lead to worsening of chronic disease, which may exacerbate the depressive symptoms. Depression also has a significant impact on medication adherence among those with comorbid chronic disease, with a depressed patient being almost twice as likely not to adhere to the medication prescription for a chronic disease compared with a nondepressed patient (Sharp et al., 2021a).

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Refugees and asylum seekers with chronic illness need to be informed about how and why to take medicine, which is related to “health literacy” (Dodson et al., 2014; Murray et al., 2022). A number of refugees are illiterate in their first language, and many refugees require an interpreter for health consultations. In a number of cases, health professionals may view refugees as noncompliant with the use of medication and recommended healthy behavior, when in fact their unhealthy behavior may be due to low health literacy. Few studies have investigated the occurrence of psychogenic non-epileptic seizures. There is some evidence that psychogenic non-epileptic seizures occur more frequently among female refugees and asylum seekers in refugee camps than among displaced males. Hallab and Sen (2021) reported that among displaced women without a history of sexual violence, the rate of psychogenic non-epileptic seizures was 16.7%. This rate was, however, much higher in forcibly displaced females with a history of sexual violence: 43.7%. There is a clear need of studies investigating multicultural factors associated with psychogenic non-epileptic seizures in order to enhance our understanding of this stress-linked phenomenon in vulnerable displaced individuals.

1.18.4 Recent Developments The COVID-19 pandemic has had a disproportionately hard impact on asylum seekers and refugees who have often very limited means to protect themselves, given the situation in which they have to live. Social distancing, self-isolation, and maintaining hand hygiene are hardly possible when many asylum seekers and refugees have to live in refugee camps. Such living conditions may not only increase the risk of getting infections but have also impact on the mental health of refugees and asylum seekers. In a study of Marchi et al. (2022), increased difficulties in following the preventive measures against COVID-19 were associated with more mental distress and experience of discrimination. Moreover, psychological distress mediated the effect of preventive measures’ use on self-perceived stigmatization. These negative effects appeared to be stronger for those with more insecure housing and residence status, thus showing the specific risk of insecure housing in the impact of COVID-19 upon mental health and infection protection. Among recent adult refugees from Ukraine, there is a high chance that a substantial number of them need medical care for hypertension, diabetes, and chronic infectious diseases as HIV and tuberculosis (Murphy et al., 2022) and for cardiovascular disease with an age-adjusted death rate for ischemic heart disease more than six times higher than in EU countries (Marchese et al., 2022).

1.19 Migrant Mental Health and Aging Hardly any research has been conducted with aging migrant patients, but there is some evidence that among refugees, older age is related to more mental health problems (Lin et al., 2020; Marshall et al., 2005; Porter & Haslam, 2005; Schlaudt et al.,

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2020). In Europe, over 64% of the mental health centers found assessment of dementia in older refugees quite challenging, primarily because of the lack of adequate assessment tools. This may lead to the fact that migrants are less likely to receive dementia diagnosis than natives (Nielsen et al., 2011, 2015), which may be related to illiteracy. A recent meta-analysis found that many dementia screening tools are not suited for individuals who are illiterate (Maher & Calia, 2022). The results of this systematic review and meta-analysis emphasize the need for the development and validation of tools that are suitable for individuals of all abilities. One of the reasons might be that often an interpreter has to be used to communicate with the patient. A recent study showed that the interpreter could affect the patient’s results during the dementia assessment (Torkpoor et al., 2022). Alterations made by the interpreter to what was being communicated led to incorrect evaluation of the patient’s cognitive abilities. Therapeutic treatments for refugees diagnosed with dementia are limited due to a lack of evidence on the effectiveness of dementia drugs on minority groups (Sheat et al., 2020).

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UNHCR. (2022). 100 million people forcibly displaced. UNHCR Refugee Statistics. Retrieved from https://www.unhcr.org/refugee-statistics/insights/explainers/100-million-forcibly-displaced.html Uphoff, E., Robertson, L., Cabieses, B., Villalon, F.  J., Purgato, M., Churchill, R., & Barbui, C. (2020). An overview of systematic reviews on mental health promotion, prevention, and treatment of common mental disorders for refugees, asylum seekers, and internally displaced persons. Cochrane Database of Systematic Reviews, 9, CD013458. https://doi. org/10.1002/14651858.CD013458.pub2 USCIS. (2019). Asylum division quarterly stakeholder meeting. Retrieved from https://www.uscis. gov/outreach/upcoming-national-engagements/outreach van den Muijsenbergh, M. (2019). Medical aspects of care in host countries: embedding refugees in health care systems. In Wenzel & Drozdek (Eds.), An uncertain safety: integrative health care for the 21st century refugees (pp. 419–430). Springer. van Heemstra, H. E., Scholte, W. F., Nickerson, A., Boelen, P. A. (2021). Can Circumstances Be Softened? Self-Efficacy, Post-Migratory Stressors, and Mental Health among Refugees. International Journal of Environmental Research and Public Health, 18(4), 1440. https://doi. org/10.3390/ijerph18041440 Verhülsdonk, I., Shahab, M., & Molendijk, M. (2021). Prevalence of psychiatric disorders among refugees and migrants in immigration detention: systematic review with meta-analysis. BJPsych Open, 7(6), E204. https://doi.org/10.1192/bjo.2021.1026 Victorian Foundation for Survivors of Torture Inc. (VFST0). (2021). Australian refugee health practice guide: Primary care for people from refugee backgrounds. Retrieved from https:// refugeehealthguide.org.au/. Vijayakumar, L. (2016). Suicide among refugees – a mockery of humanity. Crisis, 37(1), 1–4.A. Vinck, P., & Pham, P. N. (2013). Association of exposure to intimate-partner physical violence and potentially traumatic war-related events with mental health in Liberia. Social Science & Medicine, 77(1), 41–49. https://doi.org/10.1016/j.socscimed.2012.10.026 Von Werthern, M., Robjant, K., Chui, Z., Schon, R., Ottisova, L., Mason, C., et al. (2018). The impact of immigration detention on mental health: a systematic review. BMC Psychiatry, 18(1), 382. https://doi.org/10.1186/s12888-­018-­1945-­y Vu, A., Adam, A., Wirtz, A., Pham, K., Rubenstein, L., Glass, N., Beyrer, C., & Singh, S. (2014). The prevalence of sexual violence among female refugees in complex humanitarian emergencies: A systematic review and meta-analysis. PLoS Currents, 6. https://doi.org/10.1371/currents.dis.835f10778fd80ae031aac12d3b533ca7 Wachter, K., Horn, R., Friis, E., Falb, K., Ward, L., Apio, C., Wanjiku, S., & Puffer, E. (2018). Drivers of intimate partner violence against women in three refugee camps. Violence Against Women, 24(3), 286–306. https://doi.org/10.1177/1077801216689163 Wako, E., Elliott, L., De Jesus, S., Zotti, M. E., Swahn, M. H., & Beltrami, J. (2015). Conflict, displacement, and IPV: findings from two Congolese refugee camps in Rwanda. Violence Against Women, 21(9), 1087–1101. https://doi.org/10.1177/1077801215590669 Walker, S., von Werthern, M., Brady, F., & Katona, C. (2021). Mental health of forced migrants recently granted leave to remain in the United Kingdom. The International Journal of Social Psychiatry, 67(2), 188–196. https://doi.org/10.1177/0020764020939610 Wanigaratne, S., Cole, D. C., Bassil, K., Hyman, I., Moineddin, R., & Urquia, M. L. (2016). The influence of refugee status and secondary migration on preterm birth. Journal of Epidemiology and Community Health, 70(6), 622–628. Weaver, H., & Roberts, B. (2010). Drinking and displacement: A systematic review of the influence of forced displacement on harmful alcohol use. Substance Use & Misuse, 45, 2340–2355. https://doi.org/10.3109/10826081003793920 Weiler, G., Bartovic, J., Bischoff Ebbesen, B., Gottardo, G., & Puthoopparambil, S.  J. (2022). Improving health in immigration detention and promoting alternatives to detention. Lancet, 399(10338), 1849–1850. https://doi.org/10.1016/S0140-­6736(22)00742-­5

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Wells, R., Steel, Z., Abo-Hilal, M., Hassan, A.  H., & Lawsin, C. (2016). Psychosocial concerns reported by Syrian refugees living in Jordan: systematic review of unpublished needs assessments. The British Journal of Psychiatry, 209(2), 99–106. https://doi.org/10.1192/bjp. bp.115.165084 Wong, J., & Bouchard, J. (2021). Preventing intimate partner violence: a formative evaluation of an intervention programme serving immigrants, refugees and visible minority men. Journal of Gender-Based Violence, 5(2), 331–347. https://doi.org/10.1332/239868020X16082303077492 World Health Organization. (2012). Understanding and addressing violence against women: Intimate partner violence. Retrieved from http://www.who.int.proxy.library.uu.nl/reproductivehealth/publications/violence/en/index.htm World Health Organization. (2018). ICD-11: International Classification of Diseases 11th revision. Retrieved from http://www.who.int/classifications/icd/revision/en/. Xiu, D., Maercker, A., Yang, Y., & Jia, X. (2017). Prolonged grief, autobiographical memory, and its interaction with value orientations in China and Switzerland. Journal of Cross-Cultural Psychology, 48(9), 1369–1388. https://doi.org/10.1177/0022022117723529 Yanni, E. A., Naoum, M., Odeh, N., Han, P., Coleman, M., & Burke, H. (2013). The health profile and chronic diseases comorbidities of US-bound Iraqi refugees screened by the International Organization for Migration in Jordan: 2007-2009. Journal of Immigrant and Minority Health, 15(1), 1–9. https://doi.org/10.1007/s10903-­012-­9578-­6 Yehuda, R., Hoge, C.  W., McFarlane, A.  C., Vermetten, E., Lanius, R.  A., Nievergelt, C.  M., Hobfoll, S. E., Koenen, K. C., Neylan, T. C., & Hyman, S. E. (2015). Post-traumatic stress disorder. Nature Reviews. Disease Primers, 1, 15057. Yun, K., Hebrank, K., Graber, L. K., et al. (2012). High prevalence of chronic non-communicable conditions among adult refugees: implications for practice and policy. Journal of Community Health, 37, 1110–1118. https://doi.org/10.1007/s10900-­012-­9552-­1 Yuval, K., Aizik-Reebs, A., Lurie, I., Demoz, D., & Bernstein, A. (2020). A functional network perspective on posttraumatic stress in refugees: implications for theory, classifcation, assessment, and intervention. Transcultural Psychiatry, 58(2), 268–282. 1363461520965436. Yuval, K., & Bernstein, A. (2017). Avoidance in posttraumatic stress among refugee survivors of violent conflict and atrocities: testing trans-cultural risk processes and candidate intervention targets. Behaviour Research and Therapy, 99, 157–163. Zettl, M., Akin, Z., Back, S., Taubner, S., Goth, K., Zehetmair, C., Nikendei, C., & Bertsch, K. (2022). Identity development and maladaptive personality traits in young refugees and firstand second-generation migrants. Frontiers in Psychiatry, 12, 798152. https://doi.org/10.3389/ fpsyt.2021.798152 Zwi, K., Mares, S., Nathanson, D., Tay, A. K., & Silove, D. (2018). The impact of detention on the social–emotional wellbeing of children seeking asylum: A comparison with community-based children. European Child & Adolescent Psychiatry, 27(4), 411–422. https://doi.org/10.1007/ s00787-­017-­1082-­z Zwi, K., Sealy, L., Samir, N., Hu, N., Rostami, R., Agrawal, R., Cherian, S., Coleman, J., Francis, J., Gunasekera, H., Isaacs, D., Larcombe, P., Levitt, D., Mares, S., Mutch, R., Newman, L., Raman, S., Young, H., Norwood, C., & Lingam, R. (2020). Asylum seeking children and adolescents in Australian immigration detention on Nauru: A longitudinal cohort study. BMJ Paediatrics Open, 4(1), e000615. https://doi.org/10.1136/bmjpo-­2019-­000615

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Mental Health of Refugee Minors

2.1 Introduction Children younger than 18 years old represent more than half of total refugees worldwide (United Nations High Commissioner for Refugees, 2019). Refugee children are highly vulnerable individuals exposed to poverty, discrimination, social exclusion, exploitation, forced repatriation, and associated health risks (e.g., Kienzler et al., 2018). Not surprisingly, children and adolescents represent the most at-risk group of refugees for getting mental health problems (Brown et al., 2017). Having witnessed terrible events of war, including viewing people being tortured, hurt, or even murdered, often experiencing uncertainty of residential status, refugee children often feel not welcome in the host country due to stigmatization and becoming victims of problematic living conditions (Earnest et al., 2015). In addition, schooling is disrupted, and educational opportunities decrease (Alexander et al., 2010). Further, refugee children may worry about the family in the home country, who might have been murdered. Adolescent refugees from Afghanistan, Iraq, and Syria often have ambivalent feelings between the culture of their homeland and the Western culture. All these factors may increase the risk of developing psychological disorders (Groen et al., 2017).

2.2 Prevalence of Mental Disorders Child refugees are more at risk of developing mental problems than adult refugees. Accompanied and unaccompanied refugee children and adolescents have a high vulnerability for mental health problems (Betancourt et  al., 2015; Bronstein & Montgomery, 2011; van Os et al., 2016). Refugee and asylum seeker children have high rates of post-traumatic stress disorder, depression, and anxiety (Ellis et  al., 2008; Fazel et al., 2012; Blackmore et al., 2020). It should be noted, however, that most studies fail to distinguish between (1) male and female, (2) accompanied and © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 P. M. G. Emmelkamp, Mental Health of Refugees, https://doi.org/10.1007/978-3-031-34078-9_2

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unaccompanied, and (3) younger and older children/adolescents in terms of factors linked with their mental health (Mahadevan & Jayasinghe, 2022; Pritchard et al., 2020). Establishing a reliable psychological diagnosis remains difficult in children, not only because children tend to exhibit various symptoms rather than fulfilling specific diagnostic criteria, but also because there is no specific screening tool currently recommended for child refugees. Studies conducted among refugee adolescents from Syria at schools in Istanbul indicated that the prevalence of a probable post-­ traumatic stress disorder diagnosis ranged from 18% to 51% and that rates of depression ranged between 27% and 48% and for anxiety between 30% and 69% (reviewed by Uysala et al., 2022). Refugee and asylum seeker children and adolescents have high rates not only of post-traumatic stress disorder, depression, and anxiety, but also of externalizing disorders (e.g., ADHD and conduct disorder). In a meta-analysis, involving 17 studies and nearly 8000 children, prevalence rates of post-traumatic stress disorder and depression were 47% and 53%, respectively (Attanayake et al., 2009). In a recent review of prevalence studies in young refugees and asylum seekers in European countries, the prevalence of the investigated psychiatric disorders and mental health problems in children and adolescents varied widely among studies (Kien et al., 2019). The prevalence for post-traumatic stress disorder was between 19.0% and 52.7%, for depression between 10.3% and 32.8%, and for anxiety disorders between 8.7% and 31.6%. For emotional and behavioral problems (e.g., ADHD and conduct disorder), the prevalence varied between 19.8% and 35.0%. Of note, structured clinical interviews using standard diagnostic criteria (e.g., DSM) resulted in lower prevalence than self-report questionnaires. The refugee and asylum-­seeking children and adolescents were to a much greater extent affected by depression, anxiety, and emotional and behavioral problems than native children and adolescents (Kien et al., 2019). Not surprisingly, unaccompanied minors have a higher risk of having post-traumatic stress disorder, anxiety disorders, and depression than accompanied minors. Thus, unaccompanied refugee minors constitute a high-risk group and deserve special attention (Demazure et al., 2017; Fazel et al., 2012; Pejovic-­Milovancevic et al., 2018).

2.3 Unaccompanied Children Unaccompanied children form a particular vulnerable group, because they often are exposed to not only severe traumatic events but also other adverse effects, e.g., the absence of parents, lack of family support, and having to assume “adult responsibilities” at a very early age. In an investigation among homeless newcomer youth in Canada, family conflict and abuse from family were often one of the reasons why young refugees arrived unaccompanied (see Khan et al., 2022). Most unaccompanied refugee minors have experienced one or more life-­ threatening events before or during the flight from their country of origin (Höhne et al. 2023). In addition, most of them have to deal with post-migration stressors, including finding a safe house, dealing with the immigration policy in the host

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country, and experienced discrimination (Li et  al., 2016; Purgato et  al., 2017). Although young people seeking refugee status are allowed to reside in a receiving country until the age of 18, unaccompanied asylum-seeking children are in many countries required to start the asylum process, including having extended asylum interviews. They are afraid of having to return to their home country while waiting for a prolonged period of time for a decision. Of note, a history of neglect, history of sexual abuse, and longer lengths of stay in long-term foster care in the guest country are associated with greater adverse outcomes for unaccompanied children (Hasson et al., 2021). Studies of mental disorders among unaccompanied young refugees reported that the prevalence rates among unaccompanied refugees are higher than among accompanied young refugees (Bean et al., 2007; Barghadouch et al., 2018; El Baba and Colucci 2018; Huemer et al., 2009; Müller et al., 2019; Norredam et al., 2018). In the study of Müller et al. (2019) among accompanied and unaccompanied refugee minors resettled in Germany, 64% of the unaccompanied refugee minors met the diagnostic criteria for post-traumatic stress disorder. In a systematic review (Ali-­ Naqvi et al., 2023) of studies investigating the impact of familial separation among refugee children >15 years and adolescents, it was found that separation from family enhanced the risk not only of post-traumatic stress disorder, depression, and anxiety, but also of intermittent explosive disorder and adult separation anxiety disorder. Mohwinkel et al. (2018) reviewed studies investigating gender differences in refugees in Europe and found that the mental health of female unaccompanied refugee minors was more affected by post-traumatic stress symptoms and depressive symptoms than of male unaccompanied refugee minors. In refugee youth in Sweden, unaccompanied children had an eightfold elevated risk for post-traumatic stress disorder compared to Sweden-born children (Björkenstam et al., 2020). Stress is not limited to traumatic experiences before and during the flight. Refusal of asylum had a rather negative effect on the well-being of unaccompanied refugee minors in a number of longitudinal studies since it results in a situation of instability and fear of return (Hornfeck et al., 2022).

2.3.1 Chronic Trajectory of Mental Health Symptoms A few longitudinal studies have investigated the course of post-traumatic stress over time in unaccompanied young refugees, which studies suggest a chronic trajectory of mental health problems in young unaccompanied refugees. In Norway, mental health of unaccompanied refugee minors reported immediately after arrival in the country did not change over the first 2 years (Jakobsen et al., 2017; Jensen et al., 2014). There was no average change in the level of post-traumatic stress disorder, depression, anxiety, or externalizing problems in this group of unaccompanied refugee children from shortly after arrival to nearly 2 years later (Jensen et al., 2014). There was, however, large variation in change scores. Mental health remained stable among unaccompanied minors who got asylum but became worse among those who were refused asylum (Jensen et al., 2014).

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Two studies revealed that post-traumatic stress did not decrease over a period of one and a half year in the host countries Belgium (Vervliet et al., 2014) and Norway (Jensen et al., 2019), but in a study of Pfeifer et al. (2022), results revealed a small but significant decrease of post-traumatic stress during 27 months in a host country in Europe. In this study, 187 unaccompanied young refugees, of whom more than three-quarters were male, were assessed several times during a period of over 2 years. This study revealed an extremely high trauma load pre- and peri-migration among unaccompanied young refugees. Witnessing and experiencing physical violence was common at any time point during their flight, or in their home country. Sexual violence was reported by at least one-third of the unaccompanied young refugees. Traumatic experiences were highly prevalent, but the number of reported daily stressors and post-traumatic stress scores significantly decreased over time. Female unaccompanied refugees had higher post-traumatic stress scores at baseline than male unaccompanied refugees, but this did not affect the longitudinal trajectory of post-traumatic stress disorder. The premigration trauma load and daily stressors at baseline did not have a significant effect on post-traumatic stress disorder. How can we explain the different findings between the longitudinal studies among unaccompanied young refugees in Norway (Jensen et al., 2019) and Belgium (Vervliet et al., 2014) on the one hand showing that post-traumatic stress remained stable in the course of 18 months post-arrival in the host country, and the study of Pfeiffer et al. which reveals a decrease of post-traumatic stress over time? The studies of Jensen et  al. (2019) and Vervliet et  al. (2014) were conducted with young unaccompanied refugees who had already arrived in their host country, while in the study of Pfeifer et al. (2022), young unaccompanied refugees were “on the move” in several different countries. As noted by Pfeiffer et al., being in transit is associated with unpredictable changes in daily needs and stressors, as well as continuous traumatization, which may lead to living in a “survival mode.”

2.4 Refugee Minors Living with Family Research in high-income countries discussed above primarily studied unaccompanied minors, who reported high level of distress (e.g., El Baba and Colucci 2018; Höhne et al. 2018; Norredam et al., 2018), but less research has been reported on refugee minors living with their families. Rostami et  al. (2022) investigated in Australia the prevalence of child and adolescent mental health problems, and how this is related to resettlement stressors by comparing the mental health of asylum seeker youngsters with the mental health of permanent young refugees or young refugees who had gained temporary protection (up to 5 years). Psychosocial problems of children were assessed with the Strengths and Difficulties Questionnaire (SDQ), measuring not only emotional problems, but conduct problems, hyperactivity-­ inattention, and peer problems as well. Results revealed that asylum seeker youngsters had significantly more mental health problems compared to those with full refugee protection. Thus, the findings revealed that children and adolescents living

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with insecure residency report higher psychosocial problems than age- and languagematched refugees with refugee status resolution. Further, higher post-traumatic stress disorder symptoms of parents were associated with poorer child and adolescent mental health, especially in families with insecure residency.

2.5 Child Marriage Child marriage, involving two persons with at least one of them under 18 years old, is considered a human rights violation by the United Nations (UNFPA, 2020). There is some evidence, however, that the rate of child marriage among refugee children and internally displaced children is increasing due to increased poverty, as well as economic insecurities, which may lead to an increased positive attitude toward child marriage among family members (Indira et al., 2023). A number of studies have shown an increase in child marriage among refugee populations in Jordan and Lebanon (see Gausman et al., 2021; Goers et al., 2022). In 2016, 34% of all marriages of Syrian refugees in Jordan involved a minor, the most common age for girls to marry being 15 years (range 13–20 years). Less educated, poorer females were more likely to marry before the age of 18 years than better educated and wealthier women (Gausman et al., 2021). A quarter of a million Syrian refugees reside in the Kurdistan Region of Iraq. Goers et al. (2022) investigated the rate of child marriages among Syrian refugee children and Iraqi displaced children living in the Kurdistan Region of Iraq. Interviews were conducted in 664 internally displaced Iraqis, 580 Syrian refugee households, and 617 host families. Child marriage was present in all the populations in the study but was highest among Iraqi displaced persons. There was a significant higher rate of child marriages among Iraqi displaced children (12.9%) compared to the rate of child marriage in the host community (9.8%). Lower education and unemployment were associated with a higher rate of child marriage. Refugees from Syria had a lower percentage of child marriage than internally displaced children and the Kurdistan Region of Iraq host population, which may be due to cultural differences between Iraqis and Syrians. However, the risk of child marriage among Syrian refugees was also higher in situations of low education and unemployment of the head of the household compared to the rate of child marriages in the Kurdistan Region of Iraq.

2.6 Resignation Syndrome There is some evidence that young asylum-seeking children may be vulnerable for developing a stuporous condition (“resignation syndrome”). Children with resignation syndrome do not react to any sensory stimulation. In one study (Von Knorring & Hultcrantz, 2020), a rather severe form of this illness was found among young asylum-seeking children in Sweden, most of whom had enuresis/encopresis, and who did not feel touching, cold, or pain and did not react to any question. More than two-thirds of them belonged to an ethnic or religious minority in their homeland.

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Not all children came from war zones, but nearly all were persecuted or had either experienced violence themselves or had witnessed violence against close family members. A number of them had witnessed violence, rape, or killing of other people, and a few children saw a parent try committing suicide. The symptoms started when the child was about 11.5 years (range 9.6–13.2 years) accumulating in falling into stupor at a mean age of 12.9 (range 11.6–14.2 years). One-third of the parent(s) of the children suffered from a mental disorder. Nearly all children suffered from post-traumatic stress syndrome and/or depression before the resignation syndrome developed. Half of the children developed the resignation syndrome by falling into coma after having been present at the meeting with the Migration Board when informed of the coming deportation. The child who fell ill “was usually the one who had been responsible in the family, who often acted as a translator (the oldest or only son), and/or most often the one who had witnessed the most traumatic event in the home country (rape of mother, torture or killing of father)” (Von Knorring & Hultcrantz, 2020, p. 1107). There is a clear need for other studies among young refugees and asylum seekers to investigate the occurrence of this syndrome and the best ways to prevent this. Of note, in ICD-11 (and in DSM-5), stupor is no longer a special diagnosis, but the disorder is named catatonia associated with another mental disorder.

2.7 Executive Functioning Few studies have investigated executive functioning in refugee youth. Executive functioning is cognitive abilities which enable goal-directed behavior consisting of three core executive functioning skills: (1) inhibitory control to control attention, behavior, thoughts, and emotions; (2) working memory to mentally hold and manipulate information; and (3) cognitive flexibility to adjust to changing priorities (Miyake et al., 2000). Given that trauma exposure has been found to be related to poorer executive functioning skills in non-refugee adolescents (see Op den Kelder et  al., 2018), Scharpf et  al. (2022) investigated executive functioning among Burundian youth in three refugee camps. Results revealed that trauma exposure was associated with cognitive flexibility. Post-traumatic stress was related to selective attention and working memory. Higher levels of maltreatment by the mother and mother-child relationship quality resulted in a lower inhibitory control. Although certainly of interest, the findings need to be replicated before they can be generalized to other samples of refugee youth.

2.8 Substance Abuse Migration can be profoundly stressful for youth, due to cultural stressors such as discrimination and a negative context of reception, and—in a number of cases— lack of family members (Schwartz et  al. 2018). Weaver and Roberts (2010) and Posselt et al. (2014) reviewed studies which investigated mental health and drug and

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alcohol problems in young people of refugee background. They concluded that young refugees are at a high risk of developing mental health and substance abuse disorders. This was confirmed in children aged 11–18 years old, residing at refugee centers in the Republic of Serbia (Vasic et al., 2021). Over 50% consumed energy drinks, 13% used alcohol, 4.6% used marijuana, and nearly 2% used other drugs, which is higher than among non-refugee children in Europe (Kraus & Nociar, 2015). Male children more frequently used alcohol or substances than female children. Younger children were less frequently using substances than older children. A substantial number of children experienced post-traumatic stress symptoms as well as emotional and behavioral difficulties, but this was unrelated to alcohol and substance use. There is some evidence that unaccompanied refugee children are at higher risk for substance abuse (Ivert & Magnusson, 2019). Additionally, children of parents who were less well acculturated or integrated than their children appear to have a higher risk of juvenile drug use and misuse (Lemmens et  al., 2017). Although there is some evidence in the United States that youth refugees and asylum seekers use alcohol and drugs at lower rates than US-born youth (Salas-Wright et al., 2016), there is increasing evidence that migration may lead to a higher risk for mental health problems and substance abuse; 48% of youth reported alcohol consumption (Salas-Wright et al., 2020; Salas-Wright et al., 2021). According to the family stress model, parent stress can influence youth mental health and substance use by negatively affecting family functioning. A study by Lorenzo-Blanco et al. (2016) investigated whether a parent acculturation stress factor affects youth mental health and substance use via parent- and youth-reported family functioning among recently arrived Cuban and Mexican immigrant youth (mean age 14.5 years) in the United States. Positive family functioning reported by youth predicted lower symptoms of depression and lower aggressiveness, while parent-reported positive family functioning predicted lower alcohol use of their children. In a study of Lorenzo-Blanco et al. (2019), cultural stressors experienced by youth such as discrimination and the attitude that one is not welcome in the host country predicted lower parent involvement, parental warmth, and family cohesion. Such negative family functioning, on the other hand, predicted substance use in youth.

2.9 Other Psychological Problems The formal mental health disorders described above are not fully representative of the psychological problems children and adolescent refugees experience. In refugee minors, both guilt and shame are often present and related to the severity of post-­ traumatic stress disorder symptoms experienced by them (Stotz et  al., 2015). Further, the formal disorders described above fail to recognize hopelessness, acculturation stress and cultural bereavement, experience of discrimination and bullying, and uncertainty about the future which many refugee youngsters experience. Presumably, the COVID-19 pandemic has had additional negative influence on psychological adjustment and the mental health of young asylum seekers and

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refugees. The social restrictions and lockdowns to prevent the spread of SARSCoV-2 with closure of schools and isolation from peers led to increased psychological distress and increased levels of anxiety and depressive symptoms in young people (Cost et al., 2022; Ford et al., 2021). Not surprisingly, given the experienced traumas and post-conflict negative experiences in resettlement countries, the COVID-19 pandemic has posed additional burdens on young asylum seekers and refugees. A particular vulnerable group is unaccompanied asylum-seeking children. As noted by Hodes (2022), government-led public health demands such as social distancing and recommendations for vaccination may be understood quite differently by young people who have had negative experiences with abusive government before the flight. In addition, the long waiting lists for Child and Adolescent Mental Health Services in a number of Western countries as a result of the pandemic do not help to refer asylum-seeking youth and young refugees to these services (Benjamen et al., 2021). Not all refugee children and adolescents are equally vulnerable for mental health problems. There is considerable evidence that parenting behavior in times of war affects child adjustment (Eltanamly et  al., 2021), which may have long-lasting effects. In a study among immigrants (including refugees) in Canada (Sim & Georgiades, 2022), results showed that negative parenting behavior was consistently associated with higher levels of internalizing and externalizing problems in the child. In addition, parental trauma exposure and parental distress were associated with higher levels of internalizing and externalizing problems in the child as well. Results showed that living in a neighborhood with immigrants of similar socioeconomic, ethno-cultural, or migration backgrounds had a protective effect by enhancing social support.

2.10 Negative and Protective Factors There is some research which reveals that certain protective factors may mitigate adverse effects of traumatic events.

2.10.1 Parenting Behavior and Social Support Not all refugee children and adolescents are equally vulnerable for mental health problems. There is considerable evidence that parenting behavior in times of war affects child adjustment (Eltanamly et  al., 2021), which may have long-lasting effects. In a study among immigrants (including refugees) in Canada (Sim & Georgiades, 2022), results showed that negative parenting behavior was consistently associated with higher levels of internalizing and externalizing problems in the child. In addition, parental trauma exposure and parental distress were associated with higher levels of internalizing and externalizing problems in the child as well. Results showed that living in a neighborhood with immigrants of similar socioeconomic, ethno-cultural, or migration backgrounds had a protective effect by

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enhancing social support. Immigrant children living in neighborhoods with a high level of immigrant concentration had fewer externalizing problems.

2.10.2 Attachment One other protective factor is attachment security (O’Connor & Elklit, 2008; Okello et al., 2014; Riber, 2016). Exposure to multiple traumas in childhood often results in developmental psychopathology. There is some evidence, however, that this is moderated by the quality of the child’s attachment to the primary caregivers (e.g., Jonsson, 2009; Solomon & George, 2011). Some studies reveal that unresolved attachment may be involved in dissociation, post-traumatic stress, anxiety, and depression (Bizzi et al., 2015; Ogle et al., 2015). Attachment theory suggests that very early on in life we form internal working models about how reliable, responsive, and understanding our caregiver is (Bowlby, 1973, 1982). Attachment becomes active when we experience separation or threat of loss from significant others and during times of stress, frustration, or anger. Attachment leads humans to “... remain in a familiar locale and among familiar people” (Bowlby, 1973, p. 147). Asylum seekers and refugees often have to leave their family. In addition, they have to make contact and bonds with new people in the host country, which suggests that attachment style might be important for adjustment of asylum seekers and refugees to new social situations in the host country. There is considerable evidence that family separation in young refugees has considerable impact on children’s attachment security with serious consequences on their well-being (Venta & Cuervo, 2022). Traumatic experiences activate one’s attachment insecurity system and disrupt behavioral, affective, and interpersonal responses. After exposure to traumatic experiences, secure attachment appears to serve as a stress-regulation resource that decreases the risk of post-traumatic stress disorder (Lim et al., 2020; Woodhouse et al., 2015). There is also some evidence that complex traumas can modify secure attachment (Besser & Neria, 2010). Caregivers’ sensitivity to distress appears to be an important differentiating factor that impacts attachment styles. Unavailability and unsupportiveness of attachment figures, which are often the case in refugee minors, hinder the development of a sense of security, so that the self and other representations are negatively depicted, and less secure attachment orientations (avoidance and anxiety) are formed. Generally, four attachment statuses are recognized: one is secure attachment, and the other three are insecure and are called dismissive, preoccupied, and unresolved. They are called attachment representations, or states of mind with respect to attachment by clinical and developmental psychologists (Arrindell et al., 1983; de Haas et al., 1994; van Ecke et al., 2005). In the case of secure attachment, the individual has received consistent, sensitive caregiving and later tends to respond in confident and flexible ways to ourselves and others. Unresolved attachment results from threats of being abandoned, hurt, or ignored by the attachment figures when they are most needed (van Ecke et al., 2005).

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Individuals with an unresolved attachment representation seem to have the highest risk for adverse outcomes after traumatic experiences (Bizzi et al., 2015; Genc and Arslan 2022; Liotti, 2006; van Ecke, 2006), which might be relevant for refugees and asylum seekers. In one study investigating whether immigration was associated with attachment style, the immigrant group had a significantly higher proportion of individuals with unresolved attachment representation than adults who were still living near their family of origin in the area where they were born (van Ecke et al., 2005). Other studies indicate that attachment styles are related to immigrants’ adjustment (Bakker et al., 2004; Polek et al., 2008; Polek et al., 2010; Santa-Maria & Cornille, 2007). There is some evidence that attachment styles may be even better predictors of adjustment than the Big Five personality traits (Bakker et al., 2004). In this study, the attachment scales were able to explain variance in sociocultural adjustment beyond that explained by the Big Five dimensions. These studies, however, involve immigrants rather than asylum seekers and refugees. Secure attachment represents the importance of a person’s ability to call upon mental representations of safety and security provided by close relationship partners earlier in life (Mikulincer & Shaver, 2007). Secure attachment may downregulate anxiety and thus may prevent the development of post-traumatic stress disorder. Although attachment security contributes to resilience in times of stress, a series of studies of Mikulincer et al. (2014) on Israeli ex-victims (prisoners of war) of the Yom Kippur War investigated associations between trajectories of post-traumatic stress disorder and disruptions in the regulatory functions of the attachment system. As compared to controls, former prisoners of war with persistent post-traumatic stress disorder over a 17-year period exhibited highly significant disruptions in attachment security representations. These disruptions were not evident among former prisoners of war with a stable resilience trajectory. According to the authors, the findings result from a reciprocal, recursive, and amplifying cycle of post-traumatic stress disorder and attachment insecurity over time. There is some evidence that adolescent refugees who are securely attached may have greater resilience in the face of traumatic events than refugees with insecure attachment styles (Bettmann & Olson-Morrison, 2020). A recent study of Sleijpen et  al. (2022) investigated changes in avoidance and anxiety attachment patterns among 918 unaccompanied refugee minors (82% male, mean age 18.6 years) after resettlement in Norway. 82% were male, and the mean age was 18.6  years (SD  =  2.61). Most unaccompanied minors revealed rather stable attachment patterns over time.

2.10.3 Violence in Host Country As discussed above there is considerable evidence that young refugees become victims of sexual exploitation and are vulnerable to gender-based violence. Violence, including being discriminated and being bullied adversely, affects the mental health of refugee children, but social relationships including friendship quality and number of friends play an essential protective role (Samara et al., 2020).

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It is generally assumed that refugee children and adolescents who are enabled to go to schools in the host country have less risk of developing mental problems than youngsters who do not go to school. Although there is evidence that greater attachment and supportive relationships in schools may protect against the development of anxiety problems and depressed mood in refugee children (e.g., Kia-Keating & Ellis, 2007) and may enable children to develop humanitarian values (Turhan & Akgül, 2017), this does not apply to all schools affiliated with refugee camps. A study of Fabbri et  al. (2022) among a representative sample of Congolese and Burundian refugee children in one of the largest refugee camps in the world (Nyarugusu Refugee Camp in Tanzania) revealed that refugee children in schools were exposed to high levels of violence not only from other children, but from teachers as well. Nearly half of the refugee children experienced physical violence from teachers in the past week. Children at schools also had an enhanced risk of sexual abuse or sexual violence from teachers or peers.

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Samara, M., El Alsam, A., Khadaroo, A., & Hammuda, S. (2020). Examining the psychological well-being of refugee children and the role of friendship and bullying. The British Journal of Educational Psychology, 90(2), 301–329. Santa-Maria, M.  L., & Cornille, T. (2007). Traumatic stress, family separations, and attachment among Latin American immigrants. Traumatology, 13, 26–31. https://doi. org/10.1177/1534765607302278 Scharpf, F., Kaltenbach, E., Nickerson, A., et al. (2021). A systematic review of socio-ecological factors contributing to risk and protection of the mental health of refugee children and adolescents. Clinical Psychology Review, 83, 101930. https://doi.org/10.1016/j.cpr.2020.101930 Scharpf, F., Mueller, S. C., & Hecker, T. (2022). The executive functioning of Burundian refugee youth: Associations with individual, family and community factors. Journal of Applied Developmental Psychology, 80, 101399. Schwartz, S. J., Salas-Wright, C. P., Pérez-Gómez, A., Mejía-Trujillo, J., Brown, E. C., Montero-­ Zamora, P., Meca, A., Scaramutti, C., Soares, M. H., Vos, S. R., Javakhishvili, N., & Dickson-­ Gomez, J. (2018). Cultural stress and psychological symptoms in recent Venezuelan immigrants to the United States and Colombia. International Journal of Intercultural Relations, 67, 25–34. https://doi.org/10.1016/j.ijintrel.2018.09.001 Sim, A., & Georgiades, K. (2022). Neighbourhood and family correlates of immigrant children’s mental health: a population-based cross-sectional study in Canada. BMC Psychiatry, 22, 447. https://doi.org/10.1186/s12888-­022-­04096-­7 Sleijpen, M., Keles, S., Mooren, T., & Oppedal, B. (2022). Attachment insecurity in unaccompanied refugees: a longitudinal study. International Journal of Migration, Health and Social Care, 18(1), 66–82. https://doi.org/10.1108/IJMHSC-­05-­2021-­0045 Solomon, J., & George, C. (2011). Disorganized attachment and caregiving. Guilford Press. Stotz, S. J., Elbert, T., Muller, V., & Schauer, M. (2015). The relationship between trauma, shame, and guilt: findings from a community-based study of refugee minors in Germany. European Journal of Psychotraumatology, 6, 25863. https://doi.org/10.3402/ejpt.v6.25863 Turhan, M., & Akgül, T. (2017). The relationship between perceived school climate and the adolescents’ adherence to humanitarian values. Universal Journal of Educational Research, 5, 357–565. UNFPA. (2020). Child marriage. Retrieved from https://www.unfpa.org/child-­marriage. United Nations High Commissioner for Refugees (UNHCR). (2019). Global appeal 2018–2019. Retrieved from http://www.unhcr.org/en-­au/publications/fundraising/5a0c05027/unhcr-­global-­ appeal-­2018-­2019-­full-­report.html. Uysala, B., Yanika, M., Tasteknea, F., Tuzgena, E., Altinisika, E., & Acarturk, C. (2022). Psychological problems and resilience among Syrian adolescents exposed to war. European Journal of Trauma & Dissociation, 6(3), 100258. van Ecke, Y. (2006). Unresolved attachment among immigrants: An analysis using the adult attachment projective. The Journal of Genetic Psychology, 167(4), 433–442. https://doi.org/10.3200/ GNTP.167.4.433-­442 van Ecke, Y., Chope, R.  C., & Emmelkamp, P.  M. G. (2005). Immigrants and attachment status: Research findings with Dutch and Belgian immigrants in California. Social Behavior and Personality: An International Journal, 33(7), 657–674. https://doi.org/10.2224/ sbp.2005.33.7.657 van Os, E. C., Kalverboer, M. E., Zijlstra, A. E., Post, W. J., & Knorth, E. J. (2016). Knowledge of the unknown child: a systematic review of the elements of the best interests of the child assessment for recently arrived refugee children. Clinical Child and Family Psychology Review, 19(3), 185–203. Vasic, J., Grujicic, T., & O. & Pejovic Milovancevic M. (2021). Mental health, alcohol and substance use of refugee youth. Frontiers in Psychiatry. https://doi.org/10.3389/fpsyt.2021.713152 Venta, A., & Cuervo, M. (2022). Attachment, loss, and related challenges in migration. Current Opinion in Psychology, 47, 101406.

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Vervliet, M., Lammertyn, J., Broekaert, E., & Derluyn, I. (2014). Longitudinal follow-up of the mental health of unaccompanied refugee minors. European Journal of Child and Adolescent Psychiatry, 23(5), 337–346. Von Knorring, A.-L., & Hultcrantz, E. (2020). Asylum-seeking children with resignation syndrome: catatonia or traumatic withdrawal syndrome? European Child & Adolescent Psychiatry, 29, 1103–1109. https://doi.org/10.1007/s00787-­019-­01427-­0 Weaver, H., & Roberts, B. (2010). Drinking and displacement: A systematic review of the influence of forced displacement on harmful alcohol use. Substance Use & Misuse, 45, 2340–2355. https://doi.org/10.3109/10826081003793920 Woodhouse, S., Ayers, S., & Field, A.  P. (2015). The relationship between adult attachment style and posttraumatic stress symptoms: A meta-analysis. Journal of Anxiety Disorders, 35, 103–117. https://doi.org/10.1016/j.janxdis.2015.07.002

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Social Support and Resilience: Impact on Mental Health

3.1 Introduction Most of the research on mental health among refugees has predominantly been on negative psychological consequences of the refugee process such as post-traumatic stress, anxiety, and depression. As discussed in Chap. 1, premigration factors (e.g., traumatic experiences; having to leave family), stressors along the migration journey (e.g., harsh conditions, violence), and post-migration factors (e.g., difficulties with language, discrimination, lack of social support, unemployment) have an impact on the (mental) health of asylum seekers and refugees (George et al., 2015; Siriwardhana et al., 2014). However, not all refugees and migrants are equally vulnerable to develop mental health or health problems as a result of such life-­ threatening situations and a number of traumatic experiences prior to and during the process of flight or afterwards during resettlement. Despite all sorts of negative experiences before, during, and after the flight, it is important to know that a substantial proportion of this population does not develop mental disorders (Giacco et al., 2018; Giacco & Priebe, 2018; Lenferink et al., 2022; Purgato et al., 2022; van der Boor et al., 2020) and that a substantial number of refugees are able to rebuild their lives (Blackmore et al., 2020a). In the study of Purgato et al. (2022), lower well-being was predicted by the murder of family member, having been kidnapped, close to death experiences, and being longer than 2 years in the host country. Taken together results of the studies discussed, there is evidence that a number of refugees have the capacity to adapt positively to the situation in the host country despite the prolonged exposure to traumatic experiences. As suggested by Guichard (2020), some self-selection mechanisms may be involved whereby individuals with particular strengths and resources are more likely to risk flight, such as a higher level of education as reported among Syrian and Iraqi refugees in Germany. The need for research and clinical practice to incorporate a strength-based rather than deficit-based view on refugee experiences is increasingly acknowledged. This strength-based view emphasizes the concept of resilience, which refers to good © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 P. M. G. Emmelkamp, Mental Health of Refugees, https://doi.org/10.1007/978-3-031-34078-9_3

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mental health and developmental outcomes, despite exposure to high adversity (Bonanno et  al., 2015; Helmreich et  al., 2017; Shen et  al., 2021; Simich & Andermann, 2014).

3.2 Resilience Resilience has been defined as “the ability to withstand, adapt to, and recover from adversity and stress. It manifests as maintaining or returning to one’s original state of mental health or well-being … and well-developed state of mental health or well-­ being through the use of effective coping strategies” (United States Department of Health and Human Services, 2018). Higher levels of resilience may prevent mental health problems, not only in adults, but also in youth (Fritz et al., 2018). After exposure to potentially traumatic experiences, many older adults show psychological resilience (Nuccio & Stripling, 2021), but whether this is also the case with older refugees is unclear. Few studies have investigated mental health resilience in refugees and asylum seekers (Schlechter et al., 2021).

3.2.1 Social Identity Evidence suggests that social identities, which provide purpose and a sense of belonging to the social world, may enhance resilience against psychological stressors (Brance et al., 2023). For example, a few studies (Çelebi et al., 2017; Smeekes et  al., 2017) with Syrian refugees revealed that increased Syrian identification derived from the sense of belonging to the Syrian community and the perseveration of this identity after migration was associated with less symptoms of common mental disorders (i.e., depression and anxiety). In a meta-analysis of Brance et al. (2023) which investigated the influence of group memberships and sense of belonging on ethnic minority and migrant mental problems, increased ethnic or social identification was associated with lower psychological symptoms of depression and anxiety, but the effect sizes were small. The authors suggest that interventions to enhance social connectedness and memberships with groups might help migrants and refugees to maintain the existing groups, while at the same time helping them identify with new social groups within the host country (Brance et al., 2023).

3.2.2 Loss of Social Support One potential resilience-enhancing factor in refugees and asylum seekers is loss of social support, which is related to mental health problems among refugees (Chen et  al., 2017). For many refugees, their usual social support network is distorted, resulting in increased risk of mental health problems not only in adults (Bogic et al., 2015; Chen et  al., 2017; Hynie, 2018; Schlechter et  al., 2021; Schweitzer et  al., 2006), but in young refugees as well (Montgomery, 2010). Given these findings,

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actively supporting refugees to build social networks could reduce psychological distress. Longitudinal studies among refugees are needed to investigate whether this would indeed lead to enhanced social support and less mental health problems (Schlechter et al., 2021). In a number of refugees, religious faith may be another potential resilience-­ enhancing factor, not only in adults (Al Akash & Boswall, 2014; Leaman & Gee, 2012; Sleijpen et al., 2016), but in youth as well (Reed et al., 2012). Although the evidence is limited yet, there are a few studies which suggest that religious faith may be a protective factor from psychological distress in a number of refugees (Molsa et al., 2017; Schweitzer et al., 2007). However, a study of Schlechter et al. (2021) revealed that religious faith was protective for refugees but not beyond social support and resilience.

3.3 Post-traumatic Growth Some studies have shown that a number of persons report experiencing positive psychological changes after traumatic events. Post-traumatic growth describes the experience of individuals whose development has surpassed what was present before the traumata were experienced: “... The individual has not only survived, but has experienced changes that are viewed as important, and that go beyond what was the previous status quo” (Tedeschi & Calhoun, 2004, p. 4). These benefits reported by people who have lived through traumatic experiences include better relationships with others, a sense of increasing personal strength, positive spiritual change, and improved meaning of life (User, 2015). Personal growth after adversity has been studied in a range of different contexts and samples (Calhoun & Tedeschi, 2014; Helgeson et al., 2006; Laceulle et al., 2015; Meyerson et al., 2011). Recently, the conceptualization of personal growth following adversity has been refined as a positive personality change including change in identity and change in the Big Five personality traits (Blackie et al., 2017). The Big Five personality traits include Neuroticism (proneness of the individual to experience unpleasant and disturbing emotions and to have corresponding disturbances in thoughts and actions); Extraversion (preference for social interactions and lively activity); Openness to Experience (receptiveness to new ideas, approaches, and experiences); Conscientiousness (organization and achievement motivation); and Agreeableness (altruism, and trust in relationships). There is some evidence that all Big Five personality factors except neuroticism are associated positively with post-traumatic growth. Most evidence, however, supports the association between extraversion and openness of experience on the one hand and post-traumatic growth on the other (Calhoun & Tedeschi, 2014; Garnefski et al., 2008; Măirean, 2016). In a study with refugee youth in Georgia (Panjikidze et  al., 2020), the main predictors of post-­ traumatic growth were extraversion, conscientiousness, and social support. In nationally representative samples of US military veterans (Fontana & Rosenheck, 1998; Campbell et al., 2018), a number of psychological benefits after traumatic experiences in war were reported. Reviews of studies on post-traumatic

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growth in the military (Habib et al., 2018; Mark et al., 2018) revealed that in about half of the studies, a higher level of combat exposure was related to post-traumatic growth. These positive psychological changes have also been found among holocaust survivors (Lurie-Beck et al. 2008), individuals exposed to terrorism (BayerTopilsky et al., 2013), and survivors of interpersonal violence (Elderton et al., 2017).

3.3.1 Post-traumatic Growth in Refugees and Asylum Seekers Asylum seekers and refugees are disproportionately affected by cumulative potentially traumatic events including armed conflict, near-death experiences, and torture, which experiences not only enhance significant distress, but may also violate the assumptions of refugees and asylum seekers about themselves and their place in the world (ter Heide et al., 2017). Yet, despite the extreme and cumulative nature of trauma in refugees and asylum seekers, studies have shown that refugees may also experience post-traumatic growth (Chan et al., 2016), but research is limited. In a study conducted in Norway, refugees reported an association between post-­ traumatic stress disorder and post-traumatic growth (Teodorescu et al., 2012): post-­ traumatic growth made the strongest contribution to the physical, psychological, and environmental quality of life in refugees who had experienced many severe traumatic situations. Also in other studies, a positive correlation was found between post-traumatic growth and severity of exposure to past traumatic experiences (Baumann, 2018; Hussain & Bhushan, 2011; Powell et al., 2003; Liu et al., 2017). However, in a study of Lee et al. (2022), a higher number of traumatic experiences was not associated with post-traumatic growth in refugees living in South Korea who came from North Korea. The different results of these studies may be explained by results of a study of Chan et al. (2016), who found that trauma exposure and post-traumatic growth may have an inverse U-shaped relationship, with refugees who experienced a moderate level of trauma showing the highest level of post-traumatic growth (Chan et  al., 2016). Thus, the dose–response relationship which posits an association between event magnitude and clinical outcome could explain to which extent refugees experience growth following traumatic experiences. The role of coping in post-traumatic growth may be of some interest. In a study of Ersahin (2022) on Syrian refugees, maladaptive coping (e.g., behavioral disengagement or denial) negatively predicted post-traumatic growth. On the other hand, positive coping enhanced post-traumatic growth. In a study of Acar et al. (2021), it was investigated whether traumatic experiences, post-migration stressors, and coping strategies were associated with post-traumatic growth of Syrian refugees living in Turkey. Results from structural equation modeling revealed that past traumatic experiences and post-migration stressors were only indirectly related to post-­ traumatic growth. They did not find a significant direct effect of past traumatic experiences on post-traumatic growth with respect to the dose–response relationship in their model. This may be due to the relatively low severity of trauma exposure experienced by the Syrian refugees in their study, which might be explained by the length of stay in Turkey; the average length of stay was 5.5  years. Interestingly,

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refugees who were exposed to past traumatic experiences were more likely to use more problem-focused and emotion-focused coping strategies which predicted higher levels of post-traumatic growth. Further, post-migration stressors were found to positively predict the use of maladaptive coping strategies such as denial and avoidance among Syrian refugees, which resulted in low levels of post-­ traumatic growth. Qualitative studies of López-Fuentes and Calvete (2015) on Spanish victims of intimate partner violence and Njie-Carr et al. (2021) on women who immigrated from Africa, Asia, and Latin America used a grounded theory approach to investigate whether intimate partner violence led to resilience in immigrants and refugees in abusive relationships. In a number of these women, profound coping skills and resilience were shown by their capacity to use religion, self-reliance, optimism, control over one’s life, and other protective factors such as accessing needed resources and support. López-Fuentes and Calvete (2015) found that the women who recovered from adversity or trauma had higher resiliency levels than individuals who did not recover. Given the relationship between resilience and post-traumatic growth on the one hand and reduced mental problems on the other, development of programs to sensitize refugees about the importance of personal growth may help to increase their ability to withstand adversities associated with the flight and resettlement. Based on coping studies conducted so far with refugees, it is tempting to assume that such interventions should focus on problem-focused and emotion-focused coping (Acar et al., 2021). Last but not least, it should be acknowledged that while post-traumatic growth may be aligned with positive well-being for some people, for others, post-­ traumatic growth may be a coping strategy to minimize distress, but may not lead to actual positive improvements in well-being.

3.4 Resilience in Children and Adolescents Resilience in children and adolescence is differently defined in publications. Resilience is often considered as a complex interplay of biological, psychological, social, and cultural factors that influence how an individual responds to stressful life events. Resilience-related factors include (1) individual characteristics of the child (e.g., genetics, personality); (2) interpersonal relationships in which the child is involved (e.g., family, school); (3) the social structures indirectly affecting the child’s development (e.g., social services); and (4) cultural values, norms, and beliefs (see Bronfenbrenner, 1979; Ungar et al., 2013). The lack of a consistent conceptualization of resilience in youth, however, did not lead to a clear definition (Anderson & Priebe, 2021). In their literature review, Anderson and Priebe (2021) found some evidence that in addition to a number of youth who might be able to adapt from traumatic experiences by recovering and experiencing either resilience or vulnerability as a result, “... perhaps some people are resistant to adversity entirely” (p. 693). There is, however, also some evidence that a number of refugee children and adolescents are highly adaptive in the new

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situation and psychological resilient (Carlson et al., 2012). In order to foster resilience in refugee children, it is important that they learn the language of the host country (Earnest et al., 2015; Weine et al., 2014), have adequate housing (Kanji & Cameron, 2010), go to school, and have access to (mental) health care.

3.4.1 Refugee Youth A number of studies have investigated resilience in children and adolescents in areas of armed conflict. In a study in Denmark among young refugees, mostly with Iraqi or Iranian nationality, about 75% had clinically significant mental problems after arrival (Montgomery, 2010). Nine years later, however, the prevalence of mental disorders was reduced to about 25%. The majority of studies have investigated resilience by assessing if putative protective variables are associated with lower rates of post-traumatic stress disorder, depression, and externalizing symptoms. Tol et al. (2013) reviewed studies which focused on school-aged children and adolescents in the Middle East (primarily in occupied Palestinian territories) and in the former Yugoslavia. Studies focused on protective factors at various socio-ecological levels (individual, family, peer, school, and community levels). Given that the studies investigated whether different variables were related to resilience, no general conclusion can be drawn with respect to which variable predicts resilience in children and adolescents living in areas of armed conflict. As concluded by the authors, resilience is a “... a complex dynamic process driven by time- and context-dependent variables, rather than the balance between risk and protective factors with known impacts on mental health” (Tol et al., p. 445). In more recent reviews (Pieloch et al., 2016; Rodriguez & Dobler, 2021), a number of factors were investigated which may promote resilience in refugee children at the individual, family, school, community, and societal levels. Despite their different cultural contexts and migratory experiences, the following factors were found to promote resilience: positive early family relationships, pro-social behavior, social support from friends and community, sense of belonging, engagement in education, optimism, connection to family and home culture, and integration of own and new culture (acculturation, see below). Based on these reviews, Rodriguez and Dobler (2021) conclude that there is a strong need specially for unaccompanied minor refugees to focus on enhancing social networks, including connectedness with positive relationships in the home country, and promoting integration of old and new cultural values. A study of Sleijpen et  al. (2019) examined whether individual resilience can protect young refugees (12–17 years) from the negative effects of trauma exposure. Adolescent refugees and adolescent non-refugees did not differ in their levels of individual resilience. The moderating effects of individual resilience on the relationship between exposure to trauma and mental health problems were mixed. Only in

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the non-refugee control group was a small positive effect of resilience found, not in the refugees. Adolescent refugees are often subject to discrimination and experience negative impacts of discrimination on mental health (Ziersch et  al., 2020). In a study of McEwen et al. (2022), adolescent refugees who reported experiencing high levels of discrimination combined with high levels of moral injury had even poorer mental health. For adolescent refugees with high levels of moral injury, discrimination experiences may reinforce appraisals that contradict deeply held moral beliefs and expectations. Interestingly, however, resilience may play a protective role. In this study, high levels of resilience appeared to buffer the association between moral injury and greater internalizing symptoms in adolescent refugees, whereas for adolescents with low levels of resilience, high moral injury was associated with greater internalizing symptoms. Laufer et al. (2022) investigated resilience among young adult refugees and asylum seekers in Germany who fled from war zones as teens, most of them arriving from Afghanistan and Syria and half of them coming to Germany unaccompanied. A high level of post-traumatic stress and depression was found among these youngsters. There was no association between traumatic events before or during migration and resilience or quality of life, which suggests that experiencing traumatic events did not diminish their ability to be resilient. In a larger study of Dehnel et al. (2022), the role of resilience was investigated in 339 Syrian refugee youth (aged 10–17  years), who had been exposed to trauma, nearly half of them to very severe traumatic events (e.g., being kidnapped, held hostage). The majority of children in this study were female. This sample of refugee children scored rather high on depression, and one-third of them had suicidal ideation. Resilience was found to serve as a strong protective factor against depression, especially social support. The higher the experienced social support, the less likely that the child would report depressed mood. Popham et al. (2022) used data from nearly thousand Syrian refugee children living in Lebanon to identify the proportion of children at low risk for mental health problems over time and to identify predictors of change in risk and resilience 1 year later. One-quarter of the refugee children improved from showing clinical levels of post-traumatic stress, depression, and externalizing behavior problems at baseline to no mental health problems at follow-up 1 year later. Over half of the children were at high risk for mental health problems on both occasions. More than 10% of children deteriorated after 1  year, especially with respect to externalizing disorders, which was higher than in the reviews of Kien et al. (2019) and Blackmore et al. (2020b). Depressive symptoms of parent and quality of the parent–child relationship were predictive of later child mental health problems. A bidirectional relationship between children’s symptoms and social factors was found. There was some evidence for a vicious circle suggesting that emotional and behavioral problems could significantly impact caregiver mental health and parent–child relationship, resulting in increases in harsh parenting, which in turn negatively affected the child (Popham et al., 2022).

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3.4.2 Family Stress Model and Resilience Masarik et al. (2022) developed a conceptual model based on research in the area of family stress, ecological systems, and resilience with respect to stress and resilience pathways during resettlement. Questions addressed are to what extent resettlement stressors contribute to family strain or to youth outcomes over the years after resettlement and which factors are involved in improving these stressor-distress pathways concurrently and in the long run. This model is based on the family stress model (Masarik & Conger, 2017), which may help to understand how environmental stressors influence individual and family functioning over time. In this model, the family stress model is adapted to environmental stressors relevant to the lives of refugee families, both before and during the resettlement process. The model includes stressors experienced prior to resettlement (e.g., religious or ethnic persecution, exposure to war and violence) and stressors that refugees may experience during resettlement (e.g., discrimination, lack of adequate resettlement resources such as housing and employment, and psychological distress of both parents and their children). The adapted family stress model hypothesizes that symptoms of psychological distress experienced by child or parent(s) may affect the family unit, in case of two parents leading to worsening of both the parents’ relationships, as well as of the relationships between parents and their children. It is hypothesized that family distress can influence negative adjustment for youth over time: “... high levels of family distress (as a result of resettlement-related stressors and individual distress) might make it more difficult to succeed in school, foster healthy relationships with peers, or otherwise develop into healthy and happy adults.”

3.5 Mental Health Stigma Stigma has been associated with mental health conditions and is associated with cultural values, norms, and beliefs (Misra et al., 2021). A number of studies revealed negative experiences of mental health stigma, including discrimination, prejudice, and exclusion for individuals from an ethnic minority, including refugees and asylum seekers (Douglass et al., 2022; Yang et al., 2014). This was not limited to the individual with mental health problems, but their family members were also treated negatively and excluded from social contact. The experiences of mental illness stigma may differ, however, which is related to the specific mental health diagnosis, culture, and race (Fox et  al., 2018). Mental health stigma is also associated with substance abuse, which results in hiding substance abuse problems in order to avoid negative consequences for their family (e.g., Horyniak et al., 2016). Immigrants with a Muslim background in the United Kingdom acknowledge that substance abuse is contrary to Islamic values (Valentine et al., 2010).

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3.5.1 Cultural Differences There is clear evidence that mental health stigma leads to a substantial reduction of access to mental health care (Kane et  al., 2019; Lu et  al., 2021; Satinsky et  al., 2019). In a study of Tomasi et al. (2022), predictors of professional help-seeking for mental health problems were investigated among Afghan and Iraqi refugees 5 years post-settlement in Australia. Among the Afghan sample, adults with high psychological distress were more likely to seek assistance from qualified mental health professionals to manage and treat these disorders: older age and female gender were also found to be associated with professional help-seeking. Within the Iraqi sample, however, poor physical health led to mental help support from qualified mental health professionals, while severity of post-traumatic stress disorder led to an increased likelihood of mental help-seeking as well. The association between physical health and professional mental help may be explained by the higher rates of somatic symptoms reported within the Iraqi sample. Probably, when seeking help for physical complaints, mental health services were offered as well. Surprisingly, neither non-trusting that health services would keep information private, nor was experiencing discrimination significantly associated with receiving professional help.

3.5.2 Screening for Mental Health and Cultural Differences A number of studies have compared scores on the Refugee Health Screener-15 (RHS-15) to compare the association between mental health and different cultures and ethnicities. In a study of Hollifield et al. (2013), 11% of refugees from Burma, 28% of refugees from Bhutan, and 51% of refugees from Iraq screened positive for mental health concerns on the RHS-15. In a study of Polcher and Calloway (2016), 54% of the refugees from Iraq who were screened exhibited a positive RHS-15, whereas only 18% of refugees from Bhutan scored positive. The largest study so far compared the results on the RHS-15 screener in refugees from Afghanistan, Bhutan, Burundi, Congo, Cuba, Eritrea, Iraq, Myanmar, Somalia, Sudan, and Syria (Schlaudt et al., 2020). Results indicated that the highest rate of positive screenings was among refugees from Syria, Iraq, and Afghanistan, respectively. In addition, experiencing trauma and torture or witnessing trauma was associated with an increased risk for screening positive (more mental problems) on the RHS-15, which was rather frequent among refugees from Iraq, Sudan, and the Democratic Republic of Congo. The rate of positive scores by Iraqi refugees was nearly identical between the Schlaudt et al. (2020) study (50%), the Hollifield et al. (2013) study (51%), and the Polcher and Calloway (2016) study (54%), which indicates that Iraqi refugees consistently report high levels of mental health distress. In sum, Iraqi individuals exhibit high rates of mental health problems, with refugees from other nations demonstrating lower rates.

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3.6 Social-Cultural Determinants of Mental Health Inequalities Acculturation and adaptation to a new culture have been specifically associated with mental health and well-being. According to Lincoln et al. (2016), research on young Somali refugees resettled in the United States indicates that higher levels of acculturation hassles were associated with higher post-traumatic stress disorder and depression symptoms among individuals with integrated, marginalized, and assimilated acculturation styles. This suggests that the relationship between acculturation styles and mental health outcomes is complex and varies within one refugee group. Acculturation has been defined as a process of cultural and psychological change resulting from contact between two or more cultural groups (Berry, 2019). This two-dimensional model of acculturation investigates both the desire to maintain one’s cultural heritage and the wish to participate in the new society in which they live. According to Berry’s model of acculturation, four main acculturation styles reflect the balance of value that one places on the culture of origin versus the host society: integration (adaptation to the host society while maintaining the culture of origin), assimilation (adaptation to the host society and rejection of the culture of origin), separation (maintaining the original culture while not adopting that of the host society), and marginalization (rejection of both cultures) (see Surkan et  al., 2023). One component of acculturation is the ability to speak the language of the host country. Lack of language skills is a significant predictor of psychological stress among Latino and South Asian refugees residing in Western host countries (e.g., Beiser & Hou, 2001; Chung & Kagawa-Singer, 1993; Kim, 2016). To improve migrant health, some researchers have suggested that conserving cultural traditions and one’s reflection on premigration life need to be balanced with gaining new skills in the host culture (Knipscheer & Kleber, 2007; Udahemuka & Pernice, 2010). In a review of studies investigating education and acculturation according to Berry’s model of acculturation, both integration and assimilation were associated with positive education experiences for refugee and asylum-seeking youngsters (Deslandes et al., 2022; Sheikh & Anderson, 2018).

3.6.1 Discrimination Migrants who are less similar to citizens in their host country in appearance, religious identification, and cultural practices are more likely to become prejudiced and discriminated (Awad, 2010; Deslandes et al., 2022). Such social stereotyping often drives refugees back into their own communities (Hamber, 2019) and may make them more vulnerable for mental health problems. Discrimination is not only limited to actions of individuals in host countries, but policies, governments, and institutes may also be discriminatory against refugees and asylum seekers (e.g., Agic et al., 2019). Discrimination can affect mental health outcomes as well (Gillespie et  al., 2023; Komolova et  al., 2020; Szaflarski & Bauldry, 2019). Discrimination related to religion and culture is associated with post-traumatic stress disorder of

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adolescent refugees in Australia, especially with younger boys (Mahadevan & Jayasinghe, 2022). Studies of Ellis et al. (2010, 2022) showed that acculturation to Somali or (host country) US culture was protective of mental health outcomes for girls and boys, respectively, and that discrimination worsened mental health outcomes in Somali immigrants with a refugee background living in North America. The relationship between discrimination and mental health outcomes varies by refugee group and specific mental health problems studied, and analysis should consider the unique circumstances and needs of each refugee subgroup (Burns et al., 2021). Studies that do not disaggregate data by refugee subgroup may obscure existing relationships, as some studies have found no significant relationships between discrimination and physical or mental health among refugees (e.g., Szaflarski & Bauldry, 2019), while others have found that discrimination is related to different types of mental health symptoms by ethnic group (Sangalang et  al., 2019). A Canadian nationally representative survey suggested that discrimination explained lower positive mental health among refugee men, but not women, compared to economic migrants (Beiser & Hou, 2017), illustrating the importance of considering refugee subgroups by ethnicity and sex.

3.6.2 Integration Versus Acculturation According to Takeuchi (2016), the concept of integration, as opposed to acculturation, can shift the discourse from migrant behaviors to structural factors at the societal level. The integration of refugees is influenced by social policies in the host country, which can have a significant impact on their psychological well-being (Surkan et al., 2023). For example, longer waiting times for asylum determination are associated with mental health disorders (Phillimore & Cheung, 2021). Restrictive entry policies such as temporary visa status and detention, and restrictive integration policies related to welfare eligibility and documentation requirements, are associated with poor self-rated health and mortality among immigrants, refugees, and asylum seekers (Juárez et al., 2019; Surkan et al., 2023). Also, a clear association has been found between unemployment and mental distress among asylum seekers and refugees (e.g., Hocking et al., 2015; Surkan et al., 2023).

3.6.3 Differences Between Parents and Children In a number of studies, a mismatch in acculturation was found between parents and their children (Deng & Marlowe, 2013). For example, Serbian refugee youth in the United States are inclined to perceive their parents as less acculturated to American culture compared to themselves (Lazarevic et al., 2012). One important difference found between parents and children refugees after resettlement is that parents are more inclined to hold onto traditional cultural practices within their family, while children are inclined to adapt the host culture. This difference was found in Cambodian refugees in the United States (Lewis, 2008) and in African migrants in

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Australia (Renzaho et al., 2011). A number of refugee parents are concerned that their children would lose their native language, would become too independent, and would lose connections with their family such as Somali refugees in the United States (Betancourt et al., 2015) and Sudanese mothers in Australia (Levi, 2014). A mismatch in acculturation between parents and their children may be associated with more stress in family relationships (Masarik et al., 2022).

3.7 Social Support An important factor that is protective of mental health outcomes among refugees, and related to acculturation and integration, is social support from one’s social network. Social support is the belief that people care about and value you and are ready to assist you when needed (Wachter et al., 2022). Social support is based on emotional, informational, and practical resources people access through their informal networks, which may enhance their sense of identity and lead to more meaning in live (Cohen et al., 2000). The death and separation from loved ones and family in war and forced migration result in dramatic losses of social support (Miller & Rasmussen, 2017; Silove et al., 2017), leading to social isolation, stress, and mental health problems (Chen et al., 2017).

3.7.1 Social Support and (Mental) Health There is considerable evidence that lack of social support which is congruent with one’s cultural values is related to higher risk for ill-health (Campos & Kim, 2017). Forced migrants who have limited social support have a higher risk of developing long-term mental health problems (Gottvall et al., 2019; Weissbecker et al., 2019). Lack of social support among refugees leads to enhanced feelings of loneliness and isolation (Dolberg et  al., 2016; Liamputtong & Kurban, 2018; Strang & Quinn, 2019), which is associated with lower physical and mental health (Belau et  al., 2021; Hawkley & Cacioppo, 2010; Jankovic-Rankovic et al., 2022; Liamputtong & Kurban, 2018; Sengoelge et al., 2020). Interestingly, refugees who reported lower social support tended to exhibit higher fingernail cortisol levels (Jankovic-Rankovic et al., 2022; Panter-Brick et al., 2020). Forced displacement for many refugees leads to the loss of social ties in their home country. Thus, it is important that refugees and asylum seekers are enabled to rebuild a social support system in the host country (Wachter et al., 2020), in order to adapt to the new living conditions. Many older refugees may lose their social networks and social support, which may lead to increased social isolation and loneliness, leading to worse older refugees’ health (Ekoh et al., 2023). Social support may comprise emotional, practical, and informational resources people access through their interpersonal networks. Especially emotional support (e.g., empathy and companionship) plays a significant role in shaping the

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post-resettlement experience and may prevent mental health problems (McAlpine et al., 2022; Newman et al., 2018, 2022). Social support has been shown to protect from depressive symptoms and/or post-traumatic stress in refugees from a variety of different cultures (Birman & Tran, 2008; Cummings et al., 2011; Gerritsen et al., 2006; Lamkaddem et al., 2015; Lin et al., 2020; Nosè et al., 2020; McAlpine et al., 2022; Schweitzer et al., 2006; Sundquist et al., 2005). Among Vietnamese refugees in the United States, findings show that premigration traumatic experiences predicted only measures of anxiety. Depressive symptoms were predicted by post-­ migration factors, including having support from a spouse and from friends from Vietnam (Birman & Tran, 2008). In a study of Comtesse et al. (2022) among refugees living in host country Germany, lack of social support was associated with prolonged grief disorder symptoms. Other studies among refugees found that lower social support was associated with lower quality of life (Carlsson et al., 2006; Ghazinour et al., 2004) and less applications for HIV care in refugees diagnosed with HIV following routine HIV testing in a Ugandan refugee settlement (Parrish et al., 2022). In the Parrish et al. study, almost three-quarters of those testing positive for HIV applied for HIV care in a clinic in the neighborhood within 3  months after diagnosis: refugees with greater social support were more likely to link to care compared to those with lower social support. Often, no gender difference is made in research on social support. Many refugee women live in social isolation in resettlement (Wachter & Gulbas, 2018), but research is lacking on how refugee women can increase their social network. Asylum-seeking and refugee women who are pregnant and in early motherhood experience a lack of social support due to the loss of the familial and social support structures in the country of origin. This has resulted in experiencing poorer physical health, more mental health problems, and poorer neonatal outcomes than experienced by nonmigrant women (Bollini et al., 2009; Gewalt et al., 2018; Heslehurst et al., 2019). Discrimination may eventually lead to social support deterioration. Mental health problems may be lessened for refugees and asylum seekers who, when experiencing discrimination, use their social support network to help them. In a study of Jones et al. (2022), Black women’s continuous exposure to discrimination was associated with less perceived social support and led to increased depressive symptoms. These findings further suggest that Black women who experience discrimination may feel safely supported only by others who experience discrimination as well. Whether these findings also apply to refugees and asylum seekers has not yet been investigated.

3.7.2 Social Support in Refugee Children Social support has largely been ignored in studies on refugee children (Garcia & Birman, 2022). In a study of Dehnel et al. (2022) in which the role of resilience was investigated in Syrian refugee youth, the degree to which a child felt social support

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had the most significant effect on the likelihood of endorsing symptoms of depression. Results suggest that empowering children and families to build resilience through social support may be a potential management approach to prevent mental illnesses. Other studies have shown that social support from peers and close friendships may be beneficial for refugee children (Berthold, 2000; Correa-Velez et al., 2015; Kovacev & Rosalyn, 2004; Scharpf et al., 2022). Such relationships may help them build new social networks and friendships in new surroundings, which may enhance their emotional feelings. In a study of Emerson et  al. (2022), the relationship between social context factors and emotional health in refugee children was investigated. Both supportive school climate, and support from adults in school and at home, and social support from peers were associated with better emotional health. The results of this study underscore the important role which schools can play for refugee children’s emotional health. As noted by the authors, school-based programming that promotes positive school climate can be considered as an important approach to support newcomer refugee children and their families.

3.8 Concluding Remarks Given that lack of social support is associated with increase in mental health problems, there is a clear need of more actively helping refugees to build social networks and to evaluate in future studies whether this would indeed lead to less mental health problems. Development of programs with an emphasis on problem-focused and emotion-focused coping (Acar et al., 2021) to sensitize refugees about the importance of personal growth is important in order to enable asylum seekers and refugees to be better able to cope with adversities associated with the flight and resettlement. Social policy of host country should focus on enhancing social connectedness with people from the host country on the one hand, but accept the importance for asylum seekers and refugees to maintain the cultural bounds with the existing groups on the other (Brance et al., 2023). Given the heightened needs for social support in the resettlement process (Wachter et al., 2022), research is needed to explain differences of social support needs across cultures and locations of resettlement. In young refugees, resilience is very important: the higher the experienced social support, the less likely that the child will report mental distress. There is a clear need for refugee children that they learn immediately after arrival the language of the host country and go to schools. This is especially important for unaccompanied minor refugees. Being fluent in the local language and going to school with children from the host country will enhance their social networks and may lead to integration of old and new cultural values. Adolescent refugees—when they are discriminated and feel not accepted by the host country—are particularly vulnerable for embitterment, a strong feeling of moral injury, and disappointment, with the felt inability to defend oneself (Linden & Teherani, 2020; Spaay et al. 2021), which eventually can result in negativism, withdrawal from social contacts, and acts of revenge.

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Overall, social policies and their influence on refugee experiences play a crucial role in their integration and psychological well-being. By recognizing the impact of societal level structural factors, we can better address the needs of refugees and asylum seekers in host countries.

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4

Cultural Adaptations of Mental Health Care

4.1 Introduction In this chapter, cultural factors are addressed which are associated with mental health in refugees. Culture is defined as a set of practices and behaviors defined by customs, habits, language, and geography that groups of individuals share (Napier et al., 2014, p. 1609). Most refugees come from non-Western countries. Not only the availability of mental health centers plays a role, but also a number of cultural factors associated with the mental health care and the psychological therapies provided in refugee settings. Although in Western countries in most refugee settings mental care is provided, most centers are not prepared for refugees and asylum seekers with severe mental disorders, which are not limited to post-traumatic stress. Indeed, the number of patients with severe mental disorders may increase during the asylum request period, which in a number of individuals leads to deterioration of mental health problems (see Chap. 1). Living in asylum centers (sometimes in detention) leads to isolation. In most host countries, asylum seekers are not allowed to follow a language course and are not permitted to have employment, which lack of structure enhances mental distress.

4.2 Use of Mental Health Services Despite high levels of mental distress, asylum seekers and refugees under-use mental health care services (Satinsky et al., 2019). There are a number of barriers in addition to structural barriers such as language proficiency, costs, and transport that prevent asylum seekers and refugees from mental health help-seeking (Arundell et al., 2021; Kantor et al., 2017; Weise et al., 2021). These barriers include not only lack of awareness of mental health and of information about the available health care services (mental illiteracy), but also cultural differences in help-seeking © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 P. M. G. Emmelkamp, Mental Health of Refugees, https://doi.org/10.1007/978-3-031-34078-9_4

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behaviors (such as “treatment” by traditional healers), lack of medical insurance, lack of trust in authority figures, mental health stigma, and shame, with the latter being more common in Islamic cultures. Stigma can be viewed as a combination of different related problems: a lack of knowledge (ignorance), negative attitudes (prejudice), and excluding or avoiding behaviors (discrimination) (Rose et al., 2007). In adolescents, stigma and negative beliefs toward mental health services and professionals were the most cited barriers from mental health care seeking (Aguirre Velasco et al., 2020). More severe symptomatology was associated with lower help-seeking, suggesting that adolescent refugees and asylum seekers who are most in need of mental help are less likely to seek help.

4.2.1 Cross-Cultural Variation in Symptomatology Common mental disorders (e.g., anxiety disorder, post-traumatic stress disorder, and depression) and psychosis are differently understood across different cultures (e.g., Codjoe et al., 2013; Gopalkrishnan, 2018; Pedersen, 2015). Although major depression may have comparable core symptoms across various cultures (Kendler et al., 2015), there is substantial cross-cultural variation in the prevalence and symptomatology of depression (Ferrari et al., 2013; Kessler & Bromet, 2013). These various ways of expression of mood are culturally influenced ways of how people cope with distress (e.g., Chentsova-Dutton et al., 2015; Kuo, 2011). The differences in cultures have consequences for mental health practice, not only with respect to how individuals view mental illness, and to treatment-seeking patterns, but also with respect to the nature of the therapeutic relationship and issues of stigma and racism (Gopalkrishnan, 2018). It is also important to realize that in a number of cultures, somatic symptoms (e.g., pain, headache, sleeping problems) may be a culturally salient idiom of distress (Kirmayer & Young, 1998). A number of refugees and asylum seekers may emphasize somatic complaints. When asked, however, most patients are able to speak about psychosocial stress factors (Kirmayer, 2001).

4.2.2 Mental Health Diagnosis The Western way of dealing with diagnosing mental illness is often also not very helpful for individuals from non-Western cultures. Using symptom checklists to enable a “psychiatric diagnosis” often does not fit with the expectations which individuals from non-Western cultures have about mental health care. It is important that mental health care workers are sensitive to cultural differences in communicating about suffering and need for help. Communication with refugees and asylum seekers in mental health care often involves communication in a second language, and interpreters have often to be involved. Cultural differences in communication styles about mental distress and use of different languages between patient and mental health care worker may lead

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to misunderstanding, which may result in less participation and dropout of treatment in asylum seekers and refugees. In a study among refugees and asylum seekers in the United States, most migrants reported that they never had discussed with their primary care physician how they were affected by past political conflicts, although they themselves would appreciate to discuss their traumatic experiences with their doctors (Shannon et al., 2012). As noted above, emotions are expressed in different ways in different cultures. As a result, the expression of anxiety and distress varies considerably across cultures (Bhui & Bhugra, 2002). For example, there is considerable evidence that social anxiety disorder is much less prevalent in Asian countries compared with Western countries and some Russian regions (e.g., Hofmann et al., 2010). There is considerable evidence that taijin kyofusho, occurring in Japan and Korea, is a specific cultural expression of social anxiety (Kinoshita et al., 2008). Individuals with taijin kyofusho are primarily concerned about offending some other rather than embarrassing oneself. In addition, there is some evidence that shame has different meanings in different cultures, which may affect the experiences of refugees with respect to traumatic experiences as well. Western clinicians are inclined to interpret the communication (or no communication) in terms of psychopathology. When patients are not inclined to say what they really feel, or are avoidant or overly expressive, Western clinicians are inclined to see this as a sign of possible psychopathology. What often is forgotten is that in a number of non-Western cultures, “ … stating things outright, directly, emotional expressiveness is viewed as a sign of poor education at best, and rudeness at worst” (Qureshi & Collazos, 2011, p. 12). In a number of cultures, self-disclosure (outside a specific family context) is seen as inappropriate, which will affect the quality of the therapeutic relationship, when therapists are not culturally sensitive for such issues. Emotional and behavioral expressiveness also varies between Western culture and a number of other cultures, which may result in false mental health diagnoses if the Western standards are used for other ethnic cultures (e.g., histrionic personality rather than culture-bound way of expressing emotions related to bereavement and trauma).

4.2.3 Use of Interpreters When using an interpreter, it is essential that the patient is informed of how the clinical communication with respect to assessment and therapy works by using a qualified interpreter who is bound by rules of confidentiality (Bäärnhielm & Mösko, 2015). The loss of important clinical information as a result of selective translation by an inexperienced translator may lead to inadequate diagnosis and inadequate treatment recommendation (Searight & Armock, 2013). A study of Gartley and Due (2017) found that mental health professionals with experience with trained interpreters hold that interpreters are an integral part of providing mental health care to refugee clients, and sometimes may even contribute to building the therapeutic

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alliance themselves. Unfortunately, a recent review found that interpreters evaluated their work with refugees as rather stressful with a lack of support, resulting in heightened levels of emotional stress and anxiety, and secondary traumatic stress reactions (Geiling et al., 2021).

4.3 Cultural Identity According to Kirmayer et al. (2021), culture includes socially transmitted aspects of a way of life, from values and knowledge to social behaviors and practices. A single refugee camp may contain a large number of coexisting ethno-cultural groups. Culture is not the same as ethnicity. For example, although many refugees may be Syrians, not all Syrians have the same cultural background. Actually, Syrians come from diverse religious and ethnic backgrounds, including not only Syrian Arabs (the largest group), but also Kurds and Assyrians among others. With respect to religious background, the largest religious group is Sunnis, followed by Christians. It is important to realize that cultural identity may change over time. Berry et al. (2006) have suggested that four acculturation processes can be distinguished: (1) assimilation with the new culture; (2) separation, in which the emphasis is on maintaining the culture of the original home country/region; (3) marginalization, in which the migrant has low involvement in the heritage culture and in the receiving culture; and (4) biculturalism, in which the migrant is more or less equally involved in the new culture of the host country and in the original culture. Be careful to assume that the culture conflict between the Western values and the values of the social environment in which people grew up applies to the whole family. Different members of the family may have different values about the original culture in which they were brought up. In a number of cases, the younger generation may appreciate the Western culture in the host country more than the original culture, whereas the older generation may still feel that they have much more in common with the culture in which they were grown up. This may lead to conflicts within families. For example, many asylum seekers and refugees in host country Israel reported that their children had adopted Israeli negative stereotypes toward their own heritage culture (Lurie & Nakash, 2015). Generally, children adapt more easily to the culture of the host country and learn the language of the host country more easily than the parents, which can lead to additional mental health problems, both in the parents (e.g., common mental disorders) and the children (e.g., externalizing problems). In a study of Groen et al. (2018a), an attempt was made to clarify the concept of cultural identity in order to make it useful in clinical practice with refugees and asylum seekers. For this purpose, refugees from Afghanistan and Iraq living in the Netherlands, who were treated for trauma, were interviewed with a brief cultural interview. Analyses of these interviews revealed three domains of cultural identity: personal identity, ethnic identity, and social identity. Refugees who were referred for psychiatric problems to a mental health institute in the Netherlands often declared that they did not feel well understood by clinicians (Groen et al., 2018b).

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Many Afghans were more negative than positive about feeling understood by clinicians, and Iraqis were slightly more positive. There was no difference between asylum seekers and refugees: residential status was not associated with the level of feeling understood.

4.4 Culture and Mental Health There is strong evidence that cultural differences contribute to unequal access to care and that is even worse in the case of asylum seekers and refugees. Help-seeking attitudes are thought to be a key barrier to mental health service use. A number of studies with different ethnic samples have shown that there are cultural differences with respect to seeking professional psychological help for mental health problems (Chen & Mak, 2008; Fung & Wong, 2007; Ho et al., 2008). In these studies, the ethnic minorities (in most studies, Southeast Asians and Chinese individuals) reported more negative attitudes toward seeking professional psychological help for mental health problems. Arab culture is very diverse reflecting various religious sects, tribal affiliations, and social and political influences (Gearing et al., 2012). In middle eastern Arab cultures, stigma with respect to having mental health problems or receiving treatment plays a major role. In some Arab cultures, families of individuals with mental health problems (e.g., female victims of child abuse) or seeking mental health care risked a damaged reputation in the community (e.g., Shalhoub-Kevorkian, 2005). In the review of Gearing et al. (2012), differences in beliefs concerning the etiology of mental illnesses were a major barrier to accept “Western” treatments for mental health disorders. Given that in middle eastern Arab cultures mental disorders are often believed to be the result of supernatural origins—including sorcery, evil spirits, and the will or punishment of God—“treatments” for mental health symptoms are often delivered by traditional and spiritual healers. This is not limited to Muslims. According to a study conducted in Ethiopia (Belete et al., 2023), most individuals hold that mental disorders are results from sprites and evil forces and prefer religious institutions rather than mental health treatment. Orthodox Christians are particularly inclined to use holy water sites, because they believe that holy water embodies the spirit of Christ (Hailemariam, 2015). In a study in Egypt, Kuwait, Palestine, and Israeli Arab communities, investigating attitudes toward perceived cultural beliefs about mental health problems, individuals in the various countries varied with respect to beliefs about mental health problems (e.g., stigmatization) and the use of traditional healing methods versus Western treatments for mental health problems (Al-Krenawi et al., 2009). In another study (Ali et al., 2007), factors influencing attitudes toward seeking formal mental health care among attendance of 25 primary health care centers in Jordan were investigated. Two-thirds of the participants were inclined to use informal mental health care for mental disorders, rather than formal mental health care. Cultural beliefs about mental illness and perceived societal stigma predicted individuals’ attitudes toward seeking formal mental health treatment.

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In a study of Schlechter et  al. (2021b), Syrian refugees in Germany reported more depressive symptoms and functional impairment than German residents. Syrian refugees displayed relatively more negative attitudes toward seeking professional mental health care compared to German residents. These differences were due to a lower tendency to disclose distressing information among Syrian refugees as compared to German residents.

4.5 Barriers to Mental Health Care Much less refugees and asylum seekers receive mental health care than the regular population in the host country. For example, in Germany, only 5% of the refugees who suffer from mental disorders receive treatment (see Schlechter et al., 2021a, 2021b). In most resettlement countries, mental health service accessibility for refugees and asylum seekers is rather different (Priebe et al., 2016). In most high-income countries, access to mental health services is rather limited for asylum seekers who have not yet been formally accepted as citizens in the host country (e.g., DeSa et al., 2022; Satinsky et al., 2019). Prolonged mental health treatment in most high-income resettlement countries is not affordable because they are delivered by expensive mental health professionals. Beliefs about the causes of mental illness, evaluation of mental health care, and stigmatization are primarily culturally and socially constructed (Lewis-Fernández & Kirmayer, 2019). In a recent review of DeSa et al. (2022) among refugee women in high-income countries, the most common barrier to accessing mental health services was stigmatization of mental illness and avoidance of mental health-seeking. It is important to distinguish between public stigmatization and avoidance of mental health services. People may choose to not seek help for mental health problems in order to avoid negative psychiatric labels. Public stigma occurs when members of the general public endorse stereotypes about mental disorders, which may result in blocking individuals’ access to schools, employment, care, and housing (Ciftci et al., 2012). Female refugees and asylum seekers were afraid that mental health would be linked to their family and could have negative consequences for resettlement in immigrant communities (e.g., Ahmed et al., 2017). In addition, a number of female refugees and asylum seekers were afraid of physical and emotional abuse from their partners as a result of their seeking mental health care (see Chap. 1). Another important barrier to access mental health care was the lack of culturally sensitive practices to encourage accessing mental health care within a religious and cultural context. Culturally sensitive care was seen as a source of strength and hope, but also withheld females accessing Western biomedical treatment which did not incorporate their cultural traditions (Byrow et al., 2020; DeSa et al., 2022). In addition, many female refugees worried about confidentiality of health care workers and lay interpreters involved in the mental health care. As noted by DeSa et al. (2022), data are presumably underreported due to the stigmatizing nature of mental health issues among refugees.

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In another recent review of barriers to mental health help-seeking among refugees (Byrow et al., 2020), refugees across 16 studies reported “... experiencing or witnessing shame and disapproval from family members and the wider community related to perceived mental illness, as well as fear of being discriminated against, isolated, or ostracised from the community as a result” (p. 12). Further, in a number of studies, individuals reported that it was especially difficult for male refugees from various cultural backgrounds to seek mental care. Of note, rates of stigma were higher in studies that used standardized measures than in studies that only superficially invested stigma.

4.6 Stigma Reduction Intervention There is some evidence that community education and stigma reduction campaigns directed at those at high risk of mental distress may have some effect in low-income countries (Clay et al., 2020; Corrigan et al., 2001; Ssebunnya et al., 2009). Since there is some evidence that theatrical performance may have some effect for destigmatizing HIV in low-income countries (e.g., Boneh & Jaganath, 2011), Lee et al. (2022) investigated whether theatre-based interventions (see Bunn et  al., 2020; Gudyanga et al., 2021; Michalak et al., 2014; Yotis et al., 2017) may affect attitudes about mental illness and stigma toward mental disorders in a rural community in sub-Saharan Africa (Busoga region of eastern Uganda). Lee et al. (2022) developed a community-led performance, which depicted a man’s struggle with severe mental illness. He first went to the traditional healer where rituals and exorcisms turned out not to be effective. Then, he went to a religious center where praying was not effective either. Finally, he then went to the health center where he attempted to receive appropriate mental care, which eventually resulted in a good functioning productive member of society (taxi driver). This program was evaluated among males and females (N = 57). Most participants were peasant farmers and Christians; ten were Muslim. Less than half of the participants had completed primary school. Although participants attributed superstitious underlying causes to mental illness, including possession by evil spirits, and witchcraft, this destigmatization community theatre play resulted in a significant decrease in participants’ stigma ratings on the Personal Acceptance Scale and on the Broad Acceptance Scales (Iheanacho et  al., 2016). In addition, most participants reported having conversations about the theatrical performance with family members, neighbors, or friends suggesting that the “destigmatization of mental illness” could affect many more people than the direct audience of the play. Taken together the results of the study of Lee et al. (2022), this suggests that such a community-led arts intervention may decrease the stigma of mental illness in a rural area of a low-income country. Whether this intervention would also be effective in decreasing mental health stigma and increasing more positive attitudes toward mental health treatment among refugees and asylum seekers with different cultural backgrounds has not yet been investigated.

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4.7 Explanatory Models of Mental Illness Studies in medical anthropology have emphasized that patient-doctor interactions are transactions between explanatory models of illness that often diverge from each other in terms of explanations and goals (e.g., Eisenberg, 1977). Explanatory models of mental illness assume that people tend to construct explanatory models when suffering from a mental illness based on cultural beliefs about illness (Kleinman, 1980), which can influence coping (Brown et al., 2007), treatment preferences and satisfaction (Callan & Littlewood, 1998; McCabe & Priebe, 2004; Saravanan et al., 2007), and compliance with therapy (Foulks et al., 1986). Explanatory models of illness are not limited to mental health patients but affect also parents and caregivers (e.g., Kpobi & Swartz, 2018; Liu et al., 2020; Smith et al. 2020). Relatively little empirical attention has been paid to understanding how refugees conceptualize mental health problems. Alemi et al. (2017) investigated beliefs about depression among Afghan refugees resettled in California. Male and female refugees shared beliefs that associate depression causality with mild traumatic experiences and post-resettlement stressors and agreed that mental health problems include culturally salient idioms of distress. However, in contrast to males, women were more inclined to associate depression with somatic items. Brea Larios et al. (2022) examined the role of explanatory models of depression and post-traumatic stress disorders among Afghan refugees resettled in Norway. Although all refugees mentioned various potential causes, and risk factors of depression and post-­traumatic stress, these factors varied among distinct categories of participants: females emphasized domestic problems and gender issues as possible causes, in contrast with males who tended to emphasize acculturation challenges and loneliness. One of the issues in the assessment of explanatory models of mental illness is the patients’ tendency to conceal or misreport their beliefs in an interview situation or to present themselves in a socially desirable manner. In a study of Ghane et al. (2010), the effect of patient and interviewer characteristics on the assessment of explanatory models of mental illness among mental health patients of Turkish and Moroccan origins living in the Netherlands was investigated. More specifically, the study examined the effect of ethnic match or mismatch between interviewer and respondent on the report of explanatory models of mental illness. Explanatory models were assessed, using the Explanatory Models Interview Catalogue (Weiss, 1997), of which semi-structured interviews for eliciting Explanatory Models of illness among specific cultural groups were adjusted for use among Turkish and Moroccan patients. Interviews were conducted by 17 interviewers, of whom 10 had native Dutch ethnicity and 7 had Moroccan or Turkish ethnicity. This study provided evidence for the effect of ethnic (mis)match between interviewer and respondent on the report of explanatory models among psychiatric patients of Moroccan and Turkish origins. Results revealed that patients scored higher on interpersonal, victimization, and religious/mystical causes, when interviewed by an ethnically similar interviewer, and scored higher on medical causes, when interviewed by an ethnically dissimilar interviewer. The differential reports of medical and religious/mystical explanatory models in the match versus mismatch

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interviews may have resulted from social pressure. Given the higher endorsement of religious and/or mystical causes among Moroccan and Turkish patients, it is likely that patients felt more pressured to acknowledge religious causes in the interview with a (perceived) fellow Muslim. As noted by Ghane et al. (2010), mismatch effects reflect important dynamics in intercultural clinical encounters. Attempts should be made to enhance disclosure in the starting phase of clinical sessions in order to facilitate a more valid assessment of the patient’s explanatory models of mental illness.

4.8 Cultural Factors in Clinical Practice Culture factors not only do have an impact on refugees and asylum seekers but may also affect the clinicians and mental health workers working with refugees and asylum seekers. This may lead to differences in mental health service provision. Cultural bias may also play a role in the diagnosis of mental health problems. Misdiagnoses of racial or ethnic refugees’ mental health problems can potentially contribute to inappropriate mental health care. There is some evidence that racial and ethnic prejudice may lead to a lower quality of mental care. In a study in the United Kingdom, depression was often not recognized by health care workers in African immigrants (Babatunde & Moreno-Leguizamon, 2012). Other studies revealed that Black people are less likely to receive a formal diagnosis for anxiety and depression (Spector, 2001) and are often underrepresented in primary care mental health services (Edge & Rogers, 2005). As noted by Qureshi et al. (2015): “There is … sufficient research that demonstrates that involuntary hospitalization, use of restraints, and so forth are more common in ‘people of color’ than in the native born” (p.  160). In a review of Liang et  al. (2016) on mental health diagnoses in minority youth, the authors concluded that there was evidence which supports the possibility of misdiagnosis of ethnic minority youth’s emotional and behavioral problems. However, the evidence was limited so it could not be determined whether results were due to mental health biases with respect to race or ethnicity on the one hand or that one group had indeed a higher level of psychopathology than another. A few investigators have interviewed (mental) health care workers to study whether clinically working with refugees with another cultural background than the therapist is a challenge (Salami et al., 2019; Schouler-Ocak & Aichberger, 2017; Storck et al., 2016). Working with patients with another cultural background led to not only difficulties because of language barriers and having to work with interpreters, but also intercultural differences between patient and mental health worker. Qualitative studies revealed that mental health workers identified a number of difficulties including cultural differences and lack of cultural competencies, lack of professional networks, having to work with interpreters, having to listen to traumatic experiences, and insufficient reimbursement of therapies (Asfaw et al., 2020; Jameel et al., 2022; Kiselev et al., 2020; Mewes et al., 2016; Peñuela-O’Brien et al., 2022; Thöle et al., 2017).

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Although many refugees and asylum seekers would need mental health care including psychotherapy, relatively few of them receive psychotherapy, even in high-income European countries with well-established health care systems, such as Switzerland (Kiselev et  al., 2020), the Netherlands (Laban et  al., 2007), and Germany (Boettcher et  al., 2021). Specialized mental health centers for refugees and asylum seekers in Germany treat about 1 out of 20 refugees and asylum seekers who need specialized psychosocial care (BAfF, 2022). Another study revealed that asylum seekers in Germany had substantially less appointments with mental health care workers compared to the normal population in Germany (Bauhoff & Göpffarth, 2018), paradoxically leading to more hospital and emergency department admissions, resulting in 10% higher expenditures for (mental) health care than for the regularly insured.

4.8.1 Readiness of Psychotherapists to Work with Refugees Schlechter et al. (2021a) investigated which factors were associated with psychotherapists’ readiness to work with refugees in Germany. Readiness of psychotherapists to work with refugees was predicted not only by experience with working with refugees in the past, but also by the therapeutic styles of self-doubt and neutrality, and by feeling comfortable working with an interpreter in therapy. Although studies have revealed that therapist’s self-doubt leads to a better therapeutic alliance and psychotherapy outcome in Western populations (e.g., Heinonen & NissenLie, 2020; Nissen-Lie et al. 2010), self-doubt was associated with a lower level of readiness to work with refugees. As suggested by Schlechter et al. (2021a) selfdoubt of psychotherapists may include cultural humility (Hook et al., 2013), which in clinical practice leads to better competence in a multicultural clinical setting: “Therapists with more self-doubt may display a greater awareness of the need for cultural learning and focus more on the client and maintain greater flexibility. In this regard, they may report a lower readiness to work with refugees but may be actually equipped with the relevant skills that are necessary for multicultural counselling ...” (Schlechter et al., 2021a, p. 339). Interestingly, although the Big Five personality trait “openness to experience” is not related to the outcome of psychotherapy (see review of Heinonen & Nissen-Lie, 2020), in the study of Schlechter et al. (2021a), “openness to experience” was associated with a higher readiness to work with refugees. In addition, “openness to experience” was negatively associated with perceived language barriers and feeling uncomfortable working with an interpreter. One issue complicating the alliance between health care worker and patient is the idea patient has about the role mental health problems may play in getting asylum in the host country. Some asylum seekers start to believe that the improvement of their mental health problems may decrease their chance of getting a positive asylum decision, which in some cases can lead to exaggerating their experiences of trauma and severity of mental health symptoms in order to strengthen their claim for asylum in the host country (Slobodin & de Jong, 2015).

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4.8.2 Cultural Competence of Mental Health Workers Cultural competence can be defined as the acquisition of cultural awareness, knowledge, and skills required to provide effective and responsive treatment for various cultural groups (Sue & Sue, 1990). Cultural competence models of therapy assume that treatments must be compatible with a client’s cultural needs and therapists must have an awareness of cultural factors and apply this knowledge to effectively achieve optimal outcome (Gainsbury, 2017). Results so far suggest that there is a clear need of intercultural therapy training of psychotherapists working with asylum seekers and refugees (Kirmayer et al., 2021; Qureshi & Collazos, 2011; Schlechter et al., 2021a, 2021b; Wampold et al., 2017), including cultural anthropological approaches (Weiss, 2018). Such intercultural therapy training may help to raise awareness among psychotherapists, clinical psychologists, psychiatrists, and other mental health workers of cultural biases and patients’ cultural perspectives and to understand specifics of mental health symptoms in refugees to increase the cultural competence of mental health workers. In addition, such training may assist in reducing the negative aspects of self-doubt of clinicians while maintaining the positive aspects of self-doubt discussed above. In this context, it is also important to teach mental health workers how to optimize the interpreter-­mediated therapeutic process realizing that the clinician himself/herself has the final therapeutic responsibility. Further, it is important to train therapists on how to conduct debriefing sessions with the interpreter to clarify unclear statements. There is also a clear need of supervision of clinicians working with refugees and asylum seekers with a different cultural background.

4.8.3 The Role of Interpreters In addition, there is a clear need of professional development for interpreters to enhance the quality of psychotherapy with interpreters. Such training of interpreters in resettlement countries can facilitate the availability of culturally well-trained interpreters (Shannon et al., 2016). As suggested by Schouler-Ocak (2015), a better term would be “linguistic and cultural mediators” rather than “interpreters.” The term linguistic and cultural mediator assumes a level of understanding in intercultural contexts, which goes beyond the verbal (see also Qureshi & Collazos, 2011). In psychological treatment with refugees and asylum seekers, the linguistic and cultural mediator is also involved in the therapeutic relationship. It is highly important that they learn how to maintain professional boundaries and how to manage privately shared information (Hassan & Blackwood, 2021). Training of linguistic and cultural mediators should also help them to be able to better cope with the traumatic experiences that are discussed during the therapy sessions. In some therapy sessions, the refugee may talk about traumatic experiences which the linguistic and cultural mediator has experienced himself/herself. The linguistic and cultural mediator should be prepared for such experiences and learn what for them is an adequate way to deal with such experiences. In addition, it is important that there is clear role

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clarification between linguistic and cultural mediator and clinician during the therapeutic process. Last but not least, regular debriefing sessions between therapist and linguistic and cultural mediator have to take place to optimize the trialogue (e.g., Mirdal et al., 2012; Winkler, 2015).

4.9 Adaptation of Psychotherapy in Lowand Middle-Income Countries Individual-centered Western psychotherapy promotes individualism, autonomy, and achievement (e.g., assertiveness training), whereas in many other cultures, people operate in a more collectivistic way. How mental health clinicians communicate with patients may also vary among cultures. Therefore, it is important to take into account how cultures vary on importance of hierarchy in interpersonal relationships when developing therapies for refugees from other than Western cultures. Relatively few studies have been published based on research into the effectiveness of psychological interventions in Africa and Arabic and Asian countries. International Clinical Guidelines are based on research from the United States and Western Europe. However, we cannot simply generalize the results of studies conducted in Western countries to other parts of the world. For example, a review of studies (Xu & Tracey, 2016) conducted in China reported on the results of 235 randomized controlled trials between 1997 and 2014 published in local journals. Three categories of psychological interventions were distinguished: cognitive-­ psychoeducational therapy (180 studies), humanistic-experiential therapy including art therapy (23 studies), and indigenous therapy (e.g., Naikan therapy, sandplay and Morita therapy; 23 studies). Although all three modalities were found to be effective in China, their efficacy was found to vary by the extent to which they are experiential (Xu and Tracey, 206, p.  363). Interestingly, in China, humanisticexperiential therapy was more effective than cognitive-psychoeducational therapy (Hedges’ g  =  0.35) and indigenous therapy was more effective than cognitive-­ psychoeducational therapy (Hedges’ g  =  0.34) as well. When the analyses were limited to studies which investigated a direct comparison of treatments, the same pattern of relative efficacy among the three types of psychological interventions was similar. According to the authors, the culturally more congruent therapies (indigenous therapy and humanistic-­experiential therapy) were found to have a larger absolute efficacy (Hedges’ g = 1.18) than did the benchmarks in Western Europe and the United States (Cohen’s d 0.75 to 0.85; Butler et al., 2006; Wampold & Imel, 2015). Xu and Tracey (2016) conclude that when working with Chinese patients, clinicians would do better when working more on experiential components (e.g., feelings and therapeutic relationships) and focus more on subjective experience (e.g., introspection and reflection): “... when working with a Chinese clientele, interpersonal and emotional processes should be the clinical priority over dysfunctional cognitive patterns, and experiential techniques ...” (p. 364). In a more recent review (Li et al., 2022) of psychological interventions related to disaster-related psychosocial problems in China, five studies used psychosocial

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interventions based on cognitive behavior therapy and four used mindfulness training to treat stress-related disorders. In a meta-analytic study (Ng & Wong, 2018) based on 55 studies with 6763 Chinese patients, the overall short-term effects of cognitive behavioral therapy were medium for anxiety and depression and small for substance use disorders and psychotic symptoms. Of note, results of cognitive behavioral therapy on dysfunctional thoughts and coping were rather small. The effect was stronger for culturally adapted cognitive behavioral therapy to Chinese culture than for unadapted cognitive behavioral therapy. Taken together research on psychological interventions in non-Western cultures, the conclusion must be one size does not fit all. Through cultural adaptations, it may be possible to go beyond the one-size-fits-all approach and investigate the effectiveness of psychotherapy that is contextualized in terms of cultural values, socioeconomic status, and gender.

4.10 Outcome of Interventions Across Different Racial/ Ethnic Groups A number of studies evaluating psychological interventions compared clinical outcomes across different racial and ethnic groups. A meta-analysis of Cougle and Grubaugh (2022) revealed that a number of previous meta-analyses that considered race/ethnicity as a predictor of treatment outcome across a number of mental health disorders did not find differences in outcomes for common mental disorders between ethnic/racial minorities relative to White participants in Western countries. However, there is considerable evidence that psychological interventions that are considered “evidence based” in Western, high-income countries may need to be culturally adapted for people living in non-Western countries and for a number of refugees and asylum seekers in Western homelands. A cultural adaptation of psychotherapy is defined as the systematic modification of an intervention taking into account language, culture, and context in such a way that is compatible with the patient’s cultural meanings and values (Bernal et  al., 2009; Chu & Leino, 2017; Lyon et al., 2014). When cultural issues are not taken into account by practitioners, patients with a different cultural background may feel themselves unsafe in the therapeutic context given that they may feel that cultural values are not appreciated by the practitioner. Among the reasons for cultural adaptation of psychological interventions are the need for cultural relevance to increase acceptability of the treatment and to address problems with local clinical practice such as lack of trained mental health workers (i.e., clinical psychologists, psychotherapists, psychiatrists) and limited literacy of the patients. Such cultural adaptation can range from surface adaptations (e.g., culturally adapted illustrations) to adaptations of the process of the psychological intervention including adaptations of the specific therapeutic elements (e.g., omitting cognitive restructuring elements) (Heim & Kohrt, 2019). Generally, cultural adaptations attempt to maintain the core elements of the evidence-­based psychological intervention while adding certain cultural elements

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to adapt it to local context in other cultures. In addition, in a number of cultural adaptations, the mental health problem is defined in a culturally appropriate manner so that they are understandable by the patient and may reduce stigma. For example, psychiatric labels are avoided and the mental problems can be defined as a medical illness rather than as mental illness. Nevertheless, it has been suggested that public mental health in developmental countries and in refugees from nonWestern countries would make a greater contribution if they would take into account the knowledge of cultural anthropology and cultural psychiatry, thus expanding the horizons of Western-oriented mental health workers and scientists (de Jong, 2014). Cultural adaptations of psychological interventions not only do involve language translation, but also concern using colloquial expressions, and stories, and integration of local practices into the therapy. A number of adapted interventions contained some provision for family engagement even if the main format of treatment was individual (e.g., Anakwenze, 2022). A review of cultural adaptations of psychological treatments for depressive disorders revealed that cultural adaptations lead primarily to adaptations in the implementation of treatments rather than their content (e.g., Chowdhary et al., 2014; Jameel et al., 2022). Cultural adaptations have been achieved for adults with mental health problems, primarily with cognitive behavior therapy, problem-solving therapy, and interpersonal therapy. In a meta-analysis of Griner and Smith (2006), involving 76 studies with over 25,000 patients, most studies (84%) included cultural values and concepts into the intervention. More than half of the studies employed ethnic matching between patient and therapist and three-quarters of the studies employed language matching. Results of the meta-analysis revealed a moderately strong benefit of culturally adapted interventions (average random effect size of 0.45). Importantly, interventions targeted to a specific cultural group were more effective than interventions for groups consisting of a variety of cultural backgrounds, and interventions conducted in the patient’s native language were twice as effective. Comparable effects were also found in more recent meta-analyses (e.g., Benish et al., 2011; Hall et al., 2016; Harper Shehadeh et al., 2016; Smith et al., 2011) and in a review of cultural adaptations of psychological treatments for depressive disorders (Chowdhary et al., 2014). These studies confirmed the findings of Griner and Smith (2006). The most effective treatments featured the greatest number of cultural adaptations. There is also some evidence that older patients were more responsive to culturally adapted treatment than younger patients, which may be due to a first-generation effect. There is also some evidence that Asian Americans are more responsive to culturally adapted treatment than other immigrants in the United States. Many studies that involved adapted psychotherapies for ethnic minority groups were conducted in the United States. Generally, cultural adaptation is made independent whether this adapted psychotherapy is applied with first, second, or third generation living in the home country. Not surprisingly, results of such studies are rather mixed and cannot be generalized to people living outside the Western world.

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4.10.1 Interventions for Young Refugees Also in psychotherapy with children, researchers have addressed the potential of cultural adaptations to specific ethnic and minority groups in cognitive behavior therapy, in interpersonal therapy, and in parent training (e.g., Bernal & Domenech Rodríguez, 2009; Bernal et al., 2009; Davenport et al., 2018; Huey Jr. & Polo, 2008; Lyon et al., 2014). Relatively few studies with children, however, have investigated whether culturally adapted psychotherapies are more effective than non-culturally adapted psychotherapies (Griner & Smith, 2006; Hall et al., 2016).

4.10.2 Qualitative Research Generally, the cultural adaptation is based on qualitative data through focus group discussions and in-depth interviews with patients with mental health problems and with health providers who have knowledge of the beliefs and customs in a specific culture. A number of these pilot studies are conducted in which trained (lay) health care providers deliver the preliminary version of the culturally adapted intervention with a small number of patients to improve the acceptability and feasibility of the intervention. To give an example, in a study of Rose-Clarke et al. (2020), the World Health Organization’s Group Interpersonal Therapy Manual was adapted for use in rural Nepal with adolescents with depression. Based on interviews and focus groups which involved not only adolescents, but also parents, teachers, and mental health professionals, adaptations were made to optimize treatment delivery and integrate cultural aspects of depression. These adaptations include integrating the group therapy into secondary schools for delivery by lay helpers from the region, adding components to promote parental engagement and parental support; using locally acceptable terms for mental illness such as “udas-chinta” for sadness and “man ko samasya” for heart-mind problem; and framing the intervention as a training program to destigmatize treatment. Whether this culturally adapted format of interpersonal therapy is more effective than the World Health Organization’s Group Interpersonal Therapy Manual has yet to be investigated.

4.11 Culturally Adapted Cognitive Behavior Therapy Most culturally adapted psychological interventions are based on evidence-based cognitive behavior therapies adapted for use with minority populations (African American and Latino patients; Huey et al., 2014) or diverse populations in several Asian countries including Bahrain, China, India, Malaysia, Saudi Arabia, and Pakistan (e.g., Algahtani et al., 2019; An et al., 2020; Husain et al., 2017; Li et al., 2015; Naeem et  al., 2015; Selvapandiyan, 2020) and in sub-Saharan Africa (Anakwenze, 2022). Cognitive behavioral therapies developed in Western countries provide a conceptual framework that uses reasoning approaches (e.g., Hollon &

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Beck, 2013), but this is inconsistent with Eastern and other philosophies. As a result, in a number of cultural adaptations, there is more emphasis on behavioral than cognitive techniques. Another issue that needs cultural adaptation is the difference between the concept of “self” and “the collective” of some cultural groups (e.g., Asian). Last but not least, involvement of the family should be considered in many cultures. It should also be realized that dependent patterns of behavior are not pathological (no personality disorder) but may be quite normal in some cultures. Thus, clinicians should accept this as a reality, not as a pathological behavior. Clinicians should also accept in a number of cultures that they are seen as an authority figure, which requires that the clinician may need to adapt their role. Although a number of studies have culturally adapted Western evidence-based treatment protocols, there is still a lack of empirical evidence on the level of cultural adaptation required for psychological interventions (Heim et al., 2021; Perera et al., 2020) to be effective for the treatment of common mental disorders among culturally and ethnically diverse groups including refugees and asylum seekers. A number of systematic reviews (Bhui et al., 2015; Chowdhary et al., 2014; Ennis et al., 2020; Healey et al., 2017) and meta-analyses (Arundell et al., 2021; Escobar & Gorey, 2018; Griner & Smith, 2006; Huey & Tilley, 2018) have evaluated the effectiveness of culturally adapted interventions. Generally, cultural adaptations made to psychological (often cognitive behavioral) interventions for mental health problems of culturally and ethnically diverse groups appear to be efficacious relative to care as usual or waitlist control. Unfortunately, adapted interventions for common mental disorders have hardly been compared to its non-adapted original intervention (e.g., Hwang et al., 2015; Kohn et al., 2002). In addition, results are difficult to interpret given the lack of clarity about the definition or the additional value and effectiveness of specific adaptations (Arundell et al., 2021).

4.12 Guidelines for Cultural Adaptation A number of issues are relevant for cultural adaptation of psychological interventions for non-Western cultures including the following: –– –– –– ––

Are treatment concepts and treatment goals framed within cultural values? Are treatment goals consonant with cultural expectations of therapy? Does the patient agree with the goals of treatment? Does the patient agree with the definition of the mental problem and the proposed specific treatment? –– Does the patient feel understood by the therapist? There is a clear need of international guidelines with respect to the development of cultural adaptation of Western psychological interventions for culturally and ethnically diverse groups including refugees and asylum seekers, and a number of steps have now been made. The ecological validity model developed by Bernal et al. (1995) evaluates cultural sensitivity of eight cultural dimensions of

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the target population (language, persons, metaphors, content, concepts, goals, methods, and context) that may be considered when culturally adapting psychological interventions. Metaphors refer to the use of culturally appropriate symbols and images. Content refers to cultural knowledge, beliefs, and values. Concepts refer to ways of understanding the mental problem, the etiology, and the therapeutic process. Assessment of cultural sensitivity using the ecological validity model has not been used as standard in all adaptations of Western psychological interventions for culturally and ethnically diverse groups including refugees and asylum seekers. Heim and Kohrt (2019) suggested to use cultural concepts of distress to describe culturally shaped mental health-related phenomena, such as hwa-byung in Korea (i.e., fire/projection of anger into the body) or khyâl attacks (i.e., wind attacks) in Cambodia. Cultural concepts of distress include not only (a) culture-specific idioms of distress encompassing expressions of suffering, but also (b) explanatory models referring to culture-­specific etiological assumption of mental problems and (c) cultural syndromes, describing the co-occurrence of symptoms within a cultural syndrome that is distinct from current diagnostic psychopathological categories (Lewis-Fernández & Kirmayer, 2019). Heim and Kohrt (2019) outlined specific elements to be adapted (i.e., cultural concepts of distress, treatment components, and treatment delivery). Following the model of Singla et al. (2017), a number of components of psychological interventions for the treatment of common mental disorders in low- and middle-income countries have to be addressed including specific and nonspecific elements; therapeutic techniques, e.g., therapeutic activities or strategies (e.g., problem-solving); and skills that are used by the therapist (e.g., role-playing). Recently, a task force for cultural adaptation of mental health interventions for refugees standardized the cultural adaptation process across several randomized controlled studies evaluating psychological mental health treatments among refugee populations in Germany (Heim et al., 2021). This task force developed the necessary criteria. In addition, a survey was conducted to seek consensus among international experts in the field of cultural adaptation and mental health. This process resulted in a number of criteria to guide the process of cultural adaptation of psychological protocols in clinical trials, which are not only relevant for studies conducted in Germany and are listed below (for more details, see Heim et al., 2021): –– The first step in cultural adaptation is to clearly define the target population in the clinical study using criteria that may have an impact on patients’ mental health problems and cultural identity. –– Further, it is recommended to describe relevant personal characteristics of the researchers who conduct the qualitative studies. –– In addition, documentation of the process of cultural adaptation, cultural process of distress, and specific needs which led to decisions that were made should be reported as well. –– If changes are made during a pilot study or randomized controlled trial, this has to be reported as well (see Chambers & Norton, 2016).

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–– The process of formative research has to be reported in a transparent manner, to enable replication. –– Thus, single treatment components in trans-diagnostic interventions have to be clearly defined, and the rationale for the selection or adaptation of each of the specific treatment components should be reported as well. –– In addition, a convincing treatment rationale has to be given to the patients and reported as well taking into account cultural explanations that are part of locally relevant cultural concepts of distress and culture-specific notions of stigma (see Rathod et al., 2019). –– Last but not least, information with respect to outcome measures used has to be delivered, including how questionnaires and clinical interviews were translated and culturally adapted. Reporting on cultural adaptation more consistently following the guidelines of the task force for cultural adaptation of mental health interventions for refugees and asylum seekers in psychological studies evaluating psychological interventions with refugees and asylum seekers will hopefully improve the effect of cultural adaptation on treatment efficacy and feasibility (Heim et al., 2021).

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5

Assessment of Mental Health Problems

5.1 Introduction To address the mental health problems of refugees and asylum seekers, good-­quality measures are needed (e.g., Tol et al., 2011). Although the vast majority of refugees and asylum seekers have been resettled in low- and middle-income countries, questionnaires to assess mental health problems are mostly developed in English-­ speaking high-income countries and based on the notion of mental health disorders that are prevalent in these countries (e.g., DSM) (Christy et al., 2021). One issue related to the assessment of psychopathology is that the verbal, emotional, and behavioral expressiveness varies between Western culture and a number of other cultures (see Chap. 4), which may result in false diagnoses if the Western standards are used for refugees and asylum seekers from other ethnic cultures. There is a large literature demonstrating the many ways that cultural variations affect the symptomatic manifestations and clinical presentation of mental health problems, not only common mental disorders like anxiety, post-traumatic stress, and depression, but also severe mental disorders like psychosis. These cultural variations have been shown to affect the assessment of mental health problems (Kirmayer et al., 2021).

5.2 Culture-Bound Values of Diagnosis Culture and the social context in which people live may affect the expression and interpretation of symptoms of mental distress, which may seriously confound the assessment of mental health problems in refugees and asylum seekers (e.g., Kuittinen et al., 2017; Lewis-Fernández & Kirmayer, 2019). “Culture” and “ethnicity” are used by default in clinical research and in clinical practice, but these terms are often not defined and seem interchangeable. However, the reality is more complicated. For example, a refugee or asylum seeker born in Syria, Afghanistan, or Uganda is usually assumed to represent the local culture, often forgetting that a © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 P. M. G. Emmelkamp, Mental Health of Refugees, https://doi.org/10.1007/978-3-031-34078-9_5

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country may have different cultures that can be experienced differently for everyone. Cultural diversity is conceptualized in different ways in different countries as a result of differences in social stratification and ideologies with respect to ethnic identity. This is referred to in the literature as individual experience of culture (Delvecchio-Good & Hannah, 2015).

5.2.1 Lay Explanatory Models of Mental Illness Lay explanatory models of illness are culturally shaped, interpretative notions about etiology, course, and treatment of (mental) illness. A number of patients are inclined to attribute their symptoms to the evil eye, magic (voodoo), or jinn (Lim et  al., 2018). Given their impact on the experience of illness and treatment response, a valid assessment of explanatory models of illness is essential for enhancing the effectiveness of mental health care (Ghane et al., 2010, 2012). This issue is also very relevant in the case of ethnic minority patients, asylum seekers, and refugees; thus, there is a clear need to develop culture-sensitive measures for the assessment of psychopathology including post-traumatic stress disorder that are valid and reliable. Answering questions about mental health in interviews and questionnaires is also influenced by cultural factors related to stigma. Studies revealed that mental health is stigmatized in Arab and Hispanic societies (e.g., Chaleby, 1987) to a greater extent than in Western countries.

5.2.2 Impact of Patient Language Proficiency on the Quality of Assessment Assessment of mental health problems in refugees and asylum seekers is also affected by language difficulties. Although the English and Spanish languages are widely used across many countries in different continents, in some continents, many languages are spoken. For example, in Africa, over 2000 different languages are spoken (Lau et  al., 2020), which may have impact on the assessment of mental health issues. In a number of African countries, people will speak the language of their local community although a number are multilingual, given that they may be taught African languages (e.g., Swahili) or Western languages (e.g., English or French) at school as well. There is some research which suggests that assessments of refugees and asylum seekers with a non-Western background may need a substantially different approach to those used with Western population in the home country. In recent years, interest in cognitive aspects of survey measurement and structured interviews has increased (Ferraro, 2016; Sha & Gabel, 2020). Studies investigating the relationship between semantic and pragmatic aspects of asking and answering questions revealed that “... even apparently ‘clear’ and ‘simple’ questions can dramatically change in meaning depending on who asks whom and in which context” (Oyserman & Schwarz, 2020, p. 13).

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When patient and clinician do not share a native language, as is the case with many migrants and refugees, problems do already occur in trying to establish a psychiatric diagnosis (e.g., Bauer & Alegría, 2010). In a study of Sandhu et  al. (2013) in a number of large cities in Europe, language difficulties were a major barrier in creating a trustful relationship between assessor and refugees or asylum seekers, assessing mental health symptoms, and formalizing a diagnosis. Using interpreters often leads to miscommunication because of incompetent interpreters who do not understand such issues of co-occurring substance abuse problems and other mental health problems (Kour et al., 2021). Professional well-trained mental health care interpreters, however, who have quite some experience in performing ad hoc translations of mental health screening questions may be linguistically tuned to analyze difficult mental health situations in which adequate language understanding is a conditio sine qua non. Mental health measures may either explicitly or implicitly use cultural concepts that are difficult to comprehend in other languages (Sha & Gabel, 2020). In non-­ Western surveys, apart from the direct impact of correct translation, comprehension problems may occur as a result of differences related to the meaning system of the culture. Thus, not only the grammatical norms associated with the language, but also the cultural norms and how the words are practiced in everyday life are important for the assessment of mental health problems in non-Western cultures. A review of surveys involving immigrant and ethnic minority populations revealed that the choice of language is associated with the quality of recall. When questions are asked in the original language, first-culture memories are more easily reminded, while second-language cues activate more recent memories (Peytcheva, 2020). Although Peytcheva suggests that language of survey administration in bilingual respondents may be switched throughout the survey, depending on life periods for which one is interested in collecting data, to the best of my knowledge this has not yet been investigated.

5.2.3 Scoring of Questionnaires May Be Primed by Culture In mental health questionnaires, often a scale is used (e.g., ranging from 1 to 5, or 1 to 7) to express the applicability of an item, but scoring is affected substantially by the scoring format (e.g., Schwarz, 2009; Truijens, 2017). Many refugees and asylum seekers are asked to complete (translated) questionnaires to assess mental problems, but valid data collection requires qualitative scrutiny of meaning within data (Truijens et al., 2019). What is often not realized by clinicians is that questions in self-report questionnaires may be affected by the reference frame primed by a culture. A number of investigations have found that individuals from East Asia are inclined to avoid extreme responses (e.g., Hayashi, 1992; Chen et al., 1995; Silva de Crane & Spielberger, 1981; Ji et al., 2000), which may be associated with cultural values of conflict avoidance and submissiveness. Chen et  al. (1995) investigated cross-cultural differences in response style regarding the use of a 7-point Likert scale among subjects from Japan, Taiwan, Canada, China, and the United States.

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The Japanese and Chinese subjects were more likely than the subjects from the United States to use the midpoint on the scales, while the subjects from the United States were more likely than the other groups to use the extreme values.

5.2.4 Concluding Remarks A diagnostic approach that places the person in a sociocultural context can help clinicians to assess mental health problems of asylum seekers and refugees in a broader context. Such a contextual approach should include developmental history including possible trauma, cultural dimensions, and family dynamics. Further, the international literature indicates that the presence of professional interpreters can improve the quality of medical care (Diamond et  al., 2019; Jaeger et  al., 2019). Although the use of professional interpreters is generally recommended for bridging the language gap in clinical assessment, in most instances, patients’ family members including minors act as “interpreter.”

5.3 Cultural Formulation Interview Based on a lack of standardized tools to conduct cultural interviews, the Outline for Cultural Formulation was developed for the fourth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The Outline for Cultural Formulation enabled mental health workers to ask patients about views of illness and treatment to individualize care rather than stereotype patients based on perceived racial or ethnic affiliation. In the most recent edition of DSM (DSM-5-TR), a number of changes have been made resulting in the Cultural Formulation Interview. The Cultural Formulation Interview was created based on literature reviews by an international consortium of culture and mental health experts (Aggarwal et al., 2015). The Cultural Formulation Interview is a brief (16 items) semi-structured interview and consists of protocols that enable mental health workers to obtain information about the impact of culture on important aspects of an individual’s mental health problems and care. In addition, an Informant Version of the Cultural Formulation Interview has been developed for obtaining collateral information from caregivers. Finally, 12 supplementary modules have been developed to inquire about topics introduced in the core Cultural Formulation Interview to assess specific populations including immigrants, asylum seekers, and refugees. The Cultural Formulation Interview distinguishes the following domains: 1. Cultural identity of the individual, including ethnic and race characteristics and other culturally defined characteristics. 2. Cultural concepts of illness, which affect how people experience mental health problems, including cultural explanations and cultural syndromes. The level of stigma of mental health problems and help-seeking plans are also relevant, including the use of traditional, alternative sources of care.

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3. Psychosocial stressors and cultural features of vulnerability and resilience, including stressors, social support, social networks, and social determinants of people’s mental health, taking into account the cultural background of people. 4. Cultural features of the relationship between the individual and the clinician, treatment team, and institution. Differences in cultural background and language may influence assessment and mental health care. Misunderstandings of the cultural significance of mental health symptoms may impede accurate diagnosis and may hinder the development of a clinical alliance. 5. Overall cultural assessment. The fifth domain summarizes information that may influence diagnosis and culturally appropriate management and treatment interventions. The Cultural Formulation Interview follows a person-centered approach to cultural assessment, focusing on individual’s experiences and cultural context of the mental health problems, and helps patients co-construct a narrative about their illness and treatment experience. The Cultural Formulation Interview is available online at www.psychiatry.org/dsm5. The Cultural Formulation Interview uses open-ended questions that increase patient satisfaction, and mental health workers are recommended to use patient terminology to build rapport. The Cultural Formulation Interview can be considered as a collaborative approach to psychological assessment focusing on questions that patients have about themselves with respect to their mental health problems. According to DSM-5, the Cultural Formulation Interview can also be used in the course of a mental health intervention, not just during the intake session. Use of the Cultural Formulation Interview can be helpful when there are differences in the cultural, ethnic, or religious background of the mental health worker and the patient, when there is uncertainty about culturally distinctive symptoms and formal DSM or ICD diagnostic criteria, or when mental health worker and patient disagree on treatment planning.

5.3.1 Research into the Usability of the Cultural Formulation Interview The Cultural Formulation Interview has been used in a DSM-5 field trial to test feasibility, acceptability, and clinical utility among patients and clinicians (Aggarwal et  al., 2015; Lewis-Fernández et  al., 2017). Results revealed that the Cultural Formulation Interview improved clinical communication among patients and clinicians by increasing alliance and eliciting patient narration. A few studies have described attitudes about cultural competence before and after Cultural Formulation Training (Aggarwal et al., 2020). In a small randomized trial, clinicians were able to implement the Cultural Formulation Interview after one training session with racially and ethnically diverse patients (Aggarwal et  al., 2022a). In another study, more than half of patients expressed in the Cultural Formulation Interview mistrust or ambivalence toward mental health workers as a result of different cultural backgrounds (Aggarwal et al., 2022b).

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A recent study in Sweden (Wallin et al., 2022) revealed that the implementation of the Cultural Formulation Interview in routine clinical practice enhanced identification of symptoms of certain psychiatric disorders (e.g., depression) among non-­ native-­speaking patients. The implementation of the Cultural Formulation Interview may be especially useful for assessing mental health problems in refugees and asylum seekers. The studies evaluating the use of the Cultural Formulation Interview have several limitations, including only very few clinical sites being involved, self-selected clinicians, and all studies discussed above being conducted by the same research group. As noted by Aggarwal et al. (2022a), studies are needed with variety in clinician disciplines and settings. One qualitative study conducted by another research group (Lindberg et  al., 2022) found less positive results with the Cultural Formulation Interview in mental health care for migrant patients in Denmark. Although the Cultural Formulation Interview was helpful for less experienced mental health workers, the study revealed that questions about cultural identity and cultural background led to distance in the interview. Half of the mental health workers felt discomfort and professional insecurity when they were forced by the Cultural Formulation Interview to discuss explanatory frameworks of culture in the mental health assessment, which had a negative effect on the alliance. This study shows that more intensive training and supervision are needed in the clinical application of the Cultural Formulation Interview. Migrant patients, however, were more positive. They found that the Cultural Formulation Interview recognized the complexity of their cultural identities and mental illness resulting in them feeling dignified and more positive about future mental health care (Lindberg et al., 2021). In another study (Skammeritz et  al., 2020), clinicians and migrant patients in outpatient clinics focusing on migrant health were quite satisfied with the use of the Cultural Formulation Interview. Patients with limited language proficiency were offered interpreting assistance. Most patients (93.0%) of a Middle Eastern origin (including patients who had to use an interpreter) were quite satisfied with the interview, which enabled them to tell their personal story, and found that the clinician showed understanding toward their cultural background. According to the clinicians, the Cultural Formulation Interview, when added to a standard clinical assessment in mental health care did in less than 10% of the cases, led to another diagnosis. The previous version of this structured interview, the Outline for Cultural Formulation, led to substantial revisions of diagnoses for 49% of patients in Canada (Adeponle et al., 2012) and for 57% of patients in Sweden (Bäärnhielm et al., 2015). Thus, the clinical utility of the Cultural Formulation Interview regarding the identification of symptoms and its usefulness in the diagnostic process were not considered high by the clinicians in the study of Skammeritz et al. (2020). Taken together, although the Cultural Formulation Interview has some value for adults, relatively few studies have evaluated the value of this interview for refugees and asylum seekers. Further, there is a clear need of studies investigating the importance of training in the administration of the Cultural Formulation Interview (Skammeritz et  al., 2020). One study revealed that training, especially about the

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concept of culture, is a conditio sine qua non (Ramírez Stege & Yarris, 2017). In addition, the surplus value of the usefulness in the diagnostic process has still to be established. Recent research shows that the Cultural Formulation Interview may also be relevant in child care. Children, adolescents, and their families with marginalized identities often experience barriers to engage in mental health services such as stigma, distrust of mental health services, and feeling not accepted by (mental) health care workers (e.g., Smith & Trimble, 2016; Young & Rabiner, 2015). Interestingly, in a randomized evaluation of the Cultural Formulation Interview in the assessment process of children and family, it was shown that the Cultural Formulation Interview is highly feasible for use with families from marginalized backgrounds (Sanchez et  al., 2022). In addition, results revealed that mental health providers reported higher satisfaction with the intake when they delivered the Cultural Formulation Interview than when they just delivered assessment as usual. Results also revealed that including a cultural focus into an intake assessment by using the Cultural Formulation Interview can significantly enhance family perceptions of being understood by their mental health workers. In addition, this study demonstrated that using the Cultural Formulation Interview during the intake assessment can improve subsequent treatment engagement. Nevertheless, it is questionable if the current version of the Cultural Formulation Interview is also useful for young children (La Roche & Bloom, 2020).

5.4 Questionnaires A number of questionnaires are widely used for assessment of the mental health needs of refugees and asylum seekers. Self-report questionnaires enable refugees to report mental problems without having to announce them loud, which may be especially useful when dealing with shame-related experiences and symptoms such as substance abuse, sexual abuse, and self-injury (Özkan & Belz, 2015). Most of these questionnaires have been translated in the native language of refugees/asylum seekers. For using these questionnaires, it is of importance that they are administered by psychologists, mental health specialists, trained medical practitioners, or trained lay people. One of the problems with the assessment of mental health problems with refugees and asylum seekers in low- and middle-income countries is that most questionnaires used are developed and investigated in Western high-income countries, thus reflecting the Western cultural interpretation of mental disorders. These cultural differences and lack of validation in other cultures (Hollifield et  al., 2002; Christy et al., 2021) may partly account for the variation in the prevalence of depression and post-traumatic stress disorder in conflict-affected people including refugees and asylum seekers (e.g., Charlson et al., 2019). A number of questionnaires which are used to assess psychopathology and quality of life are used in many different contexts around the world (e.g., Hopkins’ Symptom Checklist) and can also be used as general mental health measures with

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refugees and asylum seekers, whereas other measures have been designed specifically for refugees, asylum seekers, and other conflict-affected populations (e.g., Harvard Trauma Questionnaire). In an earlier review, the scientific quality of the mental health measures (reliability and validity) used with refugees and asylum seekers was rather low (Hollifield et  al., 2002). In a recent review (Christy et  al. 2021) of studies investigating the methodological quality of mental health questionnaires in conflict-affected adults living in low- and middle-income countries, it was found that a number of measures were adequately psychometrically validated. However, most psychometric studies did not evaluate the content validity, and in a number of studies, where this content validity was investigated, clarity about the construct that was measured was often lacking. As Christy et al. (2021) argue, there is a clear need to develop a conceptual framework as part of the process of developing new questionnaires for conflict-­ affected people including refugees and asylum seekers.

5.5 Assessment of Adults Although refugees are evaluated for (mental) health problems, currently there are no standardized screening and clinical practice guidelines for assessing mental disorders in refugees and asylum seekers.

5.5.1 Screeners to Assess Mental Health Problems There is limited available evidence with respect to screening measures used to assess mental health among refugee and asylum-seeking populations during resettlement in host countries. Generally, mental health screening is conducted by health professionals (e.g., nurses, physicians, community health workers) and/or clinical psychologists, or psychiatrists. In some cases, lay workers administered the screening (Mahmood et al., 2022). Apart from the use of structured clinical interviews (e.g., MINI, Sheehan et al., 1998), the most common specific tools for screening of refugees and asylum seekers are the Refugee Health Screener-15 (RHS-15), the Harvard Trauma Questionnaire (HTQ), the Hopkins Symptom Checklist-25 (HSCL-25) (Magwood et al., 2022), and the Kessler Screening Scale (Kessler et al., 2002). The main reason why these screeners are used widely rather than structured clinical diagnostic interviews is because of the financial resources involved by conducting structured clinical diagnostic interviews (Schlaudt et al., 2020). In clinical practice with refugees and asylum seekers for practical reasons, often culturally sensitive scales are used, such as the Arab Symptom Checklist (Stangier et  al., 2017) or the Afghan Symptom Checklist (Miller et al., 2006). The Refugee Health Screener-15 (RHS-15) (Hollifield et al., 2013) was developed to identify refugees who have symptoms of post-traumatic stress disorder, depression, and anxiety. In a number of studies, the Refugee Health Screener-15

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had good sensitivity and specificity in asylum seekers and refugees from different cultures (e.g., Bosson et al., 2017; Hollifield et al., 2013; Kaltenbach et al., 2017; Shaw et al., 2019). In a number of refugee cases, the Kessler et  al. (2002) 10-question screening scale (K10) or the 6-question short-form (K6) is used either by telephone screening interviews or by face-to-face clinical interviews. The K10 has been developed as a screening tool for mood and anxiety disorders and has shown good sensitivity and specificity for predicting mental disorders defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV/DSM-5) or by the World Health Organization Composite International Diagnostic Interview (CIDI). Translated versions of the ten-item scale (K10) and the six-item scale (K6) have good psychometric properties in Arabic (Easton et  al., 2017), Swahili/Tanzanian (Vissoci et  al., 2018), South African (Andersen et al., 2011; Hoffman et al., 2022; van Heyningen et al., 2018), Vietnamese (Kawakami et al., 2020), and Turkish languages (Fassaert et al., 2009) with generally good discriminating ability between non-cases and cases with mental disorders as defined by the DSM-IV or DSM-5. The Kessler Screening Scale has also been used in research with refugees (e.g., Acarturk et al., 2022; Bruck et al., 2021; Bryant et al., 2022; Rees et al., 2013; Slewa-Younan et al., 2015).

5.5.2 General Psychopathology The General Health Questionnaire (GHQ–28) (Goldberg, 1978) is an internationally applied and thoroughly validated self-administered questionnaire of 28 items for the assessment of psychiatric symptoms. Items are grouped into four subscales: anxiety and insomnia, severe depression, somatic symptoms, and social dysfunction. The items are rated on a 4-point Likert scale. The GHQ-28 has also been validated for Afghan and Arabic people (e.g., Alhamad & Al-Faris, 1998; Farhood & Dimassi, 2015; Kananian et al., 2022; Malakouti et al., 2007). The Hopkins Symptom Checklist (HSCL-25) (Derogatis et al., 1974) is a short version of the Symptom Checklist-90 (SCL-90). This scale is a thoroughly validated self-administered rating scale assessing the severity of anxiety and depression symptoms and consists of 25 questions, 10 regarding anxiety (HSCL-10) and 15 regarding depression (HSCL-15). Questions are rated from 1 to 4 as “Not at all,” “A little,” “Quite a bit,” and “Extremely,” respectively. Generally, there is some evidence that the 1.75 cutoff criterion for clinically relevant anxiety and depression is valid in a number of countries (e.g., Mollica et al., 1987). This scale is often used with refugees (e.g., Mollica et al., 1987; Tinghög et al., 2017). The Hopkins Symptom Checklist-25 is available in many languages including Indo-Chinese, Arabic and Farsi, Pashto (Afghanistan), Spanish, and Tibetan (e.g., Elsass et al., 2009; Mahfoud et al., 2013; Mahmood et al., 2022; Mattisson et al., 2013; Nabbe et al., 2019; Tremblay et al., 2009; Ventevogel et al., 2007). The HSCL-25 has been validated in Arabic-speaking individuals, in which group the recommended cutoff for clinical caseness of anxiety on the HSCL-10 is 2.0 and for depression on the HSCL-15 is 2.1 (Mahfoud et  al., 2013). Recently

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(Vindbjerg et  al., 2022), a computer-assisted self-interviewing variant of the Hopkins Symptom Checklist was compared with the paper-and-pen administration in a large and representative sample of refugees from sites in Australia, New Zealand, and Denmark. No significant differences between the two modalities were found, which suggests that the multilingual computer variant can be used for screening as well.

5.5.3 Post-traumatic Stress A variety of measures have been used to assess post-traumatic stress disorder in refugees and asylum seekers, which are briefly described. The Harvard Trauma Questionnaire (HTQ) is a widely applied self-administered scale assessing the severity of post-traumatic stress disorder according to DSM-IV criteria. The first 16 questions of the symptoms part are used to monitor post-­ traumatic stress disorder symptoms. The DSM-IV score is the mean of the first 16 items scored from 1 (“not at all”) to 4 (“extremely”), and a cutoff ≥2.5 is generally considered an indication of post-traumatic stress disorder. The Harvard Trauma Questionnaire has been adapted for DSM-5 (Michalopoulos et  al., 2015). The Harvard Trauma Questionnaire has been validated in many languages, including Arabic and Farsi, and cultures (e.g., Berthold et  al., 2019; Mollica et  al., 1992; Shoeb et al., 2007; Tay et al., 2017; Vindbjerg et al., 2016; Wind et al., 2017) and may be superior to other trauma screeners (Sondergaard et al., 2003). The Posttraumatic Diagnostic Scale (PDS) (Foa, 1995) is another self-report instrument to assess post-traumatic stress symptoms and traumatic events. Good validity and reliability have been found not only for the original English version (Foa et al., 1997), but for the Arabic version as well (Norris & Aroian, 2007). The Posttraumatic Diagnostic Scale has been used with refugees (e.g., Lenferink et al., 2022b; Nickerson et al., 2015). Primary Care Posttraumatic Stress Disorder screening questionnaire (PC-PTSD; Prins et al., 2003) is used to screen for post-traumatic stress disorder, based on the Diagnostic and Statistical Manual of Mental Disorders diagnostic criteria (DSM-IV). The questionnaire was developed in a primary care setting of veterans and consists of four questions related to a traumatic life event: In the past month, you (1) have had nightmares about it or thought about it when you did not want to? (2) Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? (3) Were constantly on guard, watchful, or easily startled? (4) Felt numb or detached from others, activities, or your surroundings? The screen is positive when a patient answers “yes” to three out of four questions. The performance of this four-­ item screen was found to be equal to the Posttraumatic Diagnostic Scale (Foa et al., 1997) discussed above, which assesses post-traumatic stress disorder symptom severity on all 17 criteria of the fourth revision of DSM-IV (van Dam et al., 2013). The Primary Care Posttraumatic Stress Disorder screening questionnaire is highly sensitive (van Dam et  al., 2010, 2013), translated in various languages including Arabic, and has been used with refugees (e.g., Aoun et al., 2018).

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The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) ( Weathers et al., 2013) is a 20-item self-report instrument, which assesses symptoms of post-­ traumatic stress disorder as defined by the DSM-5. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the Posttraumatic Stress Disorder Checklist-5 now includes new symptoms which reflect the four symptom clusters of DSM-5: (1) re-experiencing, (2) avoidance, (3) negative alterations in cognition and mood, and (4) increased arousal and reactivity. The items reflect the frequency with which people have experienced the item in question rated on a 5-point Likert scale ranging from “not at all” to “extremely,” with a total score (range 0–80). This questionnaire has been validated (e.g., Ashbaugh et al., 2016; Blevins et al., 2015). A total score on the Posttraumatic Stress Disorder Checklist for DSM-5 at or above the cutoff score of 33 has been recommended as an indication of possible post-­ traumatic stress disorder. However, based on the studies of Ibrahim et  al. (2018, 2019), a cutoff score of 23 is a better criterion for a diagnosis of post-traumatic stress disorder among the Arab and Kurdish communities. The International Trauma Questionnaire (ITQ) (Cloitre et al., 2018) is a rather brief self-report measure containing 18 items measuring the core features of post-­ traumatic stress disorder including complex post-traumatic stress disorder according to the criteria from the International Classification of Diseases (ICD-11). In ICD-11, the post-traumatic stress disorder diagnosis comprises three symptom clusters (re-experiencing, avoidance, and sense of current threat). In addition, in ICD-11, complex post-traumatic stress disorder is included, which encompasses the consequences of complex traumatic experiences and includes three additional symptom clusters: (1) affect dysregulation, (2) negative self-concept, and (3) difficulties in interpersonal relationships. The International Trauma Questionnaire consists of two subscales (post-traumatic stress disorder and disturbances in self-organization), yielding a total stress score as well (Kaptan et al., 2022; Vallières et al., 2018). The Global Meaning Violations Scale (GMVS; Park et al., 2016) assesses violations related to respondents’ “most stressful experience” across three dimensional subscales: Belief Violation (e.g., “violation of your sense that God is in control”), Intrinsic Goal Violation (e.g., “interference with your ability to accomplish self-­ acceptance”), and Extrinsic Goal Violation (e.g., “interference with your ability to accomplish educational achievement”). Items are rated on a 5-point scale ranging from 1 (“not at all”) to 5 (“very much”). Cronbach’s alpha values were moderate: Belief Violation, Cronbach’s α = 0.72; Intrinsic Goal Violation, Cronbach’s α = 0.66; and Extrinsic Goal Violation, Cronbach’s α = 0.61. One study (Matos et  al., 2022) evaluated the cross-cultural adaptation of the Global Meaning Violation Scale for use with Arabic-speaking Syrian refugees resettled in Portugal who endorsed exposure to multiple extreme traumatic experiences, including torture. Only 43 war-affected Syrians participated in this study, all relatively young students, which renders results difficult to interpret. The study used a sequential design, where in the first phase the Global Meaning Violation Scale-­ ArabV was investigated for the comprehensibility of test instructions, item content, and language, and in phase 2 individual interviews were held. Results of the first phase suggested a number of adaptations of the Global Meaning Violation

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Scale-­ArabV. Results of qualitative interviews in phase 2 revealed that beliefs and goals were differentially violated by different stressors.

5.5.4 Depressive Symptoms The Patient Health Questionnaire-9 (Kroenke et al., 2001; Kroenke et al., 2009) is the depression module of the Patient Health Questionnaire, which scores each of the nine DSM-IV criteria on a 4-point scale ranging from “0” (not at all) to “3” (nearly every day), and the total score indicates the intensity of depressive symptoms over the past 2 weeks. The scale has been validated in Arabic refugees (Al-Amer et al., 2020) and in sub-Saharan Africa (Gelaye et al., 2013; Kasujja et al., 2022; Nakku et al., 2016; Sebera et al., 2020; Sweetland et al., 2014). The Center for Epidemiologic Studies Depression Scale (CES-D) (Radloff, 1977) constitutes four dimensions: positive affect, negative affect, somatic symptoms and retarded activity, and interpersonal difficulties. A number of studies have addressed cross-cultural measurement invariance of this scale. Although there is some support for the originally proposed four-factor structure, a two- or three-factor model does better apply to the data in many studies on individuals from different cultures (e.g., Getnet and Alem 2019; Wang et al., 2013). The Center for Epidemiologic Studies Depression Scale has been employed in conflict-affected people including refugees in Bosnia (Miller et  al., 2002), Eritrean (Getnet and Alem 2019), and Rwanda (Lacasse et al., 2014). The scale has been translated into many languages.

5.5.5 Somatic Symptoms The Somatic Symptom Scale-8 (SSS-8) (Gierk et al., 2014) is based on items of the Patient Health Questionnaire. Each item is rated on a 5-point Likert scale from “not at all” to “very much” referring to the previous 7 days. The total scores range from 0 to 32. Psychometric measures in studies with refugees are satisfactory (Nesterko et al., 2020a, 2020b). There are clear culturally based differences in scores on the Somatic Symptom Scale between symptom presentation of ethnic populations with a different cultural background (Vietnamese versus German mental health patients) (Dreher et al., 2017).

5.5.6 Symptoms of Insomnia The Insomnia Severity Index (ISI-7) (Bastien et  al., 2001) assesses the symptom severity of insomnia. This questionnaire consists of seven items scored from 0 to 4: a sum of ≥15 indicates moderate insomnia, and ≥22 indicates severe insomnia. The Insomnia Severity Index has been translated into several languages and has been used with refugees (e.g., Al-Smadi et al., 2019; Meurling et al., 2023; Sadeghniiat-­ Haghighi et al., 2014).

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5.5.7 Grief Grief in refugees and people living in conflict areas has been assessed with structured interviews (Bryant et al., 2021) such as the Culturally Adapted Checklist for Complicated Grief (Tay et  al., 2016, 2019). More recently, a questionnaire was developed to assess complex bereavement disorder and DSM-5-TR and ICD-11 prolonged grief disorder: The Traumatic Grief Inventory-Self Report Plus (TGI-SR+) (Lenferink et al., 2022a, 2022b). The Traumatic Grief Inventory-Self Report Plus is available in Arabic, Tamil, and Farsi and has been used with refugees in Australia (Lenferink et al., 2022a, 2022b).

5.5.8 Embitterment As discussed in Chap. 1, a substantial number of refugees are characterized by embitterment as a response to unfairness and humiliation during and after their flight, which can result in dysfunctional behavior including withdrawal from social contacts, negativism, and even acts of revenge. Traumatized refugees are particularly vulnerable for clinical embitterment (Linden & Teherani, 2020). One exploratory study (Spaaij et al., 2021) investigated a short six-item version of the Bern Embitterment Inventory with refugees. Items are rated on a 5-point scale (0 = “not true at all” to 4 = “extremely true”). The items selected for the short version of the Bern Embitterment Inventory showed high internal consistency (α = 0.84). There is a clear need of further studies which psychometrically evaluate and validate this questionnaire with refugees.

5.5.9 Post-migration Living Difficulties There is increasing evidence that psychological impairment in refugees is associated with high levels of post-migration living difficulties (see Chap. 1). The Post-­ Migration Living Difficulties (PMLD) (Silove et al., 1997) questionnaire is a widely used self-report instrument, which assesses resettlement stress over the past year, covering problem areas such as applying for refugee status, having no employment, acculturation difficulties, family conflict, discrimination, feeling isolated, access to health care, and poverty. The Post-Migration Living Difficulties questionnaire contains 25 items, which are rated on a 5-point Likert scale (0 = “not a problem” to 4 = “very serious problem”). Items scored at least 2 (“moderately serious problem”) are considered positive responses, yielding a total count of living difficulties. High scores point to high levels of post-migration stressors. The developers recommended to adapt the scale to the typical context of the individuals who complete the questionnaire, which makes the results difficult to compare across studies. Schick et al. (2016) found higher scores on the Post-Migration Living Difficulties questionnaire to be associated with mental health problems among refugees. In a 3-year follow-up study by the same group (Schick et  al., 2018), Post-Migration Living

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Difficulties predicted changes over time in depression and anxiety, but not in post-­ traumatic stress symptoms. The Post-Migration Living Difficulties questionnaire is available in a number of languages including Arabic and Farsi.

5.5.10 General Well-Being and Health Status The WHO Disability Assessment Schedule (WHO-DAS 2.0) is a screener for impaired functioning. The WHO-DAS (Üstün et al., 2010) is a generic assessment instrument assessing general functioning, health, and disability, covering six domains (cognition, mobility, self-care, getting along, life activities, and participation). It assesses difficulties people have due to their mental distress across these domains during the last 30 days. The WHO-5 Well-Being Index (WHO-5) (see Topp et al., 2015) is a short self-­ administered questionnaire evaluating the quality of life, consisting of five questions asking individuals to rate their answers over the last week on a scale from 0 (“none of the time”) to 5 (“all of the time”). This scale can also be used with adolescents (e.g., Blom et al., 2012; Brown et al., 2022). The WHO-5 Well-Being Index has been validated across settings and cultures and is available in Arabic and Farsi (e.g., Bech, 2012; Sibai et al., 2009; Topp et al., 2015). European Quality of Life (EQ-5D-5L) (Balestroni & Bertolotti, 2015) is a self-­ administered questionnaire on health status comprising five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression (Janssen et al., 2013). The psychometric properties are good in many cultures (Feng et al., 2021). This self-rating scale is used with refugees (e.g., Gottvall et al., 2020; Grochtdreis et al., 2021) and available in many languages including Arabic and Farsi.

5.6 Assessment of Children and Adolescents The assessment of mental health problems in refugee children and adolescent refugees is a complex matter, which should take into account not only developmental but cultural issues as well (Song & Ventevogel, 2020). As a first step, the Cultural Formulation Interview may be helpful to get a better understanding of culture and context of mental health and behavioral problems (Sanchez et al., 2022), although it may be less useful in younger children (La Roche & Bloom, 2020). Culture may also play a role in the willingness of children to fill out questionnaires and to discuss mental problems in interviews with clinicians and case workers. Generally, parents or caregivers are interviewed as well, but they should be interviewed separately, which may facilitate more open communication. Importantly, with adolescents, it is advisable to interview the child/adolescent first, but with younger children, it is recommended to interview parents or caregivers first (Song & Oakley, 2020). A number of rating scales are used by clinicians and trained paraprofessionals with refugee children such as the Clinician-Administered PTSD Scale for Children and Adolescents (CAPS-CA-5) (Pynoos et  al., 2015). The CAPS-CA-5 is a

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modified version of the CAPS-5 Post-Traumatic Stress Disorder scale (Nader et al., 1996; Nader, 2004) but now based upon DSM-5 criteria for children and adolescents aged 7 and above. The CAPS-CA-5 assesses the 20 DSM-5 post-traumatic stress disorder symptoms and onset, duration and impact of symptoms on social functioning, and specifications for the dissociative subtype (depersonalization and derealization). The CAPS-CA-5 can also be administered by appropriately trained paraprofessionals (Pynoos et al., 2015).

5.6.1 General Psychopathology A number of questionnaires have been used with refugee children and adolescent refugees. The most important questionnaires are summarized below. The Strengths and Difficulties Questionnaire (SDQ) (Goodman, 1997; Goodman et  al., 2000) is a 25-item screening scale designed to assess general psychological distress in children from 11 to 16  years old. The questionnaire assesses not only emotional and behavioral problems, but hyperactivity, peer relation problems, and pro-social behavior as well. It can be completed either by children aged 11  years and older or by their parents, caregivers, or teachers. It contains five subscales: (1) emotional symptoms, (2) conduct problems, (3) hyperactivity/inattention, (4) peer relationship problems, and (5) pro-social behavior. To assess overall childhood mental health problems, the first four subscale scores can be summed. The sum of subscales 1 (emotional symptoms) and 4 (peer problems) results in internalizing, and the sum of subscales 2 (conduct problems) and 3 (hyperactivity) results in externalizing (Goodman & Goodman, 2009). Although the self-report version is intended for use with children older than 10 years, it has also been used and validated with younger children (Curvis et al., 2014). The Strengths and Difficulties Questionnaire is used with refugee children, adolescent refugees, and children living in conflict areas (e.g., Barron et al., 2016; Düren & Yalçın, 2022; El-Khani et al., 2021; Gormez et al., 2018; Kevers et al., 2022; Qouta et al., 2012).

5.6.2 Depressive Symptoms Depression Self-Rating Scale for Children (DSRS) (Birleson, 1981; Birleson et al., 1987) is designed to measure symptoms of depression and includes 18 items, which are scored on a 3-point Likert-type scale ranging from 0 (“never”) to 2 (“most of the time”). The total scores of the questionnaire range from 0 to 36, with a score of 15 points or higher indicating probable depression. The Depression Self-Rating Scale for Children is available in several languages, including Arabic, Farsi, and Urdu (www.childrenandwar.org), and has been used in a number of studies with child refugees and children in conflict areas (e.g., Barron et  al., 2013; El-Khani et  al., 2021; Giannopoulou et al., 2022; Lange-Nielsen et al., 2012; Sanchez-Cao et al., 2013; Ventevogel et al., 2014).

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The Patient Health Questionnaire-9 (PHQ-9) (Johnson et  al., 2002) has been used to measure symptoms of depression in adolescents (Richardson et al., 2010). A total score of ≥10 suggests an increased risk for detecting depression (Manea et al., 2012. The scale has been psychometrically investigated with Arabic-speaking adolescent refugees (Al-Amer et al., 2020).

5.6.3 Post-traumatic Stress The Children’s Revised Impact of Event Scale (CRIES-13) is a self-report questionnaire for 8- to 18-year-olds, developed by the Children and War Foundation to assess the risk of developing post-traumatic stress disorder. This questionnaire has often been used with war-affected children (Perrin et al., 2005). This scale has a child and a parent version. The measure has an 8-item version (four for intrusion and four for avoidance) and a 13-item version (with an additional five items for arousal symptoms). This scale has been used with children and youth from diverse cultural backgrounds (e.g., van Es et al., 2021). Studies (e.g., Smith et al., 2003) revealed that intrusion and avoidance on the Impact of Event Scale are robust and separable factors, based on three subscales: intrusion, avoidance, and arousal. The items are rated on a 4-point scale ranging from “not at all” to “often.” A total score of ≥30 for the 13-item version is considered as the cutoff score for post-traumatic stress disorder (Perrin et  al., 2005). The Children’s Revised Impact of Event Scale has been used with refugee children and children in conflict areas (e.g., Alzaghoul et al., 2022; Giannopoulou et al., 2022; Smith et al., 2003; Perrin et al., 2005) and is available in several languages (www.childrenandwar.org). The Children’s Post-Traumatic Cognitions Inventory (cPTCI) (MeiserStedman et al., 2009) is a 25-item self-report questionnaire that measures maladaptive or overly negative post-traumatic thoughts and appraisals of the world and the self in young people following exposure to trauma. Children indicate on a 4-point Likert scale to what extent they agree with each item. The Children’s Post-Traumatic Cognitions Inventory has been used with unaccompanied refugee minors (Giannopoulou et  al., 2022) and with war-affected children (Kangaslampi et al., 2016). The Children’s Post-Traumatic Cognitions Inventory is available in several languages, including Arabic, Farsi, and Urdu (www.childrenandwar.org). The Reactions of Adolescents to Traumatic Stress questionnaire (RATS) (Bean et  al., 2006) is a multicultural self-report scale measuring post-traumatic stress symptoms according to DSM-IV. This questionnaire has been used with adolescent refugees, including unaccompanied minors. Translations are available in 19 languages (Pfeiffer et al., 2022). A few studies (e.g., Brown et al., 2022; Bryant et al., 2022) have used other measures related to mental health of refugee children, e.g., the Child Behavior Checklist (CBCL) to assess emotional and behavior problems in unaccompanied refugees (Bean et  al., 2006; Walg et  al., 2022); the Pediatric Symptom Checklist (Jellinek

5.7  Other Issues Relevant for Assessment

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et  al., 1999) to assess internalizing, externalizing, and attentional problems; the Child Trauma Screening Questionnaire (CTSQ; Kenardi et al., 2006); and a caregiver version of the Child PTSD Symptom Scale (Marshall & Venta, 2021). Other measures which may be relevant for parental and family functioning are the Alabama Parenting Questionnaire-42 (APQ; Maguin et  al., 2016) to measure parental involvement, inconsistent discipline, and parental punishment and the Systemic Clinical Outcome and Routine Evaluation (SCORE) Index of Family Functioning (Jewell et al., 2013).

5.7 Other Issues Relevant for Assessment 5.7.1 Assessing Partner Violence Intimate partner violence is a serious problem among refugees and asylum seekers (see Chap. 1; Brooks et al., 2022; Wirtz et al., 2013). Intimate partner violence may consist of verbal, physical, and/or sexual violence resulting not only in (severe) injuries, but in mental problems as well including post-traumatic stress symptoms, suicidal ideation, and substance use disorders. Assessment of partner violence is difficult in Western countries and may even be more difficult among refugees and asylum seekers (Sprague et al., 2012; Wirtz et al., 2013). The Conflict Tactics Scale (Straus et al., 1996) is often used to assess perpetration and victimization of intimate partner violence, including in individuals from diverse cultural backgrounds (e.g., African Americans and Hispanic Americans), in over 20 different countries (Straus, 2004). However, this questionnaire consists of 78 items; it is not realistic to use this questionnaire with refugees and asylum seekers. Kraanen et  al. (2013) developed a 4-item screening instrument, the Jellinek Inventory for assessing Partner Violence. Important strengths of the Jellinek Inventory for assessing Partner Violence are that it takes only 2 min to administer and is easy to use and to score. This inventory has the format of a structured interview. The first two questions address victimization of intimate partner violence in the past year; the latter two questions address perpetration of intimate partner violence in the past year. This structured interview possesses good psychometric properties to detect perpetrators and victims of any as well as severe intimate partner violence. If perpetrators and victims of partner violence are identified, action can be taken to stop intimate partner violence perpetration and arrange help for victims, for example by offering perpetrators treatment or by providing safety planning to victims (Kraanen et al., 2013). Although the Jellinek Inventory for assessing Partner Violence demonstrated good psychometric properties in two different treatment centers, these findings do not necessarily generalize to refugees and asylum seekers. In a study in the United States, also a four-item screening test for intimate partner violence was investigated among active-duty service members (Heyman et  al., 2021). Results revealed that this four-item screener resulted in high sensitivity for partner violence. To the best of my knowledge, these screeners have not yet been investigated among refugees and asylum seekers.

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5.7.2 Internet-Based Tools for Screening of Refugee Mental Health Relatively few studies have used Internet-based tools for clinical assessment, including screening for identifying psychological symptoms in refugees (e.g., Morina et al., 2017; Vindbjerg et al., 2022). In the study of Morina et al. (2017), the feasibility and usability of a newly developed Audio Computer-Assisted Self-­ Interview (CASI) software for touchscreen devices were investigated for screening purposes in a clinical setting with refugees in Switzerland. Using Audio CASI allowed refugees in this study to listen to each question and response set in their own language (Arabic, Farsi, Tamil, or Turkish), which is particularly useful for illiterate patients. The administration via Audio CASI took significantly less time than the paper-pencil interview. Results were confirmed in a larger study with refugees in Australia, Denmark, and New Zealand (Vindbjerg et al., 2022).

5.7.3 Hierarchical Screening Model An interesting development for screening of mental health problems of refugees is a hierarchical screening model (see Batterham et  al., 2013). In this hierarchical model, one starts with an initial brief general screener followed by more specific screening instruments only for individuals that meet specified clinical criteria in the previous step. This hierarchical selection process has the potential to screen for multiple mental disorders and to increase efficiency gains without reducing accuracy (Batterham et al., 2013). In a recent study (Meurling et al., 2023), an online tiered screening procedure for mental health problems, adapted for refugees and asylum seekers, was investigated in Sweden. The purpose of this online screening system was to target clinically relevant symptoms of anxiety, depression, post-­ traumatic stress disorder, and insomnia. This screening procedure identifies symptoms of mental distress in the first tier to identify as many refugees as possible with psychological distress and prevent further assessment of individuals with no symptoms. The second tier differentiates between symptoms of various mental disorders, and in the last tier, the severity of mental symptoms (i.e., anxiety, depression, post-­ traumatic stress, and insomnia) is assessed. Measures are based on existing questionnaires (e.g., Refugee Health Screener in tier 1). In the study of Meurling et al. (2023), over 750 refugees and asylum seekers (youth and adults, aged 15 years or above) residing in Sweden, speaking Arabic, Dari, Farsi, English, or Swedish, completed an online questionnaire following the three-tiered procedure with screening instruments for each tier. Half of the participants were asylum seekers with no or temporary residence permits. Results revealed that the online tiered procedure could reduce the item burden while maintaining high accuracy. This online screening system identified clinically relevant symptoms of common mental disorders among refugees and asylum seekers. Only about 1% of participants with severe symptoms were missed with this online hierarchical screening model. Given the success of this procedure with refugees and asylum seekers in Sweden, there is a clear need of

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further research using such online tiered procedures to screen for mental health problems among refugees.

5.8 Concluding Remarks Assessment may provide a wealth of information to the clinician, but a standardized assessment battery including most of the measures described here is not recommended. It is important to communicate to the refugee people what the purpose of the assessment is, and not to overburden the patient with measures. As a general rule, when administering a specific questionnaire or structured interview, the clinician should consider in which way the results will facilitate the selection of the most appropriate treatment.

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Qouta, S. R., Palosaari, E., Diab, M., & Punam, R. (2012). Intervention effectiveness among war-­ affected children: a cluster randomized controlled trial on improving mental health. Journal of Traumatic Stress, 25(3), 288–298. Radloff, L. S. (1977). The CES-D Scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385–401. Ramírez Stege, A. M., & Yarris, K. E. (2017). Culture in la Clínica: Evaluating the utility of the cultural formulation interview (CFI) in a Mexican outpatient setting. Transcultural Psychiatry, 54(4), 466–487. Rees, S., Silove, D. M., Tay, K., & Kareth, M. (2013). Human rights trauma and the mental health of West Papuan refugees resettled in Australia. The Medical Journal of Australia, 199(4), 280–283. https://doi.org/10.5694/mja12.11651 Richardson, L.P., McCauley, E., Grossman, D.C., McCarty, C.A., Richards, J., Russo, J.E., Rockhill C, Katon W et al. (2010). Evaluation of the patient health questionnaire-9 item for detecting major depression among adolescents. Pediatrics,126(6):1117–1123. Sadeghniiat-Haghighi, K., Montazeri, A., Khajeh-Mehrizi, A., Nedjat, S., & Aminian, O. (2014). The insomnia severity index: cross-cultural adaptation and psychometric evaluation of a Persian version. Quality of Life Research, 23(2), 533–537. Sanchez, A.  L., Jent, J., Aggarwal, N.  K., Chavira, D., Coxe, S., Garcia, D., La Roche, M., & Comer, J. S. (2022). Person-centered cultural assessment can improve child mental health service engagement and outcomes. Journal of Clinical Child and Adolescent Psychology, 51(1), 1–22. https://doi.org/10.1080/15374416.2021.1981340 Sanchez-Cao, E., Kramer, T., & Hodes, M. (2013). Psychological distress and mental health service contact of unaccompanied asylum-seeking children. Child: Care, Health and Development, 39, 651–659. https://doi.org/10.1111/j.1365-­2214.2012.01406.x Sandhu, S., Bjerre, N. V., Dauvrin, M., Dias, S., Gaddini, A., Greacen, T., Ioannidis, E., Kluge, U., Jensen, N. K., Lamkaddem, M., & Puigpinós i Riera, R. (2013). Experiences with treating immigrants: a qualitative study in mental health services across 16 European countries. Social Psychiatry and Psychiatric Epidemiology, 48, 105–116. Schick, M., Morina, N., Mistridis, P., Schnyder, U., Bryant, R.  A., & Nickerson, A. (2018). Changes in post-migration living difficulties predict treatment outcome in traumatized refugees. Frontiers in Psychiatry, 9, 476. https://doi.org/10.3389/fpsyt.2018.00476 Schick, M., Zumwald, A., Knopfli, B., Nickerson, A., Bryant, R.  A., Schnyder, U., Muller, J., & Morina, N. (2016). Challenging future, challenging past: the relationship of social integration and psychological impairment in traumatized refugees. European Journal of Psychotraumatology, 7, 28057. https://doi.org/10.3402/ejpt.v7.28057 Schlaudt, V. A., Bosson, R., Williams, M. T., German, B., Hooper, L. M., Frazier, V., Carrico, R., & Ramirez, J. (2020). Traumatic experiences and mental health risk for refugees. International Journal of Environmental Research and Public Health, 17(6), 1943. https://doi.org/10.3390/ ijerph17061943 Schwarz, M. (2009). Is psychology based on a methodological error? Integrative Psychological & Behavioral Science, 43, 185–213. Sebera, F., Vissoci, J., Umwiringirwa, J., Teuwen, D., Boon, P., & Dedeken, P. (2020). Validity, reliability and cut-offs of the Patient Health Questionnaire-9 as a screening tool for depression among patients living with epilepsy in Rwanda. PLoS One, 15, e0234095. Sha, M., & Gabel, T. (2020). The essential role of language in survey research. RTI Press publication No. BK-0023-2004. https://doi.org/10.3768/rtipress.bk.0023.2004 Shaw, S.  A., Karim, H., Bellows, N., & Pillai, V. (2019). Emotional distress among Rohingya refugees in Malaysia. Dermatologia Internationalis, 17, 174–180. Sheehan, D. V., Lecrubier, Y., Sheehan, K. H., Amorim, P., Janavs, J., & Weiller, E. (1998). The Mini-International Neuropsychiatric Interview (M.I.N.I.): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. The Journal of Clinical Psychiatry, 59(Suppl 20), 22–33; quiz 34–57. PMID: 9881538 Shoeb, M., Weinstein, H., & Mollica, R. (2007). The Harvard Trauma Questionnaire: Adapting a cross-cultural instrument for measuring torture, trauma and posttraumatic stress disorder in

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Mental Health and Social Support Interventions

6.1 Introduction Research into the treatment of mental health problems in refugees and asylum seekers has primarily focused on post-traumatic stress disorder, but the prevalence of anxiety, depression, and somatization symptoms is comparable to the prevalence of post-traumatic stress symptoms among refugees and asylum seekers. Post-migration living difficulties also account for common mental disorders in refugees and asylum seekers (e.g., Hartonen et al., 2020; see Chap. 1). Cognitive behavioral techniques and narrative exposure therapy are the most well-established intervention methods for treating post-traumatic stress in refugees and asylum seekers, which will be discussed in Chaps. 7 and 8, but there is a need for randomized intervention studies, investigating other mental health problems such as anxiety, depression, and somatization (Sambucini et al., 2020). Evidence-based psychological treatments are among the most effective mental health interventions for treating common mental disorders (Ormel & Emmelkamp, 2023), but they are not accessible for most individuals living in low- and middle-­ income countries (Koesters et al., 2018), not only due to limited number of specialists to provide evidence-based psychological interventions (Kohrt et al., 2015), but also due to the stigma of seeking help for mental health problems (Semrau et al., 2015). Thus, although effective evidence-based interventions to treat common mental disorders are available, these interventions require expert mental health specialists providing psychological interventions that are often rather lengthy and thus very costly to the health service in low- and middle-income countries. As a result, refugees have a reduced chance of receiving adequate and evidence-based mental health care (Böge et al., 2020; Jefee-Bahloul et al., 2016; Silove et al., 2017). In addition, psychotherapeutic methods tend to focus on past trauma and symptoms of post-­ traumatic stress disorder in refugees and asylum seekers and to pay less attention to post-migration psychosocial stressors and to the role of sociocultural factors in the development and reduction of symptoms (Orang et al., 2022). © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 P. M. G. Emmelkamp, Mental Health of Refugees, https://doi.org/10.1007/978-3-031-34078-9_6

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Thus, there is a clear need for the development and evaluation of mental health interventions, which are culturally sensitive and can be easily implemented in lowand middle-income countries. There is some evidence that culturally adapted mental health interventions which are targeted for a specific cultural group and are conducted in the patents’ native language are more effective than traditional mental health treatment programs (e.g., Griner & Smith, 2006). The Adaptation and Development After Persecution and Trauma (Silove, 2013) model has been proposed as a conceptual framework for providing mental health and psychosocial support to support conflict-affected populations, including refugees and asylum seekers. In addition, targeting trans-diagnostic processes have been proposed for the treatment of mental health problems in refugees. The advantage of trans-diagnostic approaches is that these approaches enable to address multiple disorders at the same time, hopefully resulting in generalization of treatment effects (McEvoy et al., 2009). A trans-diagnostic approach has the advantage that it can be delivered to a great number of refugees by providing (group) interventions to refugees who are homogeneous in culture and language, but may differ in diagnoses (Koch et al., 2020a; Koch et al., 2020b).

6.2 Mental Health Gap Action Programme Therefore, short treatments based on “evidence-based” interventions have been recommended by the WHO (2010a, 2010b) in the Mental Health Gap Action Programme in order to address the global treatment gap and the limited mental health workforce in low- and middle-income countries (e.g., Murray et al., 2011). As recommended by the WHO, interventions should be short and relatively easy to administer, so they can be carried out by nonspecialist helpers in the community, such as lay health workers. Further, according to the Mental Health Gap Action Programme, interventions should not target one outcome only such as post-­traumatic stress, but should focus on a broad range of mental health problems, including common mental and psychosocial health problems and general functioning. Thus, the primary principles of these WHO interventions are that they are: –– Trans-diagnostic in order to relieve distress in common mental disorders –– Have a restricted number of sessions –– Are deliverable by lay health workers The limited mental health workforce has been addressed by training and supervision of lay workers and adaptation of mental health interventions which have been found effective in Western cultures (e.g., Murray et al., 2011; Patel et al., 2010). In addition, necessary cultural adaptations of evidence-based mental treatments have been made as well (Dawson et al., 2015). Most of these interventions can be applied by nonmental health professionals after brief training and include the Common Elements Treatment Approach (CETA) (Murray et  al., 2013), Integrative Adapt Therapy (IAT) (Tay & Silove, 2016),

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Problem Management Plus (Dawson et  al., 2015), and Self-Help Plus (Epping-­ Jordan et al., 2016). These interventions aim to improve general mental health by focusing on resilience and learning skills to cope with stress, including psychoeducation, stress management, behavioral activation, and cognitive reappraisal. These WHO programs and a few other programs have been developed and evaluated with refugees (e.g., Bolton et al., 2014; Epping-Jordan et al., 2016; Koch et al., 2020a; Koesters et  al., 2018; Tay et  al., 2020; Trilesnik et  al., 2019; van Heemstra et al., 2019). Most studies have evaluated the effectiveness of Problem Management Plus, a five-session psychological intervention program, that can be delivered by nonspecialist lay workers as “counselors” that addresses common mental disorders in people affected by adversity (Dawson et al., 2015).

6.3 Problem Management Plus The WHO has produced Problem Management Plus as a low-intensity evidence-­ based intervention aimed at reducing symptoms of common mental disorder in people living in communities affected by adversity, which are manageable in low-­ income countries (Turrini et  al., 2017). More specifically, Problem Management Plus is a brief intervention (five sessions) developed for adults suffering from symptoms of common mental health problems including anxiety, stress, depression, or grief, as well as for practical problems such as interpersonal conflict or unemployment. Treatment with Problem Management Plus is not recommended for individuals with more severe mental health problems such as severe cognitive impairment (e.g., severe intellectual disability or dementia), psychosis, or high risk for suicide (Dawson et al., 2015; Rahman et al., 2016a, 2016b). Problem Management Plus is developed as a trans-diagnostic intervention based on the idea that addressing multiple problems at the same time may be more efficient than treating one disorder after the other. One of the advantages of this approach is that making differential diagnoses is not needed. The Problem Management Plus intervention consists of relatively simple, nonintrusive, non-­ trauma-­focused techniques. It can be offered by briefly trained but supervised lay helpers to men and women impaired by distress. In Problem Management Plus, problem-solving and other evidence-based behavioral treatments are integrated (e.g., Bennett-Levy et  al., 2010). Cognitive techniques were not included since these would likely be much more difficult to learn by patients and lay helpers (Dawson et al., 2015). In Problem Management Plus, patients are seen face to face (individually) by trained and supervised lay workers for five weekly sessions of 90 min each. Patients are recommended to practice the strategies learned in each session, which “homework” is discussed in the following sessions. Problem Management Plus starts with psychoeducation about common reactions to adversity and with the treatment rationale. A brief motivational interviewing component is included as well. Four core strategies are included:

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Managing stress Managing problems Get going, keep doing Strengthening social support

In managing stress, the lay worker teaches a simple stress management strategy in order to reduce anxiety and to enhance relaxation by teaching slow breathing given that this is acceptable in a number of different cultures. In managing problems, starting in the second session, patients have to learn skills to address their practical problems, based on the evidence-based problem-solving approach (e.g., Bowen et  al., 1995), including differentiating problems as “solvable,” “unsolvable,” or “unimportant,” which had been found to be effective in deprived communities (van’t Hof et al., 2011). Get going, keep doing is based on the behavioral activation strategy of Lewinsohn (1974) to address depression, which focuses on increasing positive reinforcement from the social network. Behavioral activation has been shown to reduce depressed mood in a larger number of randomized controlled trials with clinically depressed patients (Emmelkamp, 2013). Strengthening social support aims to teach individuals how to re-engage in the community, how to elicit emotional and practical support from others, and how to provide practical and emotional support to oneself. Social support had been found to be important in resettled refugees (see Schweitzer et al., 2006). The emphasis in the last session of Problem Management Plus is on relapse prevention, which involves identifying personal warning signs of relapse and teaching how best to apply learned specific strategies to manage specific problems in the future (Dawson et al., 2015). Problem Management Plus is delivered by lay helpers who have completed at least high school but have not had mental health training. The duration of training of lay workers in previous studies varied considerably from 1 week (Ali et al., 2003) to 2 months (Patel et al., 2010), but for Problem Management Plus, an 8-day training program is recommended, followed by a 3-week period of clinical practice with weekly supervision by experienced mental health professionals, who themselves have received training in Problem Management Plus (Dawson et al., 2015).

6.4 Problem Management Plus in Conflict-Affected Individuals Rahman et  al. (2016a) investigated in a pilot study the effects of Problem Management Plus among conflict-affected Peshawar in Pakistan. Lay workers who had received an 8-day training program and had received 4 weeks of clinical practice under the supervision of the local trainers were the “counselors” delivering individual Problem Management Plus in a randomized controlled clinical trial. The control condition was enhanced treatment as usual, but this is not further defined. Participants were adults who were referred for screening by the primary care

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physician. Participants had to score 2 or above on the General Health Questionnaire (GHQ-12) assessing general psychological distress and 17 or above on the WHO Disability Assessment Schedule (WHO-DAS 2.0), a screener for impaired functioning assessing general functioning, health, and disability. It assesses difficulties people have due to their mental distress across these domains during the last 30 days. Individuals who had experienced a major traumatic event during the past month were excluded as were individuals with severe cognitive impairment, psychosis, or high risk for suicide. Nearly three-quarters of the participants completed all five sessions of Problem Management Plus. Problem Management Plus showed improvement in functioning on the WHO-DAS 2.0 and in post-traumatic stress symptoms assessed with the PCL-5, but there was no significant change in GHQ-12 scores. Improvement in functional impairment and post-traumatic stress symptoms was higher in the Problem Management Plus intervention than in the control condition, but this was not formerly statistically tested. In a larger randomized clinical trial from the same group (Rahman et al., 2016b) in primary care centers in a conflict-affected area (Peshawar, Pakistan), adults with high levels of psychological distress assessed with the GHQ-12 and impaired functioning assessed with the WHO-DAS were randomly assigned to five weekly 90-min individual sessions of Problem Management Plus (N = 172) delivered by trained and supervised lay health workers or enhanced usual care (controls: N = 174). At follow-up, 3 months after treatment, Problem Management Plus improved more on the Hamilton Anxiety and Depression Scale (HADS), post-traumatic stress symptoms (PCL-5), and functional impairment (WHO-DAS) than controls.

6.4.1 Gender-Based Violence Dawson et al. (2016) evaluated the effects of Problem Management Plus in women survivors of adversity, including women who had experienced gender-based violence, residing in three peri-urban settings in Nairobi, Kenya. In a randomized controlled study, women affected by adversity received either five sessions of Problem Management Plus (N = 35) delivered by lay health workers or enhanced treatment as usual (control group: N = 35). Unfortunately, results revealed that women survivors of adversity who received Problem Management Plus did not show greater reductions in psychological distress (GHQ-12) or better improvement in functional impairment (WHO-DAS) compared with women in the control condition (enhanced treatment as usual). However, Problem Management Plus was more effective than enhanced treatment as usual on post-traumatic stress disorder symptoms. Results of this study suggest that Problem Management Plus can be delivered to women exposed to urban adversity by trained and supervised lay health workers. Another study by the same group of researchers evaluated the effectiveness of Problem Management Plus on female victims of gender-based violence in Nairobi, Kenya (Bryant et al., 2017). In this large randomized controlled trial, adult women who had experienced gender-based violence were randomly allocated to the active intervention Problem Management Plus (N = 209) provided by trained lay helpers

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or to enhanced usual care (N = 212) provided by community nurses. At 3-month follow-up, Problem Management Plus was moderately more effective than the control condition enhanced usual care on the GHQ-12. On the PCL-5 (Post-traumatic stress Disorder Checklist, based on DSM-5) and WHO-DAS, the difference was also significant in favor of Problem Management Plus, but with rather small effect sizes. Problem Management Plus and enhanced usual care did not differ in their effects on either stressful life events or health service utilization at follow-up. Thus, there is a clear need of studies comparing Problem Management Plus with longer versions of evidence-based psychological treatments to determine the effectiveness in victims and perpetrators of gender-based violence (e.g., Capasso et  al., 2022; Keith et al., 2022; Kraanen et al., 2013; Pinto e Silva et al., 2022). Finally, Hamdani et al. (2021) investigated the effectiveness of adding individual Problem Management Plus to routine care in a specialist mental health facility in Pakistan. Problem Management Plus led to improvements on the HADS (symptoms of anxiety and depression), post-traumatic stress (PCL-5), and functioning (WHO-­ DAS) at posttest and 4-month follow-up compared to routine care alone.

6.5 Group Problem Management Plus Problem Management Plus has been adapted to be delivered in a group setting consisting of five group sessions, which last 3 h each. The treatment components (1) managing stress, (2) managing problems, (3) get going, keep doing, and (4) strengthening social support have all been retained in Group Problem Management Plus. Group discussions are encouraged. Although a ratio of one “counselor” to eight patients has been recommended (Dawson et al., 2015), this cannot always be realized. As in the individual Problem Management Plus intervention group, Problem Management Plus can be delivered by trained and supervised lay workers. Khan et al. (2019) evaluated the feasibility of a locally adapted Group Problem Management Plus intervention for women in the conflict-affected settings in rural Swat, which may be considered a highly conservative society. In a randomized controlled feasibility trial, adult women with a score of >2 on the General Health Questionnaire and a score of >16 on the WHO-DAS received either five group sessions of 2  h of Group Problem Management Plus or enhanced usual care. The group intervention was delivered by trained local nonspecialist female lay helpers under group supervision. The group format of supervision enabled lay helper to not only supervise, but offer peer support as well, which was important given difficult situations arising during field activities, including lay helpers’ emotional wellbeing. During the group sessions of the intervention, many women were reluctant to discuss their problems in the presence of family members. Although both treatment conditions led to statistically significant improvements in depression, anxiety, general psychological profile, and functioning, only scales assessing depressive symptoms (Patient Health Questionnaire (PHQ-9)) and post-traumatic stress symptoms (PCL-5) showed a trend in favor of the Group Problem Management Plus condition.

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In a randomized controlled study of Sangraula et  al. (2020), five sessions of Group Problem Management Plus (N = 61) were compared with enhanced usual care (N = 60; control), for female and male adults in an earthquake-affected region of rural Nepal. Community-based psychosocial workers were the service providers for the groups. The primary clinical outcome was depression symptoms assessed using the Patient Health Questionnaire (PHQ-9). The mean improvement was slightly larger in the Group Problem Management Plus condition than in the control condition, but this was not formerly statistically tested. In a large randomized controlled study, Rahman et  al. (2019) investigated the effectiveness of Group Problem Management Plus delivered by trained and supervised lay workers for adult women in a conflict-affected setting in rural Swat, Pakistan. The Group Problem Management Plus intervention consisted of five group sessions of 2  h per week, with approximately 6–8 participants per group. “Group therapists” were local graduates with bachelor’s degrees, who did not have any mental health care experience. Participants, who scored >2 on the General Health Questionnaire-12 and >16 on the WHO-DAS, were randomly assigned to Group Management Plus (N = 306) or enhanced usual care (N = 306). Symptoms of depression and anxiety were measured with the Hopkins Symptom Checklist (HSCL-25), which was the primary outcome measure. The HSCL-25 consists of 25 items, 15 items measuring depression (e.g., “Crying easily”) and 10 items assessing anxiety (e.g., “Suddenly scared for no reason”). At 3-month follow-up, women who had received Group Problem Management Plus had significantly lower mean total scores on the primary outcome, Hospital Anxiety and Depression Scale, and functional impairment (WHO-DAS) than women in the control group. Initial problem severity did not affect the outcomes. Although participants improved on post-­ traumatic stress symptoms assessed with the PCL-5, Group Problem Management Plus was not more effective than enhanced usual care at 3-month follow-up, which is in contrast with their previous study in primary care settings (Rahman et  al., 2016b). In that study, the individually administered Problem Management Plus intervention led to sustained improvements in trauma symptoms. Thus, although Group Problem Management Plus resulted in clinically significant reductions in anxiety and depressive symptoms at 3-month follow-up, substantial symptom reduction occurred also in the control group. In another large randomized controlled trial (Jordans et al., 2021), conducted in disaster-prone regions of Nepal, Group Problem Management Plus (N = 319) was compared with enhanced usual care (N = 324). Participants were psychologically distressed adults (primarily women) who were functionally impaired. Of the included participants, 50% had recently experienced a natural disaster, and 31% had a chronic physical illness. Results were small on the primary outcome measure: GHQ-12. At 3-month follow-up, mean GHQ-12 total score was only 1.4 units lower in Group Problem Management Plus compared to control. Group Problem Management Plus did not lead to lower post-traumatic stress symptoms (PCL-5) or functional impairment (WHO-DAS) than controls. However, a larger number of participants attained more than 50% reduction in depression symptoms on the Patient Health Questionnaire (PHQ-9) at 3-month follow-up. Compared with the

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study which evaluated Group Problem Management Plus among women in Pakistan (Rahman et  al., 2019), this study resulted in smaller effect sizes on all outcome measures.

6.5.1 Concluding Remarks Thus, there is some evidence that Problem Management Plus may be effective for adults impaired by distress in communities exposed to adversity, but results are not very large when compared with control groups. A number of case studies in Ethiopia, Syria, and Honduras have shown that a number of organizations were able to provide training of lay helpers and supervision in various humanitarian settings (Nemiro et al., 2021).

6.6 Problem Management Plus: Refugees and Asylum Seekers The evidence base for psychological treatment of refugees and asylum seekers is sparse and limited mainly to trauma-specific treatments (see Chaps. 7 and 8), but many refugees and asylum seekers suffer from other mental health problems such as psychological distress, anxiety, or depression. In a pilot study about the feasibility of training lay helpers to deliver Problem Management Plus in refugee camps with Eritrean refugees in Ethiopia, intensive supervision was required (Gebrekristos et  al., 2021). Lay helpers were Eritrean refugees, who had experienced comparable adversity as the refugees they were being trained to help. According to the authors, the mental health symptoms of a large number of refugees were too severe or not a good fit for Problem Management Plus. The authors conclude that Problem Management Plus may be more appropriately applied with the local population facing adversity, rather than with refugees in camps since a number of primary needs and mental health symptom severity encountered in refugee camps could not adequately be dealt with. In another study, however, Dozio et al. (2021) found some support for the effectiveness of Group Problem Management Plus led by lay helpers among internally displaced persons in the conflict-affected Central African Republic. Treatment led to a significant reduction in post-traumatic stress symptoms (PCL-5) and functional impairment (WHO-DAS). However, this was a feasibility study without a control group. De Graaff et al. (2020) investigated the effectiveness of Problem Management Plus among Syrian refugees resettled in the Netherlands, which is the first study exploring how Problem Management Plus can be delivered by peer refugees in a high-income country. Adult Syrian refugees with elevated psychological distress assessed with the Kessler Psychological Distress Scale (K10; score >15) and reduced psychosocial functioning assessed with the WHO-DAS (score >16) were randomly assigned to two conditions: Problem Management Plus (N  =  30)

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individually delivered by lay peer refugee helpers or care as usual (N = 30). The intervention was delivered by eight Arabic-speaking Syrian lay helpers. They received 8  days of training followed by weekly face-to-face group supervision throughout the study. Training and structural supervision of peer refugees as lay helpers were perceived as feasible. Primary outcomes were symptoms of depression and anxiety assessed with the Hopkins Symptom Checklist (HSCL-25) at 3-month follow-up, which were significantly lower for the Problem Management Plus condition than for the control condition care as usual (d = 0.58). In addition, moderate improvements in post-traumatic stress and psychosocial functioning were found: significant differences in favor of Problem Management Plus were reported on post-traumatic stress symptoms (PCL-5; d = 0.66) and psychological impairment (WHO-DAS; d  =  0.73). The moderate improvements across these symptoms confirm the studies into the effectiveness of individually administered Problem Management Plus conducted in non-refugees (Bryant et  al., 2017; Rahman et al., 2016a, 2016b). In a randomized controlled study of Spaaij et al. (2022), feasibility and acceptability of individual Problem Management Plus were investigated in a randomized controlled trial among Syrian refugees in Switzerland. The intervention was delivered by Syrian lay helpers, who were fluent in Arabic. All lay helpers had a diploma of higher education and had an 8-day training course in line with WHO training criteria. Psychologically distressed Syrian refugees assessed with the Kessler Screening Scale for Psychological Distress (K10 >15) were randomized to Problem Management Plus (N = 31) or enhanced treatment as usual (N = 28). Although the study showed that Problem Management Plus was feasible and acceptable for Syrian refugees in Switzerland, no statistical tests were reported with respect to the outcome measures. Inspection of Table 2 reveals, however, that results were small with respect to improvement up to 3-month follow-up on the HADS anxiety and depression scales, and functional impairment assessed with the WHO-DAS. In a study of Akhtar et al. (2021), Group Problem Management Plus was investigated in a refugee camp in Jordan with adult Syrian refugees, who were parent of a child aged 10–16 years. Inclusion criteria were nearly identical as in the study of de Graaff et  al. (2020) conducted in the Netherlands discussed above. Interestingly, given that refugee children are at increased risk for the development of mental disorders (Charlson et al., 2019) and parental mental problems are a predictor of children’s mental problems (Bryant et al., 2018), a child’s psychological distress was also assessed in this study. Psychologically distressed refugees (K10 score >16) were randomized to receive either five sessions of group Problem Management Plus (N = 35) or enhanced treatment as usual (N = 29). Post-assessments were conducted 1 week following the last group session. Children whose parents received Group Problem Management Plus had greater reductions in internalizing and externalizing symptoms at the posttest. Unfortunately, the results of the adults are not statistically tested. Inspection of Table 3 shows, however, that the differences in effectiveness of Problem Management Plus compared with controls were rather small on HSCL-25 anxiety and depression scales and on post-traumatic stress symptoms (PCL-5).

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In a large study in Jordan (Bryant et al., 2022a), the impact of Group Problem Management Plus on the mental health of refugees on children’s mental health was investigated. Psychologically distressed adult Syrian refugees living in Azraq refugee camp (≥16 on the Kessler Psychological Distress Scale) were randomly allocated to Group Problem Management Plus (N = 204) or enhanced usual care (N  =  206). At 3-month follow-up, patients who had received Group Problem Management Plus had a greater reduction on HSCL depression scale than controls (effect size, 0.40), but not on HSCL-25 anxiety scale (effect size, −0.03). Relative to controls, refugees who had received Group Management Plus had greater reductions in inconsistent disciplinary parenting, but this did not lead to better mental health outcome of their children. Unfortunately, Group Problem Management Plus did not show more changes in post-traumatic stress symptoms (PCL-5), disability, or grief. The effect sizes observed in this study were generally lower than those in Rahman et al. (2019). As noted by the authors, over 60% of the refugees met the criteria for post-traumatic stress disorder, which suggests that a brief trans-­diagnostic intervention as Group Problem Management Plus is less suited for refugees with post-traumatic stress disorder living under harsh conditions of a refugee camp. In addition, at 12-month follow-up (Bryant et  al., 2022b), no significant differences were found between Group Problem Management Plus and enhanced care as usual neither on the primary outcome measures (HSCL-25 depression and anxiety), nor on the secondary outcomes of post-traumatic stress symptoms, disability, prolonged grief, personally identified problems, prodromal psychotic symptoms, parenting behavior, and children’s mental health. Actually, depression severity worsened more frequently in Group Problem Management Plus than in the control condition. Group Problem Management Plus, delivered by trained and supervised Arabic-­ speaking lay workers who were refugees themselves, was also investigated in a randomized controlled study with Syrian refugees resettled in Turkey (Acarturk et  al., 2022a). Refugees with psychological distress (Kessler Psychological Distress Scale, K10 >15) were randomized to either five sessions of group Problem Management Plus delivered by lay workers (N = 24) or enhanced care as usual (N = 22). Although results indicated an improvement in depression, anxiety, post-­ traumatic stress symptoms, and self-identified problems from pretest to follow-up in both groups, this was not significant. At 3-month follow-up, Group Problem Management Plus was not found to be more effective than enhanced care as usual, neither on the primary outcome symptoms of depression and anxiety (HSCL-25), nor on psychosocial functioning assessed with the WHO-DAS, post-traumatic stress symptoms (PCL-5), and self-identified problems. Thus, although Group Problem Management Plus delivered by lay workers was found to be an acceptable and feasible intervention for Syrian refugees in Turkey with elevated levels of psychological distress, results of this study do not yet support implementation.

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6.6.1 Adapted Problem Management Plus Knefel et al. (2022a) evaluated a trans-diagnostic treatment protocol for treatment-­ seeking Afghan refugees in Austria, which addresses both mental health problems and post-migration living difficulties. Of note, in Austria, self-reported (mental) health among Afghan refugees is worse compared to refugees from Iraq and Syria (Georges et al., 2021). Treatment was based on an adapted version of the Problem Management Plus intervention, which adapted protocol consisted of six 90-min sessions. The six sessions of the adapted Problem Management Plus intervention included not only stress management, problem-solving, behavioral activation, and strengthening social support but also either anger regulation or increasing self-­ efficacy. Patients themselves decided whether they preferred a session on improving anger regulation or on increasing self-efficacy. “Anger regulation” is a combination of strategies used in dialectical behavior therapy (Linehan, 2015), such as emotion regulation. “Self-efficacy” is based on a specific German systemic psychotherapy approach (Röhrbein, 2019) consisting of exercises, which may help patients to reidentify with their strengths. In this randomized controlled trial, Afghan refugees in Austria received either (a) Problem Management Plus in addition to treatment as usual or (b) treatment as usual alone (Knefel et al., 2022a). In contrast to the studies investigating the five-­ session Problem Management Plus intervention delivered by lay workers, the adapted version was delivered by clinical psychologists with the support of an interpreter if needed. Unfortunately, dropout was high: of the 88 included patients, 42% did not participate in the post-treatment assessment, but of the patients who started treatment, less than 20% dropped out. Due to the Corona pandemic, the planned 6-month follow-up could not be executed, which limits the results to a pre–post-­ comparison only. On the primary outcome measure (GHQ-28; somatic symptoms, anxiety, social dysfunction, and depression), adapted Problem Management Plus (N = 26) was more effective than care as usual (N = 25) at the posttest. Interestingly, distress by post-migration living difficulties was reduced in the adapted Problem Management Plus condition. Compared with the study of de Graaff et al. (2020), who found that individual Problem Management Plus delivered by lay therapists was effective for Syrian refugees resettled in the Netherlands, the effects in the study of Knefel et al. (2022a) were larger. Thus, refugees’ mental health problems can be successfully treated in a number of patients with a brief psychological intervention that also focuses on skills in the context of post-migration stressors. As shown in the study of Knefel et al. (2022a), a low-intensity intervention may also be useful in high-income countries delivered by mental health professionals instead of trained lay helpers. In a related study, Knefel et al. (2022b) investigated mental health professionals’ opinions and views on the adapted Problem Management Plus intervention following a webinar. The most favored specific

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strategies were the two additionally developed strategies to reduce distress caused by post-migration living difficulties either by reducing anger regulation difficulties or by enhancing self-efficacy. Thus, the adaptation of the Problem Management Plus intervention regarding more flexibility of the manual and addressing coping with post-migration living difficulties may enhance the likelihood that mental health professionals will use the adapted Management Plus in their daily practice. They further emphasized the importance of situation-specific adaptations to the structure of the intervention, depending on their patients’ living situations. They favored a noncognitive approach, and less language-based intervention, which could be rather useful when language barriers restrict therapeutic interventions.

6.6.2 Concluding Remarks Taken together the results of studies evaluating the effectiveness of Problem Management Plus, results are rather mixed. Generally, the effects of Problem Management Plus are less effective with refugees than with individuals confronted with adversity. Unfortunately, a number of studies with refugees did not publish statistical analyses, which renders results difficult to interpret. A number of other studies have investigated other trans-diagnostic interventions for refugees, which will be discussed below.

6.7 Common Elements Treatment Approach A major challenge in global mental health is how to provide access to evidence-­ based mental health interventions to patients with comorbidity living outside urban areas in low- and middle-income countries. The Common Elements Treatment Approach is a trans-diagnostic intervention which was developed by Murray et al. (2013). This intervention is based on existing trans-diagnostic manuals (e.g., Barlow et al., 2011) and is designed specifically for delivery by nonprofessional providers (lay workers) in low-resource settings. Trans-diagnostic psychological treatments consist of a set of common practice elements that can be delivered in varying combinations to address various mental health problems. The Common Elements Treatment Approach was specifically developed in order to be able to scale up multiple structured evidence-based interventions, to enable flexible treatments of comorbid disorders among trauma survivors in a low-resource setting. This intervention consists of a set of common practice elements that can be delivered in varying combinations to address a range of problems including post-traumatic stress, anxiety, depression, and alcohol abuse. The selection and ordering of elements for problem areas involved integrating findings from existing evidence-based treatments for adult post-traumatic stress disorder, anxiety disorders, and depression (e.g., Emmelkamp & Ehring, 2014).

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The following cognitive-behavioral strategies were included in a number of components in the Common Elements Treatment Approach: –– –– –– –– –– ––

Encouraging participation Anxiety management (e.g., relaxation) Behavioral activation Cognitive restructuring Gradual imaginal exposure (talking about difficult memories) or in vivo exposure Brief intervention for alcohol abuse

For training purposes, each component has a 1–5-page “manual” section and a 1–2-page “steps sheet,” which provide extra guidance for lay helpers. Local lay workers and supervisors learn how to identify the main problem area or areas for each patient and a “default order” of treatment components. This is based on self-report assessment measures, clinical presentation of the patient, and opinion of an expert trainer of the Common Elements Treatment Approach (Murray et al., 2011). Bolton et  al. (2014) investigated the effectiveness of this trans-diagnostic Common Elements Treatment Approach, delivered by lay workers to Burmese refugees, who had survived imprisonment and torture. Patients were recruited among refugees who had experienced trauma and met the criteria for depressive symptoms and/or post-traumatic stress symptoms. Patients were randomly assigned to the Common Elements Treatment Approach (N = 182) or waiting list control (N  =  165). The average number of weekly sessions in the Common Elements Treatment Approach was 9.7, with a maximum of 13 sessions. Results suggest that this approach was acceptable, as dropout was lower in the Common Elements Treatment Approach condition (18%) than in the control condition (26%). Patients who had received the Common Elements Treatment Approach improved significantly more than patients in the control condition not only on depression, posttraumatic stress symptoms, and anxiety symptoms, but also on aggression and functional impairment. The effect sizes (Cohen’s d) were large for depression (d = 1.16) and post-­traumatic stress symptoms (d = 1.19) and moderate for anxiety (d = 0.79), aggression (d = 0.58), and functional impairment (d = 0.63). In addition, intervention effects for the more severely affected sample were even slightly better: depression (d  =  1.44), post-traumatic stress symptoms (d  =  1.61), anxiety (d = 1.05), aggression (d = 0.60), or functional impairment (d = 0.80). Interestingly, no statistically significant differences in effect were found for males and females on any of the outcome measures. Thus, results revealed that the Common Elements Treatment Approach provided by trained and supervised lay workers was highly effective across a variety of mental disorders among trauma survivors compared to the control condition. There is a clear need of further studies evaluating this promising intervention with other interventions (e.g., Problem Management Plus).

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6.8 Skills-Training of Affect Regulation: A Culture-Sensitive Approach In a number of studies, deficits in emotion regulation significantly contributed to anxiety, depression, and post-traumatic stress symptoms in refugees (Doolan et al., 2017; Koch et al., 2020b; Nickerson et al., 2015). Koch and Liedl (2019) developed a trans-diagnostic low-threshold group intervention: Skills-Training of Affect Regulation—a culture-sensitive approach. This intervention focuses on emotion regulation, defined as the capacity to monitor, evaluate, and modify emotional reactions in a way that facilitates adaptive functioning (Gratz & Roemer, 2004). This is a group intervention which was developed for adolescent and adult refugees aiming to improve emotional understanding, clarity, and expression on the one hand and adaptive emotion regulation on the other hand. The intervention consists of 14 weekly 90-min sessions. The intervention is based on elements from Skills Training in Affective and Interpersonal Regulation Therapy (STAIR; Cloitre & Schmidt, 2015), the Dialectic Behavioral Therapy (Linehan, 2015), and the Culturally Adapted Cognitive Behavioral Therapy (Hinton et al., 2011). In a randomized controlled study (Koch et al., 2020a)—conducted in a routine clinical setting with Afghan refugees and asylum seekers—Skills-Training of Affect Regulation was compared with waiting list control. Taking into account cultural barriers, only (young) males were included in the groups. Participants were refugees who had been exposed to multiple traumas for years and were still facing post-­ migration stressors at the time of treatment, including insecure residence status. Exclusion criteria were psychosis, serious suicide risk, and serious dissociation. All group sessions were conducted by the authors of the Skills-Training of Affect Regulation program (Koch & Liedl, 2019). Results revealed that comparative effect sizes relative to waiting list control on all measures were medium to large. Refugees who had received Skills-Training of Affect Regulation significantly improved more than controls on the Difficulties in Emotion Regulation Scale (d = 1.22), symptom severity (General Health Questionnaire; d = 1.69), post-traumatic stress symptoms (PCL-5; d  =  1.19), and caregiver-reported emotional competence (d  =  −0.90). Effects were maintained up to 3-month follow-up. Thus, results of this study revealed that Skills-Training of Affect Regulation is an acceptable and feasible trans-diagnostic low-threshold intervention for young male refugees. Given the large reductions in post-traumatic stress symptoms, trans-diagnostic symptoms, and emotion dysregulation, larger studies in which the effectiveness of this approach is compared with evidence-based mental health interventions for male and female refugees and asylum seekers with other therapists are clearly needed. In (primarily male) refugees, substance use disorders are prevalent (Horyniak et al., 2016), often triggered by the higher acceptance of substance use in the host country. In a study of Lotzin et  al. (2021), cultural concepts of Syrian refugees related to substance use were considered in order to culturally adapt the Skills-­ Training of Affect Regulation program to the needs of Syrian refugees with substance use disorders. Based on the results of focus groups with refugees on cultural concepts of substance abuse, a number of adaptions were made. There is a clear

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need of studies to assess the effectiveness of this culturally sensitive Skills-Training of Affect Regulation program for refugees with substance abuse. One large study is investigating the effectiveness of this culturally sensitive group therapy approach to improve affect regulation in refugees with substance-related problems in Germany, but results are not yet available (see Schäfer et al., 2022).

6.9 Integrative Adapt Therapy Integrative Adapt Therapy is based on the Adaptation and Development After Persecution and Trauma model (Silove, 2013), specific to the refugee experience. This model is based on five “pillars,” psychosocial systems that are seriously affected by the experiences of refugees and asylum seekers, including: –– The impact of recurrent threats to safety and security, which can lead to post-­ traumatic stress disorder –– The effects of traumatic losses and separations on interpersonal bonds and networks, which may lead to prolonged grief –– Exposure to human rights violations (Justice), which may lead to ill-directed aggression –– Loss of roles and identities, which can result in depression –– Disruption of existential meaning, which can result in alienation and depression Integrative Adapt Therapy is based on psychotherapeutic elements specific to the refugee experience. Refugees participating in Integrative Adapt Therapy are stimulated to reflect on experiences related to their families, and their personal lives as they transitioned through the trajectory of mass conflict, displacement, flight, and resettlement. Therapeutic strategies used include psychoeducation, emotion regulation, trauma exposure, stress management, problem-solving, and cognitive reappraisal. In a randomized controlled study (Tay et al., 2020), the effectiveness on common mental health symptoms of six weekly sessions of Integrative Adapt Therapy (N = 170) was compared with the effectiveness of a culturally adapted six weekly cognitive behavioral therapy (N  =  161). Participants were Rohingya, Chin, and Kachin refugees from Myanmar living in Kuala Lumpur, Malaysia, who had experienced on average ten traumatic events and had at least one common mental disorder, i.e., (complex) post-traumatic stress disorder, major depressive disorder, generalized anxiety disorder, or persistent complex bereavement disorder. Patients in both therapies were treated by trained and supervised lay workers from the Chin, Kachin, and Rohingya communities. Each lay counselor received an 8-day training in cognitive behavioral therapy and an 8-day training in Integrative Adapt Therapy (Tay et al. 2019). Lay worker conducted both therapies. At 6-week follow-up, both therapies resulted in statistically significant reductions on all primary outcomes: (complex) post-traumatic stress disorder, major depressive disorder, and resilience. Compared to cognitive behavioral therapy, Integrative Adapt Therapy was slightly more effective, but the differences in effect sizes were

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rather small. The results reveal that Integrative Adapt Therapy, delivered by lay counselors, was an effective treatment for improving mental health, adaptive stress, and resilience among refugees, but results of Tay et al. (2020) were limited to only 6-week follow-up and may not generalize to refugees in other settings. In a 12-month follow-up of this study (Tay et al., 2022), the large treatment effects for common mental disorder symptoms were maintained, but there were no significant differences between cognitive behavioral therapy and Integrative Adapt Therapy 1  year after treatment for (complex) post-traumatic stress disorder, depression, and anxiety. Refugees who had received cognitive behavioral therapy, however, showed greater improvement in functioning than refugees who had received Integrative Adapt Therapy.

6.10 Method for the Empowerment of Trauma Survivors Another trans-diagnostic intervention (7ROSES) was developed to enhance self-­ efficacy among refugees in dealing with post-migration stress. This intervention is based on the “Method for the Empowerment of Trauma Survivors,” which intervention was developed to increase self-efficacy and enable to deal more adequately toward stressors for traumatized refugees, facing post-migration challenges on a social level and suffering from psychological distress (Sulaiman-Hill & Thompson, 2013; van Heemstra et al., 2019). This intervention does not focus on the content of traumatic experiences. This intervention can be delivered by trained nonspecialist health care workers. The 7ROSES intervention consisted of nine weekly group sessions of 2.5 h each. In a study by van Heemstra et al. (2019), 49 refugees living in the Netherlands were treated with this intervention by social workers or psychologists with experience in working with refugees, who received once-a-month supervision. All refugees were diagnosed with at least one common mental health disorder. Although about a quarter of the refugees who had received the 7ROSES intervention reported an increased selfefficacy and mental health improvement, effects were rather small both on the Brief Symptom Inventory assessing general psychopathology and on the General SelfEfficacy Scale. Results of an intent-to-treat analysis did not result in significant improvement on general psychopathology. Results are difficult to interpret given that prior mental health treatments and cocurrent pharmacotherapy were not exclusion criteria. In addition, given the lack of a control group, it is unclear whether changes in general mental health and self-efficacy were the result of the 7ROSES intervention. Thus, the lack of a control group renders results difficult to evaluate.

6.11 Self-Help Plus Self-Help Plus was developed by the World Health Organization (WHO) as a five-­ session, self-help intervention for managing stress, coping with adversity, and enhancing psychological flexibility. Self-Help Plus is delivered in groups by trained lay

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workers (Epping-Jordan et al., 2016). Self-Help Plus is a trans-diagnostic intervention which is based on Acceptance and Commitment Therapy (ACT), which is a variant of cognitive behavior therapy which has been found to be quite effective in patients in high-income countries with anxiety disorders, addiction, and somatic health problems (A-Tjak et al., 2015) and in patients with depression (A-Tjak et al., 2018). Acceptance and Commitment Therapy focuses on the acceptance of private events rather than on the attempt to change them. It emphasizes on learning new ways to accommodate difficult thoughts and feelings—primarily through mindfulness approaches—and guides patients to take proactive steps toward living in a way that is consistent with their goals and values, thus increasing their psychological flexibility. Self-Help Plus uses a guided self-help format and is delivered through a pre-­ recorded audio course. In a controlled study with severely distressed South Sudanese female refugees in Uganda, the Self-Help Plus intervention (N = 331) led to significant more reduction in psychological distress assessed using the Kessler 6 symptom checklist at posttest than enhanced care as usual (N  =  363) (Tol et  al., 2020). However, at 3-month follow-up, the effect of Self-Help Plus decreased significantly. Compared with controls, Self-Help Plus was only slightly more effective on psychological distress 3 months post-intervention (d − 0·26). Purgato et al. (2021) investigated whether Self-Help Plus could also be used as a public health strategy for preventing mental disorders in refugees and asylum seekers living in high-income countries. In a randomized controlled study, they compared in five European countries the effectiveness of the Self-Help Plus Intervention (N = 230) as a preventive intervention for reducing the frequency of common mental disorders with enhanced care as usual (N = 229) in refugees and asylum seekers experiencing psychological distress (General Health Questionnaire-12 score ≥3), but who did not have a formal mental disorder according to DSM-5 or ICD 10. Self-­ Help Plus was delivered in groups as an audio course and included a culturally adapted self-help book (WHO, 2020). Unfortunately, more than 30% of participants were lost to follow-up, which renders results difficult to interpret. The primary outcome measure was the presence of any mental disorder assessed by the Mini International Neuropsychiatric Interview (MINI) at 6-month follow-up. Although the Self-Help Plus intervention resulted in a significant improvement assessed with the MINI immediately after the intervention, this was not found at follow-up 6 months later. At the 6-month follow-up, the majority of the reported mental disorders concerned major depressive disorders, with no significant difference between Self-Help Plus and enhanced usual care. At follow-up, the occurrence of post-­ traumatic stress disorder and anxiety disorder was comparable for both conditions as well. Also, on secondary outcome measures, Self-Help Plus was not more effective than enhanced usual care. The only statistically significant difference in favor of Self-Help Plus was found on well-being assessed with the WHO-5. Also, at 12-month follow-up, there was no evidence that Self-Help Plus was successful in preventing the onset of mental disorders (Turrini et al., 2022). To quote the authors: “The present study failed to show any long-term preventative effect of Self-Help Plus in refugees and asylum seekers resettled in Western European countries” (Turrini et al., p. 1).

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Another randomized controlled study (Acarturk et al., 2022b) was conducted in Turkey with adult Syrian refugees experiencing psychological distress (General Health Questionnaire ≥3), but without a diagnosis of mental disorder. Participants were randomly assigned to either Self-Help Plus (N  =  322) or enhanced care as usual (N  =  320). The Self-Help Plus intervention was not effective immediately after treatment but resulted at 6-month follow-up in better outcome than enhanced care as usual with respect to symptoms of depression and quality of life. In contrast to the study of Purgato et al. (2021), Self-Help Plus participants were significantly less likely to have any mental disorders at 6-month follow-up compared to participants who received enhanced care as usual (21.7% vs. 40.7%).

6.12 Value Based Counseling Value Based Counseling is a brief manualized psychological intervention, which is focused on improving the self-efficacy of the patient and uses a culturally sensitive approach communicated in the native language of the patient (Missmahl, 2018). Treatment lasts usually 3–5 sessions. If longer care is needed, the patient might be referred to specialized mental health care. Value Based Counseling avoids pathologizing psychological symptoms, traumatic experiences, and social stressors, but aims to empower patients to cope with these stressors. In the first part of the treatment, the counselor develops a narrative of the client’s biography by focusing on understanding of present problems and psychosocial stressors, identifying the patient’s dominant feeling tone which impairs daily functioning the most, and the counselor may provide psychoeducation. In the second part, the emphasis is on patients’ current living condition and daily functioning and is designed to enable them to deal with personal challenges in the future. Value Based Counseling may use intervention methods such as relaxation, reframing, changing automatic thinking, distancing techniques for trauma symptoms, or behavioral activation for depression and includes homework assignments. Ayoughi et  al. (2012) evaluated the efficacy of Value Based Counseling in a randomized clinical trial in Mazar-e-Sharif (Afghanistan) with Afghan women with mental health problems. Value Based Counseling led to clinically significant improvements of symptoms of anxiety and depression, which symptoms did not improve in the control group who received routine medical treatment. Orang et al. (2022) assessed in a randomized clinical trial the efficacy of Value Based Counseling versus waiting list control in asylum seekers and refugees (e.g., from Afghanistan, Iran, and Syria) residing in Germany. The counseling sessions were conducted by counselors who had received a 1-year full-time training; nearly all counselors were refugees themselves. Counselors were supervised by experienced psychotherapists. Counselors were matched with participants based on language, cultural background, and gender. At pretest, 81% of participants showed moderateto-severe depressive symptoms, 73% post-traumatic stress symptoms, 78% moderate-to-severe anxiety symptoms, and 64% medium-to-high somatic symptom

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severity. Patients who had received Value Based Counseling improved substantially more on depression (PHQ-9), post-traumatic stress symptoms (PCL-5), anxiety (GAD-7), and somatic complaints (PHQ-15) than the control group up to 3-month follow-up with medium-­to-­large effect sizes. Thus, results suggest that Value Based Counseling is a promising short intervention for asylum seekers and refugees residing in host countries.

6.13 Other Interventions 6.13.1 Depression Although depression is one of the major mental health problems of asylum seekers and refugees, the vast majority of them do not receive any mental health treatment, especially in low- and middle-income countries (Thornicroft et  al., 2017). In Germany, the Mental Health in Refugees and Asylum Seekers (MEHIRA) project has recently started, which investigates the clinical effectiveness and cost-­ effectiveness of a stepped care model for adolescent and adult refugees with depressive symptoms and affective disorders. The principal aim of the stepped care model is to match refugees with different severity of depressive mood with a set of culturally sensitive psychological interventions which are cost-effective, starting with low-threshold treatment interventions, such as manual-based therapies, and group interventions. In a large randomized controlled trial (Böge et al., 2022)—conducted in seven regions in Germany—asylum seekers and refugees (N = 584) with depressive symptoms (Patient Health Questionnaires-9 (PHQ-9) score of ≥5) were randomly allocated to either the stepped care and collaborative model or care as usual. Treatment lasted 3  months. In the active treatment condition, the interventions which they received were dependent on the severity of depression and could assist of (1) “watchful waiting,” (2) peer-to-peer or smartphone intervention, (3) psychological group therapy, or (4) mental health expert treatment. The primary endpoint was defined as the change in depressive symptoms (PHQ-9) after 12 weeks. Refugees and asylum seekers treated with the Stepped and Collaborative Care Model showed a larger reduction of depressive symptoms compared with care as usual. Differences between both conditions were small: a reduction in depressed symptoms of more than 50% was achieved in only 12.9% of patients in the Stepped and Collaborative Care Model and 9.6% in care as usual condition. Dropout was also considerable, which renders results difficult to interpret. The Stepped and Collaborative Care Model was more cost-effective compared with care as usual. The group psychotherapy which is part of the stratified Stepped and Collaborative Care Model within the MEHIRA project discussed above has been evaluated as a stand-alone treatment in asylum seekers and refugees. Group psychotherapy was found to be more effective than care as usual. Pretreatment depression severity was a significant predictor of outcomes in the treatment condition (Strupf et al., 2023).

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6.14 Digital Mental Health Digital interventions are suggested to be easier to access for refugees than face-to-­ face treatments, given that they are flexible in use regarding time and place and are anonymous, which is important for a number of refugees (Spanhel et  al., 2022). Step-by-Step is a new guided digital mental health intervention developed by the WHO (Carswell et al., 2018; Burchert et al., 2019) based on behavioral activation, which is an evidence-based behavioral intervention for depression not only in high-­ income countries (Emmelkamp, 2013), but also potentially for low- and middle-­ income countries (Bockting et  al., 2016). Step-by-Step includes additional therapeutic techniques such as stress management, positive self-talk, and increasing social support. Cuijpers et al. (2022) investigated the efficacy of this digital mental health intervention, Step-by-Step, in displaced people from Syria residing in Lebanon. In a large randomized clinical trial, 569 displaced individuals who had moderate or severe depressive symptoms (PHQ-9 ≥10) received either five sessions of digital Step-by-Step or only usual care. The digital text of Step-by-Step was adapted to the local context with respect to linguistic and cultural nuances among displaced Syrians. The digital intervention was supported by trained “e-helpers” who had a background in psychology or health. Results revealed that the displaced persons who received the digital treatment were less depressed after the intervention than the people who only received usual care, which persisted at 3-month follow-up. Effects were moderate to large for reduction in depressive symptoms. Unfortunately, a large number of participants dropped out of the study. Of the 283 participants in the intervention condition, less than three-quarters finished the introduction session, and only one-third of the participants finished five sessions, which renders results difficult to interpret. Although the authors suggest that the guided WHO Step-by-­ Step intervention should be made available to communities of displaced people that have digital access, further studies are needed to prevent that two-thirds of depressed patients stop a mental health intervention prematurely. Refugees do have often sleep disturbance, which is associated with mental distress (Al-Smadi et  al., 2017). In a randomized controlled study (Spanhel et  al., 2022), the efficacy of a digital sleep intervention for refugees was investigated in 66 refugees with insomnia severity, with most of them showing depressive symptoms (mean PHQ-9 >12). The culturally adapted digital self-help intervention included four modules on sleep hygiene, rumination, and information on mental health conditions associated with sleep disturbances. Two-thirds of the participants completed all modules. Dropout of the intervention was higher among participants with lower levels of education and language skills. Although the refugees showed high satisfaction with the digital sleep intervention, intervention effects on insomnia severity were nonsignificant and small. At 3-month follow-up, the digital sleep intervention was not more effective than the waiting list control group, neither on sleep quality nor on depressive symptoms assessed with the PHQ-9.

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6.15 Stepped Care Stepped care aims to treat mental health patients with an evidence-based intervention of the lowest possible intensity while continuously monitoring progress (e.g., Clark et al., 2009). Stepped care interventions integrate self-help, low-intensity cognitive behavioral interventions, and medication into one model. Within stepped care, treatment is distributed to several steps with different treatment thresholds, ranging from lower to higher intensities (Trilesnik et al., 2019). Although stepped care has been found to be cost-effective in the treatment of depression and anxiety disorders in Western cultures (e.g., Firth et al., 2015; Härter et al., 2018; Ho et al., 2016; van Straten et al., 2015), this approach has hardly been investigated in refugees and asylum seekers with mental health problems. In a study of Trilesnik et  al. (2019), the feasibility and effectiveness of the refuKey project were investigated. The aim of the refuKey project is to optimize psychosocial, psychotherapeutic, and psychiatric care services by means of stepped care approaches for refugees and asylum seekers residing in Germany. The project not only provides clinicians with professional interpreters, but also assists with bureaucratic procedures and with clinical assessment and therapeutic recommendations, thus giving refugees low-threshold access to appropriate mental health care services. Results of a pilot study revealed significant improvements on anxiety, depression, somatization, and psychotism at the end of the treatment. However, a randomized controlled trial is needed to evaluate the specific effectiveness of treatment within refuKey as compared to treatment as usual. Thus, there is a clear need of further studies using a control group to evaluate stepped care for refugees to facilitate implementation in routine mental health care.

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controlled trial investigating the efficacy of value-based counselling. Clinical Psychology & Psychotherapy, 29(4), 1433–1446. https://doi.org/10.1002/cpp.2728 Ormel, J., & Emmelkamp, P.  M. G. (2023). More treatment … but not less anxiety and mood disorders. Why? Seven hypotheses and their evaluation. Psychotherapy and Psychosomatics. (in press). Patel, V., Weiss, H.  A., Chowdhary, N., Naik, S., Pednekar, S., Chatterjee, S., et  al. (2010). Effectiveness of an intervention led by lay health counsellors for depressive and anxiety disorders in primary care in goa, India (MANAS): A cluster randomised controlled trial. Lancet, 376(9758), 2086–2095. https://doi.org/10.1016/S0140-­6736(10)61508-­5 Pinto e Silva, T., Cunha, O., & Caridade, S. (2022). Motivational interview techniques and the effectiveness of intervention programs with perpetrators of intimate partner violence: a systematic review. Trauma Violence Abuse. https://doi.org/10.1177/15248380221111472 Purgato, M., Carswell, K., Tedeschi, F., Acarturk, C., Anttila, M., Au, T., et al. (2021). Effectiveness of Self-Help Plus in preventing mental disorders in refugees and asylum seekers in Western Europe: a multinational randomized controlled trial. Psychotherapy and Psychosomatics, 90(6), 403–414. https://doi.org/10.1159/000517504 Rahman, A., Hamdani, S.  U., Awan, N.  R., Bryant, R.  A., Dawson, K.  S., Khan, M.  F., & van Ommeren, M. (2016b). Effect of a multicomponent behavioral intervention in adults impaired by psychological distress in a conflict affected area of Pakistan: A randomized clinical trial. JAMA, 316(24), 2609–2617. https://doi.org/10.1001/jama.2016.17165 Rahman, A., Khan, M. N., Hamdani, S. U., Chiumento, A., Akhtar, P., Nazir, H., Nisar, A., et al. (2019). Effectiveness of a brief group psychological intervention for women in a post-conflict setting in Pakistan: a single-blind, cluster, randomised controlled trial. Lancet, 393(10182), 1733–1744. https://doi.org/10.1016/S0140-­6736(18)32343-­2 Rahman, A., Riaz, N., Dawson, K. S., Usman Hamdani, S., Chiumento, A., Sijbrandij, M., et al. (2016a). Problem Management Plus (PM+): pilot trial of a WHO transdiagnostic psychological intervention in conflict-affected Pakistan. World Psychiatry, 15, 182–183. Röhrbein, A. (2019). Der Ressourcenbaum  – Vergangenes, Gegenwärtiges und Zukünftiges in Einem. In A.  Eickhorst & A.  Röhrbein (Eds.), Systemische Methoden in Familienberatung und-Therapie (pp. 321–336). Vandenhoeck & Ruprecht. ISBN 978-3-525-40622-9. https://doi. org/10.13109/9783666406225.321 Sambucini, D., Aceto, P., Begotaraj, E., & Lai, C. (2020). Efficacy of psychological interventions on depression anxiety and somatization in migrants: A meta-analysis. Journal of Immigrant and Minority Health, 22(6), 1320–1346. https://doi.org/10.1007/s10903-­020-­01055-­w Sangraula, M., Turner, E., Luitel, N., Van ‘t Hof, E., Shrestha, P., Ghimire, R., et  al. (2020). Feasibility of Group Problem Management Plus (PM) to improve mental health and functioning of adults in earthquake-affected communities in Nepal. Epidemiology and Psychiatric Sciences, 29, E130. https://doi.org/10.1017/S2045796020000414 Schäfer, I., Hiller, P., Milin, S., & Lotzin, A. (2022). A multicenter, randomized controlled trial to compare the effectiveness of STARC-SUD (Skills Training in Affect Regulation – a Culture-­ sensitive approach) versus treatment as usual in trauma-exposed refugees with substance use problems. Trials, 23(1), 915. https://doi.org/10.1186/s13063-­022-­06761-­4 Schweitzer, R., Melville, F., Steel, Z., et al. (2006). Trauma, post-migration living difficulties, and social support as predictors of psychological adjustment in resettled Sudanese refugees. The Australian and New Zealand Journal of Psychiatry, 40, 179–188. Semrau, M., Evans-Lacko, S., Koschorke, M., Ashenafi, L., & Thornicroft, G. (2015). Stigma and discrimination related to mental illness in low- and middle-income countries. Epidemiology and Psychiatric Sciences, 24, 382–394. Silove, D. (2013). The ADAPT model: a conceptual framework for mental health and psychosocial programming in post conflict settings. Intervention, 11(3), 237–248. https://doi.org/10.1097/ WTF.0000000000000005 Silove, D., Ventevogel, P., & Rees, S. (2017). The contemporary research crisis: an overview of mental health challenges. World Psychiatry, 16, 130–139. https://doi.org/10.1002/wps.20438

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Spaaij, J., Kiselev, N., Berger, C., Bryant, R. A., Cuijpers, P., de Graaff, A. M., Fuhr, D. C., Hemmo, M., McDaid, D., Moergeli, H., Park, A., Pfaltz, M. C., Schick, M., Schnyder, U., Wenger, A., Sijbrandij, M., & Morina, N. (2022). Feasibility and acceptability of Problem Management Plus (PM+) among Syrian refugees and asylum seekers in Switzerland: a mixed method pilot randomized controlled trial. European Journal of Psychotraumatology, 13(1), 2002027. https:// doi.org/10.1080/20008198.2021.2002027 Spanhel, K., Hovestadt, E., Lehr, D., Spiegelhalder, K., Baumeister, H., Bengel, J., & Sander, L.  B. (2022). Engaging refugees with a culturally adapted digital intervention to improve sleep: a randomized controlled pilot trial. Frontiers in Psychiatry, 13, 832196. https://doi. org/10.3389/fpsyt.2022.832196 Strupf, M., Wiechers, M., Bajbouj, M., Böge, K., Karnouk, C., Goerigk, S., et al. (2023). Predicting treatment outcomes of the Empowerment group intervention for refugees with affective disorders: Findings from the MEHIRA project. Journal of Affective Disorders, 323, 241–250. https://doi.org/10.1016/j.jad.2022.11.050 Sulaiman-Hill, C.  M., & Thompson, S.  C. (2013). Learning to fit in: An exploratory study of general perceived self-efficacy in selected refugee groups. Journal of Immigrant and Minority Health, 15(1), 125–131. Tay, A.  K., Miah, M.  A. A., Khan, S., Badrudduza, M., Morgan, K., Balasundaram, S., et  al. (2019). Theoretical background, first stage development and adaptation of a novel Integrative Adapt Therapy (IAT) for refugees. Epidemiology and Psychiatric Sciences, 29, e47. https://doi. org/10.1017/S2045796019000416 Tay, A. K., Mohsin, M., Foo, C. Y. S., Rees, S., & Silove, D. (2022). Long-term efficacy of brief psychological treatments for common mental disorders in Myanmar refugees in Malaysia: 12-month follow-up of a randomized, active-controlled trial of integrative adapt therapy vs. cognitive behavioral therapy. Psychological Medicine, 1–13. https://doi.org/10.1017/ S0033291722003245 Tay, A. K., Mung, H. K., Miah, M. A. A., Balasundaram, S., Ventevogel, P., Badrudduza, M., et al. (2020). An Integrative Adapt Therapy for common mental health symptoms and adaptive stress amongst Rohingya, Chin, and Kachin refugees living in Malaysia: A randomized controlled trial. PLoS Medicine, 17(3), e1003073. Tay, A. K., & Silove, D. (2016). The ADAPT model: bridging the gap between psychosocial and individual responses to mass violence and refugee trauma. Epidemiology and Psychiatric Sciences, 26, 142–145. Thornicroft, G., Chatterji, S., Evans-Lacko, S., Gruber, M., Sampson, N., Aguilar-Gaxiola, S., et al. (2017). Undertreatment of people with major depressive disorder in 21 countries. The British Journal of Psychiatry, 210, 119–124. https://doi.org/10.1192/bjp.bp.116.188078 Tol, W. A., Leku, M. R., Lakin, D. P., Carswell, K., Augustinavicius, J., Adaku, A., et al. (2020). Guided self-help to reduce psychological distress in South Sudanese female refugees in Uganda: a cluster randomised trial. The Lancet Global Health, 8(2), e254–e263. Trilesnik, B., Altunoz, U., Wesolowski, J., Eckhoff, L., Ozkan, I., Loos, K., et  al. (2019). Implementing a need-adapted stepped-care model for mental health of refugees: Preliminary data of the state-funded project “RefuKey”. Frontiers in Psychiatry, 10, 688. https://doi. org/10.3389/fpsyt.2019.00688 Turrini, G., Purgato, M., Ballette, F., Nosè, M., Ostuzzi, G., & Barbui, C. (2017). Common mental disorders in asylum seekers and refugees: Umbrella review of prevalence and intervention studies. International Journal of Mental Health Systems, 11, 51. https://doi.org/10.1186/ s13033-­017-­0156-­0 Turrini, G., Purgato, M., Tedeschi, F., Acartürk, C., Anttila, M., Au, T., et al. (2022). Long-term effectiveness of Self-Help Plus in refugees and asylum seekers resettled in Western Europe: 12-month outcomes of a randomised controlled trial. Epidemiology and Psychiatric Sciences, 31, E39. https://doi.org/10.1017/S2045796022000269 van Heemstra, H. E., Scholte, W. F., Haagen, J. F. G., & Boelen, P. A. (2019). 7ROSES, a transdiagnostic intervention for promoting self-efficacy in traumatized refugees: a first quantitative evaluation. European Journal of Psychotraumatology, 10(1), 1673062.

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7

Psychological Interventions for Post-­traumatic Stress Disorder in Adults

7.1 Introduction Post-traumatic stress disorder is characterized by intrusions (e.g., flashbacks, nightmares), avoidance of stimuli associated with the traumatic event(s), negative cognitions and negative mood (e.g., persistent negative emotional state), and changes in arousal and reactivity (e.g., sleep disturbances). In the past few decades, a number of therapies have been developed to treat post-traumatic stress disorder. Generally, a distinction is made between trauma-focused therapies and non-trauma-focused therapies. Most therapies have been developed and evaluated for adults with post-­ traumatic stress disorder, which will be discussed in this chapter. In trauma-focused therapies, trauma related thoughts, memories, and associated feelings are directly addressed (e.g., exposure therapies, cognitive therapy, and EMDR). Non-trauma-­ focused therapies, however, do not directly target thoughts and feelings related to the trauma (e.g., stress inoculation training, relaxation, meditation, and interpersonal therapy).

7.2 Prolonged Exposure for Post-traumatic Stress Disorder Prolonged exposure is based on emotional processing theory, which holds that post-­ traumatic stress disorder is maintained by fear structures. According to this theory, emotions are represented in memory as cognitive networks that include representations of distressing stimuli, emotional responses, and their meaning (Foa & Kozak, 1986). Chronic post-traumatic stress disorder is assumed to develop because there is a failure to process the traumatic memory because of extensive avoidance of trauma situations and memories. Emotions underlying post-traumatic stress are

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characterized by a large number of distressing stimuli representations, which trigger the emotional network. The aim of prolonged exposure therapy is to activate these fear structures through contact with feared stimuli (e.g., trauma memory, situations related to the trauma which are avoided) and experiencing information incompatible with the problematic components of this fear structure. Components of prolonged exposure therapy include psychoeducation, imaginal exposure in which the patient is asked to repeatedly describe aloud a trauma memory to the therapist, and in vivo exposure consisting of approaching trauma stimuli in real life. Patients, together with their therapist, develop a hierarchy of feared trauma-related situations and are instructed to gradually approach these situations (in vivo exposure exercises). Patients are encouraged to continue in vivo exposure as homework assignment between sessions and to listen to audio recordings of their imaginal exposure recorded during therapy sessions. Imaginal and in vivo exposure leads to habituation of anxiety and promotes extinction of conditioned distress. Prolonged exposure therapy usually consists of 8–15 sessions of 90 min (McLean & Foa, 2022). In a meta-analysis of randomized controlled clinical trials investigating the effects of prolonged exposure in patients with post-traumatic stress disorder, Powers et al. (2010) reported that repeated imaginal or in vivo exposure to trauma memories led to more improvement on post-traumatic stress, anxiety, and depression than no treatment. There was no significant difference in effect sizes across types of trauma (e.g., childhood abuse, rape, and war). These positive effects of prolonged exposure therapy are confirmed in recent randomized controlled clinical trials with patients with post-traumatic stress disorder (Galowski et  al., 2021; McLean & Foa, 2022). In a recent meta-analysis into the effects of exposure therapy in post-traumatic stress disorder (McLean et al., 2022), updating the Powers et al. meta-analysis of 2010, including all studies published since then, exposure therapy (including prolonged exposure, narrative exposure therapy, written exposure therapy, and EMDR) showed large effects relative to treatment as usual and was equally effective as other trauma-­focused treatments. Results were maintained at follow-up. At follow-up, exposure therapy was more effective than pharmacotherapy. Effect sizes were larger in studies of refugees compared to military samples. Prolonged exposure is recommended as a first-line treatment in clinical practice guidelines (Hamblen et  al., 2019) including the American Psychological Association (APA, 2017), and the National Institute for Health and Care Excellence (NICE, 2018).

7.2.1 Dissociation and Depersonalization Although it has been argued that prolonged exposure therapy is less suited for patients with post-traumatic stress and dissociation and/or depersonalization, results so far do not support this (e.g., Hagenaars et al., 2010; Hoeboer et al., 2020; Wolf et al., 2016; Zoet et al., 2018).

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Besides psychological dissociation, disruptions in bodily functions and sensations, such as loss of motor control, analgesia, seizures, and pain, could also be considered forms of dissociation, which is referred to as somatoform dissociation (Holmes et al., 2005). In a recent study (Zoet et al., 2021) into the effectiveness of prolonged exposure therapy, the course of both post-traumatic stress disorder and somatoform dissociative symptoms was compared for patients reporting low and for those reporting high levels of somatoform dissociative symptoms. Somatoform dissociation did not affect post-traumatic stress symptom reduction. The severity of somatoform dissociative symptoms decreased significantly as a result of prolonged exposure therapy. Although results need to be replicated, this study has clear relevance for the treatment of refugees, who are often characterized by somatoform dissociation (see Chap. 1). When replicated, refugees with post-traumatic stress disorder with severe somatoform dissociative symptoms do not have to be excluded from prolonged exposure therapy.

7.2.2 Cultural Factors Most studies have investigated prolonged exposure in Western samples with post-­ traumatic stress disorder. In a study of Kline et al. (2020), the role of race and culture on the effects of therapy was investigated in African Americans and Caucasian Americans with post-traumatic stress disorder. In a randomized controlled trial, African American (n = 43) and Caucasian (n = 130) patients with post-traumatic stress disorder received either prolonged exposure or pharmacotherapy (sertraline) for post-traumatic stress disorder. Although African Americans reported stronger ethnic identity, less positive attitudes toward other groups, and less acculturation than Caucasians, African Americans and Caucasian Americans showed clinically equivalent outcomes for post-traumatic stress disorder, depression, and general functioning in prolonged exposure and in pharmacotherapy. African Americans and Caucasians both showed strong treatment responses to prolonged exposure and sertraline, despite the fact that African Americans in both treatments attended significantly fewer sessions. Interestingly, positive cultural attitudes toward other ethno-racial groups led to better treatment outcome and better treatment attendance. Importantly, the extent to which individuals identify with their own culture versus that of the dominant culture did affect the relationship between race and outcomes. Prolonged exposure was preferred to sertraline for both Caucasians and African Americans.

7.3 Imagery Rescripting A variant of exposure is imagery rescripting (Arntz, 2012; Arntz & Weertman, 1999). Imagery rescripting is a therapeutic method addressing specific memories of earlier experiences associated with current problems. In imaginary rescripting, a traumatized patient has to imagine different outcomes related to their trauma

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experiences, which may change the meaning of the trauma memory, and the patient’s core belief systems and behaviors. In this treatment, the patient is requested to recall a trauma memory from their self-perspective, identifying their thoughts, feelings, and needs. They are then guided by the therapist to imagine a more positive ending of the traumatic situation described, such as someone intervening by stopping the traumatic situation. Later on in therapy, the patient would step into the image of himself/herself and intervene in a positive way. There is some evidence that imaginary rescripting is effective in patients with post-traumatic stress symptoms (Arntz, 2012), especially with traumatic experiences during childhood (Boterhoven de Haan et al., 2020).

7.3.1 Refugees In a case series (Steel et al., 2023), the clinical outcome of imaginary rescripting was evaluated in ten refugees and asylum seekers with post-traumatic stress disorder, using a multiple baseline design. Imaginary rescripting led to clinically significant changes on the Post-traumatic Symptom Scale and depression assessed with the Physical Health Questionnaire-9 (PHQ-9). This improvement was attributable to the imagery rescripting phase of the intervention, and not the passage of time or nonspecific therapy phases. When replicated in a randomized controlled trial, imaginary rescripting could be an interesting variant of prolonged exposure for refugees.

7.4 Cognitive Processing Therapy In cognitive processing therapy (Resick et al., 2002), patients are instructed by the therapist about the relationship between thoughts and emotions and how to identify “automatic thoughts” that may exacerbate their symptoms. Patients are invited to write a statement about their understanding of why the traumatic event occurred and the impact it has had on their beliefs about themselves, others, and the world in general. According to cognitive trauma theory, distressing trauma-related emotions do not require systematic exposure to achieve habituation or extinction. The role of the therapist is to assist the patient in challenging negative thoughts associated with the trauma in an effort to modify maladaptive thinking and processing the traumatic experiences. Thus, patients are encouraged to change their minds in such a way that they are more realistic about their thoughts over the traumatic events (Galowski et al., 2022). In a more recent version of the protocol of cognitive processing therapy, the written account of the patient is made optional (Resick et al., 2017). A number of randomized controlled clinical trials support the effectiveness of cognitive processing therapy in patients with post-traumatic stress disorder. Resick et  al. (2002) found cognitive processing therapy equally effective as prolonged exposure therapy up to 10-year follow-up in female rape survivors (Resick et al., 2012). In a randomized controlled clinical study (Thompson-Hollands et al., 2018; Sloan et  al., 2018) with patients with post-traumatic stress disorder, cognitive

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processing therapy was equally effective as written exposure therapy. The sample in this study included both civilian and veteran participants with a range of traumas (e.g., motor vehicle accidents, combat, natural disasters, and sexual abuse). In another controlled clinical trial, cognitive processing therapy was more effective than a therapy with a background in gestalt theory (Butollo et al., 2016). The clinical effectiveness of cognitive processing therapy has been supported in a number of randomized clinical trials with victims of interpersonal violence, combat veterans, and victims of sexual trauma (see Galowski et al., 2022).

7.4.1 Refugees In a study with 94 Syrian refugees residing in Egypt, who had experienced war trauma, cognitive processing therapy resulted in significant reduction in post-­ traumatic stress, depression, and anxiety symptoms up to follow-up (ElBarazi et al., 2022), but this study was uncontrolled. In another uncontrolled study, the effectiveness of cognitive processing therapy was evaluated with refugees who were exposed to combat experiences, torture, bombings, sniper fire, loss of loved ones, and witnessing of atrocities. Effect sizes for improvement on post-traumatic stress symptoms were comparable to those in the randomized controlled clinical studies discussed above (Schulz et al., 2006). In this study, evaluation data from a community mental health agency that served war refugees living in the United States were analyzed. In half of the patients, interpreters were used in conducting therapy. This study is particularly important because it demonstrated that cognitive behavioral treatment for post-traumatic stress disorder developed in the Western culture was also effective when applied in other cultural groups who have experienced severe traumas. Interestingly, cognitive processing therapy was equally effective even when administered through an interpreter. A study of Bass et  al. (2013) with female victims of sexual assault in the Democratic Republic of Congo is of interest for refugees and asylum seekers as well. In this study, cognitive processing therapy was delivered in group sessions. Therapy was provided by community-based paraprofessionals, supervised by psychosocial staff at a nongovernmental organization. All paraprofessionals had experience in providing case management and individual supportive counseling to survivors of sexual violence and at least 4 years of post–primary-school education and had received a 5-day training session. The therapy was adapted for illiterate participants. Group cognitive processing therapy led to better improvement on anxiety, depression, and post-traumatic stress symptoms than individual support by community-based paraprofessionals. Participants who received therapy were significantly less likely to meet the criteria for probable depression or anxiety or probable post-traumatic stress disorder. At 6-month follow-up, 9% of participants in the therapy group and 42% of participants in the individual support condition still met the criteria for probable depression, anxiety, or post-traumatic stress disorder. As noted by the authors, because therapy, but not individual support, was provided in groups, it is unclear how much of the treatment effect was due to the group context.

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In addition, paraprofessionals who provided cognitive processing therapy received substantially more supervision than paraprofessionals who provided individual support. Not all studies found positive results for cognitive processing therapy. A study conducted in Iraq (Weiss et al., 2015) investigated the effectiveness of two therapies for use among rural survivors of systematic violence (torture and militant attacks) in Southern Iraq who were experiencing trauma symptoms. Most of these participants also experienced symptoms of depression and anxiety, as well as general dysfunctioning. In this study, survivors who had experienced or witnessed physical torture or militant attacks and who had post-traumatic stress symptoms based on a screening instrument were treated with cognitive processing therapy or Common Elements Treatment Approach, a transdiagnostic intervention including psychoeducation, relaxation, behavioral activation, cognitive coping and restructuring, imaginal exposure, and in vivo exposure (Murray et al., 2014). This Common Elements Treatment Approach included 8–12 weekly individual sessions of 50–60 min. Both treatments were provided by community mental health workers (medics or nurses) who were trained to provide mental health services locally and who worked in rural Ministry of Health primary health care centers. Patients who received the Common Elements Treatment Approach showed large clinically and statistically significant improvements in trauma, depression, anxiety, and dysfunction compared to wait list control patients. Patients receiving cognitive processing therapy, however, reported moderate improvements in trauma and depression, but hardly any improvement in anxiety and general functioning, compared with patients in the waiting list control group. In a study of Bernardi et al. (2019), a modified cognitive processing group therapy was investigated for refugees from Myanmar with post-traumatic stress disorder. Although all patients no longer fulfilled the criteria of post-traumatic stress disorder at posttest immediately after treatment, at 3-month follow-up, four of the seven participants had a significant worsening in post-traumatic stress symptoms when compared with their post-treatment symptom levels. Also, in a study of Steil et al. (2021), who treated 16 refugees in Germany with cognitive processing therapy, therapy was not very successful; the effect on post-traumatic stress symptoms was not significant. More than half of the patients dropped out of therapy. The authors suggest that the failures of cognitive processing therapy in this study may be due to low motivation and problems with reading skills and writing skills of refugees, and they propose adjustment of cognitive processing therapy before it is used with refugees in Western countries.

7.4.2 Cognitive Therapy Cognitive therapy for post-traumatic stress disorder is a trauma-focused therapy that is based on Ehlers and Clark’s model of post-traumatic stress disorder (Ehlers & Clark, 2000). Cognitive therapy focuses on changing cognitive appraisals that induce a sense of current threat, by identifying and modifying excessively negative appraisals of the trauma and its sequelae, elaborating the trauma memory and

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discriminating triggers of intrusive reexperiencing, and changing problematic behaviors that maintain the problem such as thought suppression, rumination, and safety-seeking behaviors. Patients are given homework assignments to complete between sessions (Ehlers & Wild, 2022). Cognitive therapy for post-traumatic stress has been shown to be rather effective and acceptable to patients with post-traumatic stress disorder (Ehlers et al., 2003; Ehlers et al., 2005; Ehlers et al., 2014) and may also be effective when delivered through the Internet (Ehlers et al., 2003). Subjects in these randomized clinical trial studies were adults with acute (Ehlers et al., 2003) and chronic post-traumatic stress disorder (Ehlers et al., 2005; Ehlers et al., 2014). In the study of Ehlers et al. (2013), it was shown that cognitive therapy for post-­ traumatic stress disorder could be effectively implemented in routine clinical care in the United Kingdom, resulting in clinically relevant treatment effects, not only on post-traumatic stress symptoms but on depression and anxiety measures as well. Results were maintained at follow-up approximately 9 months after the end of the therapy, but the follow-up was based on only two-thirds of the patients who had been treated with cognitive therapy. The effect size for post-traumatic stress symptoms in the Ehlers et  al. (2013) study was lower than the effect sizes for post-­ traumatic stress symptoms in the randomized controlled trials of Ehlers et al. (2003), Ehlers et al. (2005), and Ehlers et al. (2014) studies. Nevertheless, results of cognitive therapy in clinical practice are rather positive. However, an intensive training for therapists is needed: relatively inexperienced therapists had substantially more dropouts.

7.4.3 Refugees To date, no controlled studies have yet been published on the effectiveness of cognitive therapy for post-traumatic stress disorder in refugees. In a randomized controlled trial (Duffy et  al., 2007), the effectiveness of cognitive therapy for post-traumatic stress disorder as a result of terrorism was investigated in a community treatment center in Northern Ireland. Three months after the start of the cognitive therapy, treatment resulted in greater improvement than the waiting list control group, not only on post-traumatic stress symptoms, but also on depression and social functioning. No change was observed in the waiting list control group, thus supporting the view that cognitive therapy is an effective treatment for post-­ traumatic stress disorder as a result of terrorism and other civil conflicts.

7.5 Mindfulness-Based Cognitive Therapy Mindfulness-based cognitive therapy has been found to be effective in reducing stress (Gu et al., 2015) and depression (Goldberg et al., 2019; Segal et al., 2018) and in preventing depression relapse (Kuyken et al., 2016). Research with respect to the usefulness of mindfulness-based cognitive therapy as treatment for post-traumatic stress disorder is limited (e.g., Hopwood & Schutte, 2017; Bhatnagar et al., 2013;

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Dutton et al., 2013; Possemato et al., 2016), especially for low-income, disadvantaged individuals (e.g., King et al., 2013; Watson-Singleton et al., 2019).

7.5.1 Refugees Few studies have investigated the effects of mindfulness approaches with refugees. One study (Buhmann et al., 2016) evaluated the effects of a rather broad “flexible” cognitive behavior therapy program (average of 12 sessions), including mindfulness exercises, acceptance and commitment therapy (A-Tjak et al., 2015), schema therapy (Young et al., 2003), and exposure in refugees with post-traumatic stress disorder resettled in Denmark. The psychological treatment was compared with pharmacotherapy and a waiting list control condition in a large randomized controlled clinical trial. Neither this broad cognitive behavioral therapy nor pharmacotherapy resulted in a clinically significant reduction of post-traumatic stress symptoms. In addition, most patients scored still above cutoff for depression on the Hamilton Rating Scale for Depression. The negative effects of this “flexible” psychological treatment in this study may be due to a number of factors including the mix of a number of rather different interventions (too flexible) in a much too short time period, which had to be translated in more than half of the patients. In addition, only one-quarter of the patients in the psychological treatment condition received any form of exposure treatment and the majority of these patients were only exposed to trauma once or twice, which is not according to the exposure guidelines (e.g., Emmelkamp & Ehring, 2014). Last but not least, the psychotherapy was not culturally adapted. Given these shortcomings, results of this study are difficult to interpret. In another randomized controlled study (Aizik-Reebs et al., 2021), a mindfulness- and compassion-based, trauma-sensitive, and socially and culturally adapted intervention for refugees and asylum seekers was evaluated with 158 asylum seekers from Eritrea with severe trauma history living in an urban post-displacement setting in the Middle East. Half of the patients received the mindfulness-based therapy, and the other half were in the waiting list control condition. This mindfulness therapy is a trauma-sensitive and socioculturally adapted group therapy, lasting 9  weeks. The mindfulness-based trauma recovery treatment led to significantly more reduction in post-traumatic stress symptoms, depression, and anxiety at the posttest and at 1-month follow-up. In a related study (Aizik-Reebs et al., 2022), the role played by self-compassion and self-criticism in the process of trauma recovery was investigated in this randomized wait list control trial. Results revealed that self-­ compassion and self-criticism were associated with trauma- and stress-related psychopathology and that, in contrast to the waiting list control condition, the mindfulness-based intervention led to significant elevation in self-compassion and reduction in self-criticism at the posttest. Interestingly, enhancement of self-­ compassion and reduction in self-criticism significantly mediated therapeutic effects of the mindfulness-based intervention on post-traumatic stress symptoms. In a recent study (Powers et al., 2022), it was shown that a culturally adapted mindfulness-based group cognitive therapy was promising for Black adults who

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screened positive for post-traumatic stress disorder and major depression. The results of the few studies with mindfulness-based approaches with refugees taken together suggest that mindfulness-based approaches may be an acceptable mental health intervention for refugees and asylum seekers. Offering trauma-informed mindfulness-based group cognitive therapy within refugee camps with limited access to mental health services could be a valuable step forward for refugees and asylum seekers with comorbid post-traumatic stress symptoms and depression, but this has not yet been investigated.

7.6 Stress Management Other interventions have focused on current problems rather than on processing of traumatic experiences such as stress management. In a study of Carlsson et  al. (2018), stress management training and cognitive restructuring were compared in 126 refugees with post-traumatic stress disorder who were resettled in Denmark. Treatment in both conditions consisted of 16 individual sessions and lasted for 6–7  months. Psychologists carried out both treatments. Stress management was based on stress inoculation training (Meichenbaum, 2017), and patients were trained to acquire and consolidate adequate coping skills. Training included relaxation, attention diversion involving shifting the focus away from unwanted thoughts and feelings, and behavioral activation to break a vicious circle of inactivity. Cognitive restructuring involved psychoeducation and cognitive restructuring of negative thoughts resulting from traumatic experiences and exposure. Results revealed that stress management was equally effective as cognitive restructuring on the Harvard Trauma Questionnaire and even slightly more effective on the observer-rated Hamilton Anxiety Rating. Cognitive restructuring led to increased somatization and anxiety symptoms between pre–posttreatment. In a follow-up study (Barhoma et al., 2021) after 18 months, no significant between-group differences between the two interventions were found with respect to post-traumatic stress symptoms. Stress management led to a larger reduction in symptoms of somatization, depression, and anxiety at 18-month follow-up compared to the cognitive restructuring condition.

7.7 Eye Movement Desensitization and Reprocessing Therapy (EMDR) Eye movement desensitization and reprocessing therapy (EMDR) involves that post-traumatic stress patients focus on a traumatic image, thought, emotion, and bodily sensations while receiving bilateral stimulation most commonly in the form of systematic saccadic eye movements. Saccades are typically induced by tracking a therapist’s finger as it is moved rapidly from side to side (Shapiro, 2018), but other bilateral stimulations such as taps or tones are used as well. Coping statements are also introduced while the scene is being imagined. According to Shapiro (2018), exposure to trauma results in neuronal changes and disruption of a physiological

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balance between excitatory and inhibitory systems in the brain, which results in inadequate processing of traumatic memories. The adaptive information processing model of Shapiro proposes that traumatic memories are not integrated into the existing memory networks and remain stored in a maladaptive form. Bilateral stimulation in EMDR is thought to access the dysfunctional information and create new neural pathways, thus enabling appropriate reprocessing of the traumatic memories (Shapiro, 2018). Current reviews on the neurobiological correlates of EMDR interventions highlighted two different frameworks in order to interpret the working mechanism of EMDR, namely the increased interhemispheric connectivity model (e.g., Keller et al., 2014; Nieuwenhuis et al., 2013) and the taxing working memory model (van den Hout & Engelhard, 2012; Pagani et  al., 2013). As shown in the review of van de Hout and Engelhard, eye movements matter, and the effects cannot be explained by exposure alone. The increased interhemispheric connectivity model, however, is not supported by recent research (Landin-Romero et al., 2018). In the preparation phase of EMDR therapy, self-control and resource development techniques are often used to enhance access to memories of positive experiences or skills that the patient has in other areas of life (Laliotis & Shapiro, 2022). The EMDR protocol involves eight phases focusing on the past experiences that have set the foundation for the pathology, the present situations or triggers that currently stimulate the disturbance, and the positive templates necessary for appropriate future action (Shapiro, 2018, p. 71). In a review of randomized controlled trials comparing the effects of EMDR versus cognitive behavior therapy in adult patients with post-traumatic stress disorder (Chen et al., 2015), EMDR was equally effective as cognitive behavior therapy in terms of total post-traumatic stress disorder scores, irrespective of the type of trauma. EMDR was more effective when delivered by more experienced therapists, and sessions which lasted longer than 60 min led to better outcomes in EMDR than shorter sessions (Chen et al., 2015). The effectiveness of EMDR for post-traumatic stress disorder was confirmed in recent meta-analyses (Cusack et al., 2016; Lewis et al., 2020; Mavranezouli et al., 2020). Direct comparisons have not found EMDR superior to other exposure therapies (e.g., Boterhoven de Haan et al., 2020; Nijdam et al., 2012; Rothbaum et al., 2005; van den Berg et al., 2015).

7.7.1 Refugees A few studies investigated the effectiveness of EMDR among refugees. In a study of Wippich et al. (2023), the efficacy of EMDR was investigated for treating post-­ traumatic stress, anxiety, and depression among 278 individuals from conflict-­ affected areas, including refugees residing in Lebanon. Treatment resulted in significant improvement in post-traumatic stress, anxiety, and depression symptoms, but this study was uncontrolled. Acarturk et  al. (2015) investigated in a small pilot study the effect of EMDR among Syrian refugees located in a refugee camp in Turkey. EMDR therapy led to more improvement on post-traumatic stress symptoms and depression scores than a

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wait list control group, but measures used were not state of the art. In a second study by the same group (Acarturk et al., 2016), results were confirmed in a larger randomized controlled trial with adequate measures. Adult refugees (N = 70) located in a refugee camp at the Turkish-Syrian border with post-traumatic stress disorder assessed with the Mini-International Neuropsychiatric Interview were randomized to EMDR or waitlist control. EMDR therapy led to a significantly larger reduction of post-traumatic stress symptoms as assessed with the Harvard Trauma Questionnaire and symptoms of depression as assessed with the Beck Depression Inventory-II and the HSCL-25. Renner et al. (2011) compared EMDR with three conditions: cognitive behavior therapy (including trauma exposure), culture-­ sensitive and resource-oriented peer group, and a waiting list control. EMDR therapy was the least effective active condition: three sessions of EMDR did not achieve a reduction in symptoms. Finally, in a study of Ter Heide et al. (2011), the effectiveness of EMDR was compared with stabilization therapy with severely traumatized refugees. Only 10 out of 20 participants completed the study, which renders results difficult to interpret. In another study of Ter Heide et al. (2016), results of EMDR with refugees were rather limited. Refugees (N = 72) who were referred for highly specialized treatment in the Netherlands were randomly assigned to EMDR or stabilization. Both in the Clinician-Administered PTSD Scale (CAPS) and the Harvard Trauma Questionnaire, no differences in efficacy between the two conditions were found. The authors conclude that EMDR in refugee patients needing specialized treatment is only of limited efficacy. However, as noted by the authors and found in other studies as well, directly targeting traumatic memories of refugees in EMDR carries no harm for refugees. Taken together the studies which investigated the efficacy of EMDR with refugees, results are rather mixed. In a recent meta-analysis (Macgowan et al., 2022), the effects of EMDR were evaluated on post-traumatic stress symptoms, anxiety, and depression for young people and adults forcibly displaced due to either natural disasters or war, conflict, or persecution (refugees and asylum seekers). Based on 17 studies, including studies without control groups, the effect size for reduction of post-traumatic stress symptoms, anxiety symptoms, and depression symptoms posttreatment was large. Results are difficult to interpret, however, given that most studies used self-reported measures focusing on symptom reduction rather than on changes in post-traumatic stress diagnosis and diagnoses of concurrent mental health disorders. Thus, it is unclear whether EMDR reduced post-traumatic stress disorder, depression, and anxiety to subclinical levels (Macgowan et al., 2022, p. 12). In addition, results should be interpreted cautiously, given that there was evidence for publication bias, which was not corrected in the meta-analysis. Nearly all the non-randomized studies had critical risk of bias. In studies in which EMDR was compared with other conditions, the effects varied considerably. In a meta-­analysis of psychosocial interventions for adult refugees and asylum seekers with post-traumatic stress disorder (Turrini et al., 2021), only randomized controlled studies were included. Results revealed that EMDR was significantly more effective than waitlist control, but not more effective than trauma-focused cognitive behavior therapy.

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7.8 Narrative Exposure Therapy Narrative exposure therapy was originally designed for adult war victims in a refugee camp (Neuner et al., 2002). It has been used for multiple traumatized adults who have undergone a number of traumatic stressors, such as war, rape, and torture (Neuner et al., 2004). Narrative exposure therapy is an adaptation of the classical form of trauma-focused exposure therapy (Foa & Kozak, 1986) for patients with post-traumatic stress. In exposure therapy, traumatized survivors of war and torture are requested to repeatedly talk about the worst traumatic event in detail and imagine these events while re-experiencing all emotions associated with the event in order that habituation of the emotional response to the traumatic memory occurs, which eventually may lead to a remission of post-traumatic stress symptoms. Exposure therapies (and EMDR) target the most distressing traumatic memory, but a number of patients experienced multiple often chronic traumatic events such as ongoing intimate partner violence, war, and torture, which makes it often “undoable” to define the worst traumatic experience. This is not a problem in narrative exposure therapy. In this therapy (ranging 6–8 sessions), the patients are assisted to construct a chronological narrative of their life stories with special emphasis on the traumatic experiences. Conforming the exposure guidelines, therapeutic re-­ exposures to traumatic experiences are not terminated before the fear responses show significant decline. Thus, in addition to exposure and habituation, narrative exposure therapy stimulates the reconstruction of autobiographical memories and contextualization of trauma memories, which is quite useful to support people experiencing symptoms of complex post-traumatic stress disorder (Schauer et al., 2011). Active listening and empathic understanding by the therapist are important elements in transforming fragmented reports of traumas into coherent narratives. Narrative exposure therapy focuses on the whole biography of the survivor, including all traumatizing events, rather than a specific event for therapy. Through this reconstruction, emotional and cognitive processing of the event may occur to form an organized narrative of the event (Schauer et al., 2011). Last but not least, before the start of narrative exposure therapy, patients are educated on which role avoidance plays in inhibiting treatment in order to reduce treatment dropout. In a randomized controlled clinical trial (Lely et al., 2019) with older patients (>55 years) with post-traumatic stress disorder, 11 sessions of narrative exposure therapy were compared with 11 sessions of a nonintrusive control condition: present-­centered therapy. Present-centered therapy involves psychoeducation about post-traumatic stress disorder and homework assignments targeting current maladaptive relational patterns by including problem-solving techniques focusing on current stressors (see Frost et  al., 2014; Steenkamp et  al., 2015). The traumatic events of the patients included in the clinical trial involved war experiences, persecution, childhood abuse, and domestic violence. Treatment dropout rates were low. Narrative exposure therapy showed a medium-to-large reduction of psychopathology, including post-traumatic stress disorder assessed with the Clinician-­ Administered PTSD Scale for DSM-IV (CAPS-IV) and the Harvard Trauma Questionnaire, and depression assessed with the Beck Depression Inventory.

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Surprisingly, hardly any significant between-group treatment effect was found (Lely et al., 2019, 2022). Only on the CAPS-IV was found a medium between-treatment effect size, favoring the control condition of present-centered therapy. At follow-up, however, a continuing symptom decline in the narrative exposure therapy was found and a (partial) relapse in post-traumatic stress symptoms in present-centered therapy. At 4-month follow-up, however, the between-treatment difference was no longer significant. In contrast to a number of other interventions for post-traumatic stress disorder, narrative exposure therapy may be delivered by trained lay therapists. In practice, nonprofessional local community members are trained to deliver narrative exposure therapy themselves within their community. Given the lack of qualified psychotherapists and mental health professionals in settings with refugees and asylum seekers, this is a clear advantage of narrative exposure therapy. In addition, cultures that value oral tradition and history telling may find the narrative nature of this approach socially acceptable, thereby potentially countering the stigma associated with traditional mental health services (Hijazi et al., 2014). Another advantage is the limited number of sessions needed for narrative exposure therapy to be effective.

7.8.1 Refugees In a study of Neuner et al. (2008), it was investigated whether trained lay counselors can carry out narrative exposure therapy in a refugee settlement in Uganda. In a randomized controlled trial with 277 Rwandan and Somalian refugees with post-­ traumatic stress disorder, narrative exposure therapy was compared with more flexible trauma counseling and a no-treatment control. The lay counselors were trained over a period of 6  weeks. Both active treatments were superior to no-treatment control but were equally effective in terms of reduction of post-traumatic stress up to 6-month follow-up. However, fewer patients (4%) dropped out of narrative exposure therapy treatment than out of the more flexible trauma counseling (21%). At follow-up, a post-traumatic stress disorder diagnosis could not be established anymore in 70% of narrative exposure therapy patients and 65% of flexible trauma counseling patients, whereas only 37% in the no-treatment control group did no longer meet post-traumatic stress disorder criteria. One study by this group focused on the treatment of post-traumatic stress disorder in former child soldiers. These child soldiers had been exposed to violence in the rebel army, including torture, forced participation in atrocities, and sexual violence. In a randomized controlled trial (Ertl et al., 2011), 85 former child soldiers (aged 12–25 years) with post-traumatic stress disorder living in Uganda were randomized to narrative exposure therapy, supportive counseling, or a waiting list control group. Treatments were carried out in the community by trained local lay therapists (seven female and seven male), who were intensively supervised. The primary outcome measure was change in post-traumatic stress disorder severity, assessed over a 1-year period after treatment. Post-traumatic stress symptoms were significantly more improved in patients after narrative exposure therapy than in

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patients in the supportive counseling and waiting list groups. Twenty of 25 of the former child soldiers who received narrative exposure therapy experienced large improvement in PTSD severity, exceeding the threshold of clinically significant change. Thus, narrative exposure therapy produced a larger within-treatment effect compared with either supportive counseling or wait listing. Both treatments were equally effective on depression symptoms, suicidal ideation, and stigmatization. Finally, narrative exposure therapy led to the largest reduction of guilt feelings, presumably due to the trauma narration during the therapy process, which may have facilitated the cognitive reappraisal of past events that previously promoted feelings of guilt. Thus, this study revealed that narrative exposure therapy is an effective treatment in former child soldiers. This study also shows that this therapy can be applied successfully by community-based lay therapists without a mental health or medical background. Most other controlled clinical trials of narrative exposure therapy have been conducted in refugee camps or Western European countries. In a pilot randomized controlled trial conducted in Germany, Neuner et al. (2010) compared the efficacy of narrative exposure therapy with treatment as usual in a small sample of 32 asylum seekers with post-traumatic stress disorder as a result of state-organized violence/ torture and other traumatic events. Treatment as usual was comparable to treatment offered in the German health care system. Asylum seekers and refugees with post-­ traumatic stress disorder with a maximum leave to remain of 3  months were recruited for this study. Narrative exposure therapy was carried out by experienced psychologists or graduate students with extensive training in narrative exposure therapy with the help of trained interpreters. Treatment consisted of nine treatment sessions (range 5–17) with an average duration of 120 min. At follow-up of 6 months after treatment, moderate but significant improvement of post-traumatic stress was found in patients who had received narrative exposure therapy, but not in the control group who had received treatment as usual. The overall effect was unsatisfactory, however, given that all but one patient who received narrative exposure therapy and all patients who received treatment as usual still fulfilled post-traumatic stress disorder criteria and treatment had no effect on depressive symptoms. One explanation for this rather limited outcome could be that participants in this trial started with a rather high symptom level presumably due to the unsafe living conditions, and the permanent threat of deportation. In another randomized controlled trial (Hensel-Dittmann et al., 2011), the effects of narrative exposure therapy were compared with the effects of stress inoculation training among refugees and asylum seekers in Germany. Although a clinically significant reduction in post-traumatic stress symptoms was found for narrative exposure therapy, and not for stress inoculation training, comorbid depression and anxiety disorders did not improve in both therapeutic conditions (Palic & Elklit, 2011). Both narrative exposure therapy and supportive counseling were superior to no treatment, but narrative exposure therapy was not consistently superior across studies (Neuner et al., 2008; Ruf et al., 2010). In another study (Stenmark et al., 2013), refugees and asylum seekers with post-­ traumatic stress disorder were treated in 11 psychiatric settings in Norway either

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with narrative exposure therapy (N = 51) or with treatment as usual (N = 30). Both narrative exposure therapy and treatment as usual led to clinically relevant symptom reduction both in post-traumatic stress disorder assessed with Clinician-­ Administered PTSD Scale and in depression assessed with the Hamilton Rating Scale for Depression. Narrative exposure therapy proved to be significantly more effective than treatment as usual. At the end of the therapy, less patients who had received narrative exposure therapy still fulfilled the criteria of post-traumatic stress disorder compared with patients who had received treatment as usual. No difference in treatment efficacy was found between refugees and asylum seekers. Thus, in contrast with the worse results of narrative exposure therapy in the study with asylum seekers in Germany, in Norway, narrative exposure therapy appeared to be a promising treatment not only for refugees, but for asylum seekers as well.

7.8.2 Brief Version of Narrative Exposure Therapy A brief version of narrative exposure therapy (three sessions only) was developed in the United States and evaluated among Iraqi refugees with elevated post-traumatic stress (Hijazi et al., 2014). The investigators hoped that a brief version of narrative exposure therapy, if effective, would be more cost-effective and thus more likely to be implemented than the longer version of narrative exposure therapy. Arabic-­speaking adult Iraqi refugees with post-traumatic stress disorder who had resettled in the United States (N = 63) were randomly assigned to the three-session version of narrative exposure therapy or to the waitlist control condition. Brief narrative exposure therapy was conducted individually, in Arabic for three weekly sessions in a private room at the patient’s preferred location (typically at home, but sometimes in a church). Although at 2 months after treatment brief narrative exposure therapy led to more reduction in post-traumatic stress symptoms and depression than no-­treatment control, post-traumatic and depressive symptoms of no-treatment controls also decreased from 2 to 4 months. Somatic symptoms decreased significantly over time after brief narrative exposure therapy, but this improvement did not differ significantly from reductions in somatic symptoms among patients in the control condition. At 4-month follow-up, brief narrative exposure therapy was no longer superior to waiting list control. Results of this study are difficult to evaluate because participants were not formally diagnosed whether they fulfilled the criteria of post-­traumatic stress disorder, which limits comparisons with other studies of narrative exposure therapy.

7.8.3 Lay Counselors In a recent study (Ellis & Jones, 2022), it was investigated whether lay counselors— who were refugees themselves—could be trained to conduct narrative exposure therapy. Trainees were Sudanese refugees who all were speaking both English and Arabic. Those who were recruited into the training were formally assessed in order to exclude trainers with symptoms of post-traumatic stress disorder or depression.

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Of the ten trainees, three were female and seven were male. None had any background working in mental health. These Sudanese refugee trainees were given 27 h of training in narrative exposure therapy, which took place over 2 months. All training materials for narrative exposure therapy, the measures used and information sheets, were provided in both Sudanese Arabic and English. After the training, the trainers gave narrative exposure therapy to seven Sudanese refugees of whom six completed the treatment. Results were positive, showing a significant decrease in symptoms of post-traumatic stress disorder and anxiety and near-significant reduction in depression from pre- to post-intervention. However, the small number of participants and the lack of a control group prohibit causal conclusions from being drawn. Nevertheless, given these preliminary positive results, there is a clear need of studies comparing the effectiveness of narrative exposure therapy delivered by trained refugee lay counselors versus narrative exposure therapy delivered by expert mental health workers.

7.8.4 Trauma-Informed Community-Based Intervention (NETfacts) A recent randomized controlled study (Robjanta et al., 2022) investigated the effectiveness of an integrated model of narrative exposure therapy and a trauma-informed community-based intervention (NETfacts): the NETfacts health system. This community-­based intervention included narrative exposure therapy when needed but also addressed change in attitudes with respect to (a) acceptance of rape, (b) stigmatization of survivors of sexual violence, and (c) skepticism about the reintegration of former combatants. This study was conducted in the Democratic Republic of Congo where people have become victims of violence over decades. Results of this study, involving over 1000 community members, revealed that the community-­ based NETfacts health system was more effective in terms of reduction of rape myth acceptance and led to less stigmatizing of survivors of sexual violence than narrative exposure therapy as a stand-alone treatment. The community-based NETfacts intervention led to a stronger reduction in rape myth acceptance than in the control condition, where individuals received narrative exposure therapy only up to 6-month follow-up. Symptoms of post-traumatic stress and depression declined more strongly after the community meetings in the NETfacts condition than in the narrative exposure therapy-only condition, but this was not confirmed at 6-month follow-up.

7.8.5 Concluding Remarks In sum, narrative exposure therapy has been shown to be effective for reducing symptoms of post-traumatic stress in refugees, asylum seekers, and people living in conflict areas, which may be the result of the cultural adaptations of narrative exposure therapy helping victims to discuss their trauma in a less stigmatizing way (Wright et al., 2020).

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7.9 Skills Training in Affect and Interpersonal Regulation (STAIR) STAIR (Cloitre et al., 2002) is an initial phase of trauma treatment focusing on preparing patients before a trauma-focused treatment starts by addressing problems in emotion regulation and interpersonal regulation. In a randomized clinical trial conducted by Cloitre et al. (2002), the efficacy of STAIR was compared with the efficacy of prolonged exposure and wait list control with female patients with post-traumatic stress disorder as a result of physical and/or sexual abuse in childhood. The first phase of therapy consisted of 8 weekly sessions of skill training in emotion regulation and interpersonal regulation; the second phase consisted of 8 sessions of prolonged exposure. Patients who received these treatments showed significant improvement in affect regulation problems, interpersonal skill deficits, and post-traumatic stress disorder symptoms up to 9-month follow-up. Treatment was more effective than waiting list control. It has been questioned whether the standard cognitive behavioral trauma-focused interventions are suitable for refugees and asylum seekers, or whether a stabilization phase is preferable (Griggs et al., 2022). Despite strong evidence for the effectiveness of trauma-focused interventions discussed above such as cognitive behavior therapy and narrative exposure therapy in refugees and asylum seekers, others still argue that the high levels of uncertainty and the ongoing threat of further trauma may limit the acceptability and effectiveness of these interventions (see Slobodin et al., 2018).

7.10 Pharmacotherapy Many patients with post-traumatic stress disorder, including refugees and asylum seekers, receive pharmacotherapy, e.g., venlafaxine, or SSRIs. In a randomized clinical trial (Sonne et al., 2016), the effects of venlafaxine (N = 98) versus sertraline (N = 109) were compared in a sample of refugees with post-traumatic stress disorder who were referred for treatment to a transcultural psychiatric outpatient clinic in Denmark. Importantly, all patients received cognitive behavior therapy and social counseling as well. Cognitive behavior therapy consisted of 16 sessions. No statistically significant group differences were found on the primary outcome measure in the Harvard Trauma Questionnaire, on the secondary outcome measures assessing anxiety and depression (Hopkins Symptom Checklist-25; Hamilton Depression and Anxiety scale), and on the quality of life assessed with the WHO-5 Well-Being Index. Since the study did not include a placebo control group, results are difficult to evaluate. Although there is some evidence that in patients with post-­ traumatic stress disorder and substance use disorder a combination of pharmacotherapy and trauma-focused therapy may be more effective than trauma-focused therapy alone (Hien et al., 2023), in a meta-analysis of pharmacotherapy-assisted psychotherapy in patients with post-traumatic stress disorder, only MDMA-assisted therapy was superior to placebo in reducing clinician-rated post-traumatic stress

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symptoms (Hoskins et al., 2021). Whether this is also the case in refugees with post-­ traumatic stress disorder has not yet been investigated.

7.11 Concluding Remarks As discussed in this chapter, a number of evidence-based interventions in Western cultures for patients with post-traumatic stress disorder, including refugees and asylum seekers, have been investigated in refugees. In a meta-analysis (Lambert & Alhassoon, 2015) on trauma-focused interventions with refugees including EMDR, cognitive behavior therapy, and narrative exposure therapy, the effect size for trauma-focused interventions was large. Interestingly, using an interpreter did not enhance the effectiveness of trauma-focused therapy. A few other psychological interventions have been investigated in randomized controlled clinical trials with refugees and asylum seekers, but results did not reveal a positive effect: body awareness therapy, mixed physical activity (Nordbrandt et  al., 2020), and imagery rehearsal therapy (Sandahl et al., 2021). In a meta-analysis of Nosè et al. (2017) with refugees and asylum seekers with post-traumatic stress disorder resettled in high-income countries, narrative exposure therapy was the best supported intervention. In a more recent meta-analysis (Kip et al., 2020) of 17 randomized controlled studies (of which 14 were conducted with adult refugees) in Western host countries, active interventions for adult post-­ traumatic stress disorder yielded a medium-to-large effect size when compared with control conditions up to 6 months after therapy. Patients in the majority of studies included met the criteria for post-traumatic stress disorder. Given that large numbers of refugees in host countries use medication for their complaints only, studies were included with less than half of the patients receiving concurrent medication. No significant differences were found based on the medication rate or number of sessions. Of note, risk of bias due to researcher allegiance may have played a role. Half of the studies in the meta-analysis of Kip et al. (2020) included researchers who were involved in the development of the manuals: Five out of six studies on narrative exposure therapy involved at least one author of the therapy manual (Schauer et al., 2011). Generally, researcher allegiance has been found to account for 69% of the variance in psychotherapy outcome studies (Luborsky et al., 1999).

7.11.1 Predictors of Treatment Outcome Few studies have investigated predictors of treatment outcome in refugees and asylum seekers with post-traumatic stress disorder. (e.g., Li et al., 2016; Opaas et al., 2022; Sonne et al., 2021). There is some evidence that refugee patients who suffer from post-traumatic stress disorder and severe comorbid depression benefit less from psychotherapy for post-traumatic stress disorder (Haagen et al., 2017). Given these results, assessment of severe depression before post-traumatic stress disorder

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therapy is warranted. Research for treatment adaptations for post-traumatic stress disorder and comorbid severe depression in traumatized refugees is needed. In a study of Koch et al. (2020), higher symptom severity of post-traumatic stress disorder, anxiety, and depression was associated with difficulties in emotion regulation, which suggests that emotion regulation may be a trans-diagnostic key factor contributing to different psychological disorders in refugees who have experienced severe trauma. It highlights the need for trans-diagnostic interventions that focus on emotion regulation difficulties. In a study of Bernardsdóttir et al. (2023), personality functioning did not predict the outcome of 16–20 sessions of cognitive behavioral interventions for post-­ traumatic stress disorder in refugees resettled in Denmark. Personality functioning was measured with the Levels of Personality Functioning Scale, an observer rating scale from the alternative model for personality disorders in DSM-5 (Morey, 2017). Psychotherapy consisted of a combination of trauma-focused cognitive behavioral therapy, acceptance and commitment therapy, mindfulness, and/or stress management, which renders results difficult to interpret.

7.11.2 Treatment Through the Internet There is some evidence that post-traumatic stress disorder can be treated with cognitive behavior therapy through the Internet (Lange et al., 2003), and a few apps have been developed. The efficacy of mobile interventions for treating post-­ traumatic stress disorder is promising (Olff, 2015), but inconclusive (see Goreis et al., 2020; Wickersham et al., 2019). Two randomized controlled trials with refugees and asylum seekers have been reported. Knaevelsrud et al. (2015) investigated the efficacy of the cognitive behavioral Internet-based intervention Interapy (Lange et al., 2003) with war-traumatized Arab patients, most of whom came from Iraq. The Dutch Interapy manual was translated into Arabic and culturally adapted for this treatment program. The treatment is based on evidence-based principles of cognitive behavior therapy for post-traumatic stress disorder and consisted of structured writing assignments: (1) self-confrontation with the traumatic event, (2) cognitive restructuring, and (3) social sharing. Internet treatment consisted of 2 weekly 45-min sessions. Ten sessions of Interapy led to a significant reduction posttreatment compared to the waiting list control group, and effects were maintained at 3-month follow-up. Completer analysis indicated that 62% of the patients who completed Interapy had recovered from post-traumatic stress symptoms versus 2% in the control condition. The effect sizes were of a similar magnitude to those reported for Western samples using the same treatment protocol (e.g., Lange et  al., 2001, 2003). Röhr et al. (2021) investigated the efficacy of a cognitive behavioral self-help trauma app in Arabic for Syrian refugees residing in Eastern Germany with mild-to-­ moderate post-traumatic stress symptom severity. Although symptom severity decreased, the app was not more effective in reducing post-traumatic stress disorder symptoms than psychoeducation control. The app showed no effectiveness on

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anxiety or depressive symptoms, somatization, general self-efficacy, and health-­ related quality of life.

7.11.3 Post-migration Stressors Most interventions described in this chapter are based on trauma-focused therapies rather than on interventions dealing with post-migration stressors. As discussed in Chap. 1, there is considerable evidence that in a substantial number of refugees and asylum seekers, their mental health problems are increased as a result of stressors during the post-migration period in the host countries rather than purely as the result of traumatic experiences in the past (e.g., Bruhn et al., 2018; Slobodin et al., 2018). Thus, there is a clear need of investigating additional treatment components addressing post-migration stressors in addition to trauma-focused interventions (e.g., Fondacaro & Mazzulla, 2017; Li et al., 2016; Miller & Rasmussen, 2017; Teodorescu et al., 2012).

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Segal, Z. V., Williams, M., & Teasdale, J. (2018). Mindfulness-based cognitive therapy for depression. Guilford Press Publication. Shapiro, F. (2018). Eye movement desensitization and reprocessing: basic principles, protocols, and procedures. Guilford. Sloan, D.  M., Marx, B.  P., Lee, D.  J., & Resick, P.  A. (2018). A brief exposure-based treatment vs cognitive processing therapy for post-traumatic stress disorder: A randomized non-inferiority clinical trial. JAMA Psychiatry, 75(3), 233–239. https://doi.org/10.1001/ jamapsychiatry.2017.4249 Slobodin, O., Ghane, S., & De Jong, J. T. (2018). Developing a culturally sensitive mental health intervention for asylum seekers in the Netherlands: A pilot study. Intervention, 16(2), 86–94. https://doi.org/10.4103/INTV.INTV_2_18 Sonne, C., Carlsson, J., Bech, P., Elklit, A., & Mortensen, E.  L. (2016). Treatment of trauma-­ affected refugees with venlafaxine versus sertraline combined with psychotherapy  - a randomised study. BMC Psychiatry, 16(1), 383. https://doi.org/10.1186/s12888-­016-­1081-­5 Sonne, C., Mortensen, E. L., Silove, D., Palic, S., & Carlsson, J. (2021). Predictors of treatment outcomes for trauma-affected refugees  – Results from two randomised trials. Journal of Affective Disorders, 282, 194–202. https://doi.org/10.1016/j.jad.2020.12.095 Steel, C., Young, K., Akbar, S., Chessell, Z., Stevens, A., Vann, M., & Arntz, A. (2023). The treatment of PTSD in refugees and asylum seekers using imagery rescripting within an NHS setting. Behavioural and Cognitive Psychotherapy, 51(2), 119–132. https://doi.org/10.1017/ S1352465822000650 Steenkamp, M. M., Litz, B. T., Hoge, C. W., & Marmar, C. R. (2015). Psychotherapy for military-­ related PTSD. A review of randomized clinical trials. JAMA, 314, 489–500. Steil, R., Görg, N., Kümmerle, S., Lechner-Meichsner, F., Gutermann, J., & Müller-Engelmann, M. (2021). Die Cognitive Processing Therapy zur Behandlung Geflüchteter mit einer Posttraumatischen Belastungsstörung: Eine Machbarkeitsstudie. Verhaltenstherapie, 31(4), 298–311. https://doi.org/10.1159/000514724 Stenmark, H., Catani, C., Neuner, F., Elbert, T., & Holen, A. (2013). Treating PTSD in refugees and asylum seekers within the general health care system. A randomized controlled multicenter study. Behaviour Research and Therapy, 51(10), 641–647. https://doi.org/10.1016/j. brat.2013.07.002 Teodorescu, D. S., Heir, T., Hauff, E., Wentzel-Larsen, T., & Lien, L. (2012). Mental health problems and post-migration stress among multi-traumatized refugees attending outpatient clinics upon resettlement to Norway. Scandinavian Journal of Psychology, 53(4), 316–332. https:// doi.org/10.1111/j.1467-­9450.2012.00954.x Ter Heide, F.  J. J., Mooren, T.  M., Kleijn, W., et  al. (2011). EMDR versus stabilisation in traumatised asylum seekers and refugees: Results of a pilot study. European Journal of Psychotraumatology, 2, 5881. Ter Heide, F. J. J., Mooren, T. M., van de Schoot, R., de Jongh, A., & Kleber, R. J. (2016). Eye movement desensitization and reprocessing therapy v. stabilisation as usual for refugees: randomised controlled trial. The British Journal of Psychiatry, 209(4), 311–318. https://doi. org/10.1192/bjp.bp.115.167775 Thompson-Hollands, J., Marx, B. P., Lee, D. J., Resick, P. A., & Sloan, D. M. (2018). Long-term treatment gains of a brief exposure-based treatment for PTSD. Depression and Anxiety, 35, 985–991. Turrini, G., Tedeschi, F., Cuijpers, P., Del Giovane, C., Kip, A., Morina, N., Nosè, M., Ostuzzi, G., Purgato, M., Ricciardi, C., Sijbrandij, M., Tol, W., & Barbui, C. (2021). A network meta-­ analysis of psychosocial interventions for refugees and asylum seekers with PTSD. BMJ Global Health, 6, e005029. van den Berg, D. P., de Bont, P. A., van der Vleugel, B. M., de Roos, C., de Jongh, A., Van Minnen, A., & van der Gaag, M. (2015). Prolonged exposure vs eye movement desensitization and reprocessing vs waiting list for posttraumatic stress disorder in patients with a psychotic disorder: A randomized clinical trial. Journal of the American Medical Association, 72(3), 259–267. https://doi.org/10.1001/jamapsychiatry.2014.2637

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van den Hout, M. A., & Engelhard, I. M. (2012). How does EMDR work? Journal of Experimental Psychopathology, 3(5), 724–738. https://doi.org/10.5127/jep.028212 Watson-Singleton, N. N., Black, A. R., & Spivey, B. N. (2019). Recommendations for a culturally-­ responsive mindfulness for African Americans. Complementary Therapies in Clinical Practice, 34, 132–138. https://doi.org/10.1016/j.ctcp.2018.11.013 Weiss, W. M., Murray, L. K., Zangana, G. A. S., et al. (2015). Community-based mental health treatments for survivors of torture and militant attacks in Southern Iraq: a randomized control trial. BMC Psychiatry, 15, 249. https://doi.org/10.1186/s12888-­015-­0622-­7 Wickersham, A., Petrides, P. M., Williamson, V., & Leightley, D. (2019). Efficacy of mobile application interventions for the treatment of post-traumatic stress disorder: A systematic review. Digital Health, 5, 2055207619842986. https://doi.org/10.1177/2055207619842986 Wippich, A., Howatson, G., Allen-Baker, G., Farrell, D., Kiernan, M., & Scott-Bell, A. (2023). Eye movement desensitization reprocessing as a treatment for PTSD in conflict-affected areas. Psychological Trauma. https://doi.org/10.1037/tra0001430 Wolf, E.  J., Lunney, C.  A., & Schnurr, P.  P. (2016). The influence of the dissociative subtype of posttraumatic stress disorder on treatment efficacy in female veterans and active duty service members. Journal of Consulting and Clinical Psychology, 84(1), 95–100. https://doi. org/10.1037/ccp0000036 Wright, A., Reisig, A., & Cullen, B. (2020). Efficacy and cultural adaptations of narrative exposure therapy for trauma-related outcomes in refugees/asylum-seekers: A systematic review and meta-analysis. Journal of Behavioral and Cognitive Therapy, 30(4), 301–314. https://doi. org/10.1016/j.jbct.2020.10.003 Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: a practitioner’s guide. Guilford. Zoet, H.  A., de Jongh, A., & van Minnen, A. (2021). Somatoform dissociative symptoms have no impact on the outcome of trauma-focused treatment for severe PTSD. Journal of Clinical Medicine, 10(8), 1553. https://doi.org/10.3390/jcm10081553 Zoet, H. A., Wagenmans, A., van Minnen, A., & de Jongh, A. (2018). Presence of the dissociative subtype of PTSD does not moderate the outcome of intensive trauma-focused treatment for PTSD. European Journal of Psychotraumatology, 9, 1468707. https://doi.org/10.108 0/20008198.2018.1468707

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Psychological Interventions for Refugee Minors

8.1 Introduction Refugee children and adolescents are exposed to pre-migratory traumatic experiences, witnessing or experiencing violence, physical and emotional trauma to the child/adolescent or family, a hazardous flight to the resettlement country, and post-­ migratory stress factors including uncertainty of formerly being accepted as refugee, cultural and linguistic problems, discrimination, and poverty in the host country (e.g., Fazel et al., 2012; Gormez et al., 2018; Soltan et al., 2022). Post-traumatic stress disorder is highly prevalent among refugee children. In a systematic review of 21 studies involving 11,000 child and adolescent victims of armed conflicts residing in Palestine, the prevalence of post-traumatic stress disorder ranged from 23% to 70% (Dimitry, 2012). The clinical manifestations of post-­ traumatic stress disorder in children and adolescents include not only symptoms of re-experiencing (e.g., flashbacks, nightmares), avoidance of stimuli associated with the traumatic events, negative cognition and negative mood, and hyperarousal, but behavioral problems, developmental degradation, and physical symptoms as well (Gillies et al., 2013). Mental health problems in refugee children and adolescents are not limited to post-traumatic stress disorder, but include anxiety, depression, and externalizing problems (outward-directed behaviors such as aggression) as well. In addition, young refugee children have higher rates of socio-emotional problems and lower levels of cognitive development than non-refugee children (Busch et al., 2023). In this chapter, the psychological interventions used in child and adolescent refugees and what is known about the efficacy of these interventions are described.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 P. M. G. Emmelkamp, Mental Health of Refugees, https://doi.org/10.1007/978-3-031-34078-9_8

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8.2 Unaccompanied Refugee Minors In Western countries, many refugee youngsters (about half) are unaccompanied and separated from their family while traveling. Unaccompanied youth refugees are particularly vulnerable to develop emotional and behavioral problems, given that they are often exposed to high rates of traumatic events, which increases their risk of developing mental health problems (e.g., Müller et al., 2019; Salari et al., 2017; von Werthern et al., 2019). Unaccompanied refugee minors miss a stable living environment and supportive family members, have often low social support (e.g., Oppedal & Idsoe, 2015), and are inclined to withdraw from social situations, which increases the risk of developing chronic post-traumatic stress disorder (Mitra & Hodes, 2019). Mental health problems in unaccompanied refugee youth do not improve without any mental health treatment (Jensen et al., 2019; Vervliet et al., 2014). Although unaccompanied refugee minors have a significantly higher prevalence of depressive disorder, personality disorder, and psychosis, when compared with refugee minors with accompanying family members (Huemer et al., 2009), there is increasing evidence that unaccompanied refugee minors do not get the right treatment for mental problems when needed (Mitra & Hodes, 2019). In a recent review of qualitative studies investigating the view of unaccompanied refugee minors on the use of mental health services, results revealed that only 11% of unaccompanied refugee minors had access to mental health services for their psychological or behavioral difficulties (Demazure et al., 2021). In a study of Michelson and Sclare (2009), an evaluation of psychological needs, patterns of service utilization, and provision of care was investigated within a sample of children and adolescents referred to a specialist mental health clinic for young refugees and asylum seekers in the United Kingdom. Significant differences were found in the way accompanied and unaccompanied refugee children were referred for mental health problems. In contrast to accompanied refugee minors, unaccompanied refugee minors were often referred by social services rather than by medical agencies (e.g., general practitioner). Generally, unaccompanied refugee children received fewer sessions of mental health treatment. Further, unaccompanied refugee children—generally having experienced more traumatic events prior to resettlement—suffered more often from post-traumatic stress disorder and bereavement than accompanied refugee children. Nevertheless, unaccompanied refugee children received less trauma-focused interventions, cognitive therapy, or anxiety management training than accompanied refugee minors. While 85% of unaccompanied refugee children who were referred to the mental health clinic had clinically significant symptoms of post-traumatic stress disorder, less than one-third of these minors received trauma-focused therapy. Nearly all unaccompanied refugee children had experienced bereavement, but only 36% of them received treatment focusing on grief processing. In a large epidemiological study in Sweden, unaccompanied and accompanied refugee minors made less use of psychiatric care than Sweden-born youth (Björkenstam et al., 2020). Within the refugee subgroup, however, the overall risk was similar for unaccompanied and accompanied refugee youth.

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Not surprisingly, unaccompanied refugee minors often have no or rather limited knowledge about the health care system in the host country and how to access it. Given their cultural background, they often have different concepts of mental health problems and their treatment than the mental health concepts used in (Western) host countries. In addition, they may fear stigmatization. Given the fact that unaccompanied refugee minors are at high risk of developing depression, anxiety, post-­ traumatic stress disorder, or externalizing problems (see Chap. 2), this should be considered a public health issue of high importance. A few studies demonstrated that offering culturally adapted therapy may overcome barriers to mental health care in unaccompanied refugee minors (e.g., van Es et al., 2021).

8.3 Treatment for Post-traumatic Stress in Children and Youth A number of treatments have been investigated in adults with post-traumatic stress disorder (see reviews Bisson et al., 2013; de Jongh et al., 2019; Ehring et al., 2014; Gerger et al., 2014, and Chap. 7), but research into the effects of treatments with children and adolescents with post-traumatic stress is still limited (Cohen et  al., 2017; de Roos et al., 2017). Exposure therapy, which had been found to be effective in anxiety disorders, was extended to post-traumatic stress disorder in children and adolescents (Foa et al., 2008). At about the same time, narrative exposure therapies, also based on cognitive behavioral principles, were investigated in children and adolescents, employing writing, or the trauma narrative, as an exposure tool (Elbert & Neuner, 2005; van der Oord et al., 2010). These therapies relied on habituation and cognitive restructuring, based on the principle that exposure to anxious stimuli, while simultaneously challenging dysfunctional cognitions, will lead to habituation and extinction of anxiety (Emmelkamp, 1982; Foa & Kozak, 1986). Given the pervasiveness of war and conflict-related trauma and trauma during the flight, interventions tailored to treatment of refugee children and adolescents are especially needed. Although repeated trauma is relatively common in refugee minors, most empirically validated interventions are not especially well tailored to meet the complex and individualized needs of child and adolescent refugee minors. Most of the interventions used with children in conflict areas and refugee children and adolescents are derived from interventions initially developed for adults. Treatments used with refugee children include trauma-focused therapy, narrative exposure therapy/KIDNET, writing therapy, eye movement desensitization and reprocessing therapy (EMDR), interpersonal therapy, and classroom-based interventions. In a number of instances, multimodal approaches have been used combining a variety of other approaches, e.g., cognitive behavior therapy, psychodynamic therapy, systemic therapy, and art therapy. The state of the art of these interventions will be discussed. For each intervention, the evidence of psychological therapies for non-refugee children with post-traumatic stress disorder will be described first followed by a review of studies which have been conducted with refugee children.

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8.3.1 Clinical Guidelines Practice guidelines for childhood post-traumatic stress disorder (e.g., AACAP, 2010; International Society of Traumatic Stress Studies (ISTSS), 2019; National Institute for Health and Clinical Excellence (NICE), 2018; WHO, 2013) recommend trauma-focused psychological therapies as the first-line approach, primarily trauma-focused cognitive behavioral therapies, involving a combination of cognitive restructuring, coping skill training, therapist- and patient-led exposure (imaginal and in  vivo), prolonged exposure (Foa et  al., 2008), cognitive therapy for post-traumatic stress disorder (Smith et al., 2010), KIDNET (Schauer et al., 2017), as well as eye movement desensitization and reprocessing (EMDR) therapy (de Roos et al., 2017). The National Institute for Health and Care Excellence guidelines (, 2018) recommend youngsters to be offered trauma-focused cognitive behavior therapy as a first-line treatment because of a larger available evidence, despite EMDR being slightly more effective (Bastien et al., 2020). A number of studies investigating the effects of psychological interventions with children and adolescents with post-traumatic stress symptoms were limited to youth who have experienced a single trauma, and the question is whether results generalize to refugee minors who often have experienced a number of traumatic events. Recently, Hoppen et al. (2023) investigated whether the efficacy of psychological interventions for post-traumatic stress disorder in children and adolescents differs depending on whether children or adolescents reported one or more lifetime trauma exposures. Results revealed that psychological interventions are effective in treating both young individuals who have suffered single and individuals who have suffered multiple trauma exposures, which makes studies with youth with single trauma events also potentially relevant for treatment of refugee minors.

8.4 Eye Movement Desensitization and Reprocessing (EMDR) Eye movement desensitization and reprocessing (EMDR) therapy is a brief, trauma-­ focused treatment for post-traumatic stress disorder. The EMDR protocol for children consists of the eight-phase protocol of Shapiro (2017). These phases include history taking, treatment planning, preparation, reprocessing, installation of a positive cognition, check for and processing any residual disturbing body sensations, positive closure, and evaluation. EMDR works with the memory network (see Chap. 7). The patient holds a disturbing image from the trauma memory in mind while engaging in sets of saccadic eye movements. The first session (where parent or caregiver is often present as well) consists of psychoeducation on post-traumatic stress disorder, and the rationale for EMDR treatment for trauma is explained. In the following sessions, eye movement desensitization and reprocessing are used in order to reduce emotional disturbance associated with the most distressing traumatic memories. Standard eye movements are applied for bilateral stimulation, although alternative distractive tasks can be chosen

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as well. If successful, this results in a transformation of the emotional, sensory, and cognitive components of the memory, so that the individual is less distressed when the memory is activated. In a review of Field and Cottrell (2011) on individual EMDR with children with a variety of trauma experiences, EMDR led to more improvement in post-traumatic stress disorder symptoms than wait list control, but EMDR was no more effective than cognitive behavior therapy. In a number of recent meta-analyses, both EMDR and trauma-focused cognitive behavioral therapies were found to be superior to wait list control or treatment as usual (Bastien et al., 2020; Brown et al., 2017; Gutermann et al., 2016; Mavranezouli et al., 2020; Morina et al., 2016).

8.4.1 EMDR in Refugee Youngsters Few studies have investigated the effects of EMDR in refugee youngsters (Matthijssen et al., 2020). In a study of Oras et al. (2004), 13 refugee children with post-traumatic stress disorder were treated with EMDR combined with a classic psychodynamic therapeutic approach. After treatment, a significant improvement was noticed in post-traumatic stress-related symptoms. Given the small numbers, the lack of a control group, and the fact that EMDR was given in a psychodynamic context, results are difficult to interpret. Results of a study of Wadaa et al. (Wadaa et al., 2010) are also difficult to interpret. In this study, 12 Iraqi children, who were exposed to the traumas of war and were diagnosed with post-traumatic stress disorder, and whose parents allowed their children to take part in the study, received EMDR. Results were compared with 25 Iraqi children of whom the parents did not allow their children to receive EMDR treatment. This was considered as the control group. Although EMDR led to less post-traumatic stress symptoms than the control group, results are difficult to evaluate given the design of the study. More recently, Perilli et  al. (2019) investigated the effectiveness of EMDR Integrative Group Treatment Protocol in 14 child refugees in a Turkey orphanage. Treatment consisted of three group sessions and was provided in three groups, one for children aged 3–7, one for children aged 9–12, and one for adolescents aged 13–18. Only the data of 8 children on the Children’s Revised Impact of Event Scale could be analyzed, which analysis revealed a significant decrease in the severity of post-traumatic symptoms. In a study of Lempertz et al. (2020), nine refugee preschool children (4–6 years) in a German day care center with post-traumatic stress disorder symptoms took part in an EMDR-based group treatment. The number of post-traumatic stress symptoms assessed with the Child Behavior Checklist before and after the intervention indicates a reduction in the symptoms only when assessed by the teacher, not when assessed by parent. Given the missing data and the lack of a control group, the results of the studies of Lempertz et al. and Perulli et al. are difficult to interpret. To date, only one randomized controlled trial was conducted in which group EMDR therapy was compared with waiting list control in Syrian refugee children of 6–15 years old residing in Turkey (Banoglu & Korkmazlar, 2022). Each child joined

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3–4 group sessions lasting 90–120  min with 8 participants on average. After the treatment, the EMDR group (N = 42) had significantly lower trauma scores compared to the waiting list (N = 19). Although EMDR led to lower scores on depression, the difference with the control group was not significant.

8.5 Cognitive Behavioral Writing Therapy Cognitive behavioral writing therapy (van der Oord et al., 2010) is a child-friendly version of the adult writing therapy for post-traumatic stress disorder (Interapy; Lange et al., 2001, 2003). Cognitive behavioral writing therapy involves exposure to the trauma memory and restructuring of trauma-related beliefs through writing and updating of the trauma memory with the support of a therapist. In a study of 23 children and adolescents (aged 8–18  years) seeking treatment for post-traumatic stress disorder, an average of 5.5 sessions of Cognitive behavioral writing therapy yielded large, within-group effect sizes for post-traumatic stress disorder, trauma-­ related beliefs, depression, and behavior problems, but this study was uncontrolled (van der Oord et al., 2010). In a large multicenter randomized controlled clinical trial, cognitive behavioral writing therapy was compared with EMDR and wait list control (de Roos et  al., 2017). Children (aged 8–18 years) with post-traumatic stress disorder after a single traumatic incident were recruited among new referrals to seven child and adolescent mental health clinics spread across the Netherlands. There was hardly any dropout, thus supporting the acceptance of both treatments by the children and parents. Both cognitive behavioral writing therapy and EMDR led to high rates of diagnostic remission of post-traumatic stress disorder and yielded clinically substantial reductions in child- and parent-reported symptoms of post-traumatic stress disorder, anxiety, depression, and behavior problems. At posttreatment, 92.5% of children who received EMDR and 90.2% of children who received cognitive behavioral writing therapy no longer met the diagnostic criteria for post-traumatic stress disorder. All gains were maintained up to 1-year follow-up. No differences were found between the effects of cognitive behavioral writing therapy and EMDR at posttreatment, and 3- and 12-month follow-ups. Compared to waiting list control, small-to-large effect sizes were obtained at posttreatment for negative trauma-related appraisals, anxiety, depression, and behavior problems. In sum, both cognitive behavioral writing therapy and EMDR, involving no training in coping skills or emotion regulation with minimal parental involvement, were well-tolerated treatments that yielded clinically significant reductions in post-traumatic stress disorder and comorbid difficulties in less than five sessions, with improvement being maintained up to 1 year posttreatment (de Roos et al., 2017). Additional analyses revealed that youth with a trauma of sexual abuse, severe symptoms of post-traumatic stress disorder, anxiety, depression, and more comorbid disorders fared worse in both treatments. In addition, parental symptomatology predicted poorer outcomes, suggesting that parents should be assessed, supported, and referred for their own treatment where indicated (de Roos et  al., 2021). Given the large response rate (>90%), low attrition rate, and

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brevity of both treatments, the findings suggest a focus on implementation and dissemination of cognitive behavioral writing therapy and EMDR and research into the effects of both treatments in refugees and asylum-seeker youth.

8.5.1 Writing for Recovery Writing for Recovery is an intervention based on writing therapy techniques for children and adolescents with a history of trauma, aged 12–18 years (Yule et al., 2005). Treatment consists of six writing sessions within 3 days. This writing therapy intervention was designed to be delivered by trained teachers. In a study of Kalantari et al. (2012), Writing for Recovery was more effective in reducing traumatic grief in bereaved refugee children from Afghanistan living in Iran than the control group. In a study of Lange-Nielsen et  al. (2012), Writing for Recovery was compared with waiting list control in waraffected adolescents in Gaza. Results at posttest showed a reduction in post-traumatic stress symptoms in both groups, no change in anxiety symptoms, and an increase in depression in the intervention group. The increase in depression may be a negative effect of the processing of traumatic memories. Thus, although structured expressive writing has been found to reduce post-traumatic stress symptoms in traumatized children (de Roos et al., 2017, 2021; van der Oord et al., 2010), Writing for Recovery delivered by teachers leads to mixed results in war-affected children and adolescents.

8.6 Narrative Exposure Therapy and KIDNET Narrative exposure therapy was originally developed for adult war victims (Neuner et al., 2002) and has been used with adult victims of war, rape, and torture (Neuner et al., 2004). This treatment is based on exposure therapy for post-traumatic stress. In addition to exposure to traumatic memories, in narrative exposure therapy, the reconstruction of autobiographical memories is used to contextualize trauma memories (Schauer et al., 2020). Narrative exposure therapy has been adapted for traumatized children for 8 years and older (Onyut et al., 2005; Fazel et al., 2020). This variant is known as KIDNET. In this child variant of narrative exposure therapy, usually consisting of ten sessions, traumatized children write a script of the traumatic event and develop a narrative lifeline in order to reconsolidate and integrate traumatic events into their biography. By focusing on the autobiographical elaboration of traumatic experiences, KIDNET enhances processing of traumatic memories of traumatic experiences. KIDNET has a number of similarities with cognitive behavioral writing therapy discussed above.

8.6.1 War-Affected and Refugee Children and Adolescents A number of studies have investigated narrative exposure therapy and KIDNET in refugee and asylum-seeker children and adolescents. A qualitative study found narrative exposure therapy suited for unaccompanied minors older than 16 years (Said

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et al., 2021). The authors stress the importance of delivering the intervention in the context of a supportive therapeutic relationship. In addition, cultural adaptations and interpreter training are essential components of intervention delivery. Four randomized controlled trials evaluated the effects of narrative exposure therapy and KIDNET in treating war-affected children and refugee children with post-traumatic stress disorder symptoms (Catani et  al., 2009; Ertl et  al., 2011; Peltonen & Kangaslampi, 2019; Ruf et al., 2010). Peltonen and Kangaslampi (2019) conducted a study with refugee children (n = 37) and children with experiences of family violence (n  =  13) aged 9–17 living in Finland. The refugee children and adolescents were from Afghanistan, Iraq, and a few other Middle Eastern or African countries. Narrative exposure therapy (7–10 sessions) was not more effective than treatment as usual on the primary outcome of reduction in levels of post-traumatic stress disorder symptoms, although the decrease was significant in the narrative exposure therapy group only. Three randomized clinical trials investigated KIDNET.  In the study of Catani et al., children (aged 8–14) who had been affected by civil war in Sri Lanka when the Tsunami wave hit the region were randomly assigned to six sessions of KIDNET or six sessions of meditation-relaxation given by trained local counselors. Although KIDNET led to substantial improvement of post-traumatic stress symptoms up to 6-month follow-up, it was not more effective than meditation-relaxation. In a study of Ertl et al. (2011) among former child soldiers in Uganda (aged 12–25), eight sessions of KIDNET proved to be more effective with respect to improvement of post-­ traumatic stress symptoms than an academic catch-up program or a waiting list control condition up to 1  year after therapy. Finally, in a randomized controlled study of Ruf et  al. (2010) conducted in host country Germany, refugee children (aged 7–16) who received KIDNET showed clinically relevant and significant reduction in post-traumatic stress disorder symptoms until 12-month follow-up. Children in the waiting list control group did not show clinically relevant improvement in symptoms and functioning. Although there is some evidence that KIDNET and narrative exposure therapy may be an effective intervention for refugee children and adolescents, it should be noted that three of the four randomized controlled studies were conducted by investigators who have written the therapy manual (Schauer et al., 2017), so researcher allegiance cannot be excluded (Luborsky et al., 1999).

8.7 Trauma-Focused Cognitive Behavioral Therapy Trauma-focused cognitive behavior therapy of children includes caregiver involvement (Cohen et al., 2017). Treatment starts with graduated exposure from the start and consists of nine modules. Each component is offered to the child and the caregiver (mostly parent) in both parallel and conjoint sessions. The nine modules include psychoeducation and parent training, relaxation, affect modulation, learning cognitive coping skills, trauma narrative, cognitive processing of the trauma, in vivo mastery of trauma reminders, enhancing safety, and future development. The whole

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program constitutes three phases: 1) stabilization and skill building, 2) exposure and cognitive processing of the trauma, and 3) fostering safety and future development. In most sessions with younger children, the parent or caregiver is present, but this usually is less with older children. Goldbeck et  al. (2016) conducted a randomized controlled trial with children with traumatic stress as a result of traumatic events, most often sexual abuse and physical violence. A number of these children suffered also from traumatic loss. They found larger effect for post-traumatic stress disorder in the trauma-focused cognitive behavior therapy than in wait list control. A secondary analysis of the data from this randomized controlled trial revealed that children who experienced traumatic loss reported less post-traumatic stress symptoms and better general functioning than those who reported sexual abuse (Unterhitzenberger et al., 2020). The loss of a parent, traumatic or sudden death, and witnessing the death or the dead body were risk factors for mental health problems. Unfortunately, grief was not formally assessed. Group trauma-focused cognitive behavior therapy has the advantage of potential cohesion among children participating in the group and cost-effectiveness. Traumatized children who were victims of Hurricane Katrina in New Orleans improved much more in Cognitive Behavioral Intervention for Trauma in Schools (CBITS) as children who were on the wait list, not only in reducing post-traumatic stress, but also in reduction of depressive symptoms (Kataoka et al., 2003). In a study of Murray et al. (2013), the effects on trauma and stress-related symptoms of trauma-focused cognitive behavior therapy given by lay health workers were investigated in orphans and vulnerable children in Zambia. Local counselors who had no or hardly any mental health background received training in how to conduct trauma-focused cognitive behavior therapy including intensive role-­ playing. They were supervised when giving trauma-focused cognitive behavior therapy themselves. Ninety-four children (aged 5–18 years), who had experienced one or more traumatic events, were included in the study. The mean number of traumas reported was 4.11, including seeing dead body, witnessing a violent death of a loved one, and sexual abuse. Trauma-focused cognitive behavior therapy was conducted through weekly sessions lasting 1–2 h over an average of 11 weeks. A number of cultural modifications were made including simplifying the psychological jargon and defining step-by-step tasks for each component. Local counselors also integrated storytelling and analogies that fit with the local culture, such as cooking nshima (a local dish), and religious or witchcraft beliefs. Treatment sessions were with the child alone, a caregiver alone, and the family members together (e.g., child, mother, aunt, or grandmother). Lay health workers met at least 2 h a week with the local supervisors either face-to-face or online. After treatment delivered by lay counselors, a significant reduction in the severity of trauma symptoms and shame symptoms was found. A few randomized controlled trials have investigated the effectiveness of trauma-­ focused therapy in Africa. In a randomized controlled trial (Murray et al., 2015), this trauma-focused cognitive behavioral intervention was compared with treatment as usual in orphans and vulnerable children with post-traumatic stress symptoms in

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Zambia. Trauma-focused cognitive behavior therapy led to more reduction of post-­ traumatic stress and better general functioning compared with care as usual. In a large randomized controlled study (N  =  640 children, aged 7–13  years), trauma-­ focused cognitive behavior therapy delivered by well-trained and weekly supervised lay counselors was more effective than care as usual in treating children with post-traumatic stress and/or grief after the death of one or two parents in Kenya, but not in rural Tanzania (Dorsey et al., 2020). Results of the study of Murray et al. (2015) and of Dorsey et al. (2020) suggest that trauma-focused cognitive behavior therapy delivered by well-trained lay counselors is feasible and suggest that a controlled clinical study evaluating trauma-focused cognitive behavior therapy delivered by lay mental health workers with refugee children is warranted (see below). In a study of Pfeiffer et al. (2020), the effect of therapist characteristics on patient outcome was investigated in traumatized children and adolescents receiving trauma-­ focused cognitive behavior therapy in Germany or Norway. Most therapists were female, with on average nearly 10 years of clinical experience; 67% had a cognitive behavior therapy background, 15% a psychodynamic background, and 12% a family therapy background. All therapists participated in a Web-based training, attended a 2-day training course, and were intensively supervised. Neither theoretical background nor gender or prior clinical experience of therapists had any effect on the improvement of post-traumatic stress. Fidelity ratings were high which supports that therapists adhered to the manual. This shows that trauma-focused cognitive behavior therapy can be applied by a variety of mental health workers, provided that they are well trained and supervised, which might help in the dissemination of this treatment among refugees and asylum seekers since prior clinical experience and theoretical background might not be crucial for delivering this exposure-based manualized treatment.

8.7.1 Refugee Minors A few studies on the effects of trauma-focused cognitive behavioral therapy found that treatment led to a higher decrease in post-traumatic stress symptoms in children and adolescents from war-affected countries compared to a control group (e.g., McMullen et al., 2013; Murray et al., 2015; O’Callaghan et al., 2013). These studies have some methodological problems, which renders generalization to other refugee minors and asylum seeker minors difficult (Nocon et  al., 2017). In a pilot study (Unterhitzenberger et al., 2019), 26 unaccompanied male refugee minors, primarily from Afghanistan, who met the diagnostic criteria of post-traumatic stress disorder were treated in a university psychotherapeutic outpatient clinic in Germany with a mean of 15 sessions of trauma-focused cognitive behavior therapy. These youth had an uncertain residence status. Caregivers played an important role in encouraging participants to stay in treatment. Nineteen of the 26 patients completed treatment until 6-month follow-up, which is high for treatment with unaccompanied male refugee minors. Treatment led to decreased post-traumatic stress disorder symptoms on the Child and Adolescent Trauma Screen and the Diagnostic Interview for

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Mental Disorders in Childhood and Adolescence up to 6-month follow-up. According to the clinical interview, 84% of the unaccompanied minors recovered after treatment. On the secondary outcome measures, treatment also led to significant improvement in depressive and behavioral symptoms as assessed by their caregivers which remained at 6-month follow-up. Physical health problems improved significantly after treatment as well. However, minors whose asylum request had been rejected showed an increase in post-traumatic stress at 6-month follow-up. To cite the authors: “The asylum decisions were life or death decisions for many young refugees” (Unterhitzenberger et al., 2019, p. 8). Pfeiffer and Goldbeck (2017) developed a cognitive behavioral based trauma-­ focused group intervention “My Way” for unaccompanied refugee minors, which has been implemented by trained and supervised social workers in schools or child and adolescent welfare programs in Germany. In a study of Pfeiffer et al. (2018) with unaccompanied minor refugees, the six-session trauma-focused group intervention called “My Way” was investigated in a randomized controlled trial. In this study, trauma-focused group therapy was compared to usual care; trauma-focused group therapy was more effective than usual care in decreasing post-traumatic stress and depression. Results were stable until 3-month follow-up (Pfeifer et al., 2019). Thus, trauma-focused cognitive behavior therapy is a promising treatment for minor refugees. Effects of trauma-focused cognitive behavioral therapies are not limited to post-traumatic stress; there is some evidence that results of trauma-­ focused therapy generalize to reduction of symptoms of anxiety and depression as well (Gutermann et al., 2016).

8.8 START: Stress-TraumasymptomsArousal-Regulation Treatment Stress-Traumasymptoms-Arousal-Regulation Treatment (START, Dixius & Möhler, 2017) focuses on stabilization and emotional regulation for extremely stressed adolescents including minor refugees. It is a low-threshold training program of 5 weeks not only to manage emotional dysregulation but also to teach skills to reduce impulsive aggressive behavior, including self-harm. Originally, START was designed as a first-aid crisis intervention for adolescents, who were too unstable for psychotherapy, dialectical behavior therapy (DBT), or reprocessing treatment (Dixius & Möhler, 2017). Compounds of START are derived from elements of dialectic behavioral therapy and trauma-focused cognitive behavior therapy for children. The program can be used for adolescents with severe emotional distress with diverse cultural backgrounds. The program consists of very playful elements for self-­ perception of inner tension. In the second step, adolescents try out skills to reduce their tension, requiring very little speech. The last step is the construction of an individual skill box and practicing and encouragement to discover own tools for self-regulation, with emphasis on individual strengths and resources (Dixius et al., 2017). The manual was originally developed for refugee minors and contains worksheets in English, Arabic, Dari/Farsi, and German for each module.

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In a pilot study, 66 adolescents (aged 13–18 years) admitted to a psychiatric unit for acute emotional or behavioral dysregulation took part in the START program for 5 weeks in an open group setting with two sessions per week (Dixius & Möhler, 2021). About 75% of the patients had experienced traumatic events. Unfortunately, results were limited. No significant improvement was found in adaptive emotion regulation strategies. However, significant improvement was observed on the Feel-KJ for the adaptive strategies “forgetting,” “problem-solving,” and “dealing with anger.” Since post-traumatic stress was not assessed at the posttest and a control group was lacking, results are difficult to interpret.

8.9 Integrated Treatment for Complex Trauma (ITCT) Multiple traumatic experiences are now referred to as complex trauma, which in children might involve emotional abuse and neglect, physical abuse, sexual abuse, witnessing domestic and/or community violence, traumatic loss of a family member or friend, and medical trauma. Such traumatic experiences can be augmented by inadequate social support, stigmatization, and discrimination. Complex trauma exposure is associated with a range of symptoms in addition to post-traumatic stress, which may include low self-esteem, hopelessness, dissociation, impulsivity and self-injurious behavior (e.g., auto-mutilation and suicidality), inappropriate sexual behavior, and alcohol and drug abuse. Integrative treatment of complex trauma was developed as a specialized, culturally sensitive treatment that is customized to the specific social and psychological issues of children with a complex trauma history. It involves structured protocols and interventions that are customized to the specific issues of each client. Based on a problems-to-components grid, the therapist develops the patient’s specific treatment (e.g., psychoeducation, affect regulation training, therapeutic exposure, relational processing). Based on the “therapeutic window,” therapists provide exposure to trauma memories when needed, but in a way that it does not lead to overly activated emotional states that might overwhelm the child’s affect regulation and lead to avoidance or even retraumatization (Lanktree et al., 2012). Sessions with parents or caretakers are provided to deal with their parenting skills, and address attachment issues and own traumatic experiences. There are two age-adapted variants of Integrated Treatment for Complex Trauma: one for children (Lanktree & Briere, 2008) using play, sand tray, and other less verbal techniques and one for adolescents (Briere & Lanktree, 2011) making more use of verbal psychotherapy and cognitive interventions. In a study of Lanktree et al. (2012), 151 traumatized children (aged 8–17 years) at a specialized child trauma center (Miller Children’s Abuse and Violence Intervention Center—University of Southern California) were included in a pilot study investigating the effects of Integrated Treatment for Complex Trauma. The mean duration of treatment was 7 months. Results revealed that this treatment may be effective for socially marginalized children and adolescents, leading to reductions in anxiety, depression, and post-traumatic stress; improvement of anger

8.10  Common Elements in Various Therapies

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problems and sexual issues, however, was marginal. The more therapy sessions, the greater the improvement. Interestingly, effects of Integrated Treatment for Complex Trauma were not influenced by gender or age. In addition, cultural factors did not affect the outcome either, since the intervention was equally effective for Hispanic, African American, and non-Hispanic White children. However, the lack of a control group limits definitive conclusions.

8.10 Common Elements in Various Therapies Interestingly, in a recent evaluation (Kooij et al., 2022), experts evaluated common elements (common techniques or common psychotherapeutic mechanisms) in the therapies for post-traumatic stress disorder for children and adolescents discussed above. Common element was defined as an element that was present in three or more therapies. They found ten common techniques (psychoeducation, relaxation, recording the critical experiences, traumatic recollection, exposure, homework, cognitive shifting, sharing the trauma story with others, future perspectives, and termination) and seven common therapeutic mechanisms (consolidation, trauma processing, therapeutic relationship, motivation, affect modulation, reciprocal integration, and sharing) in the evidence-based trauma therapies. Remarkably, nearly all of the identified common mechanisms were found to be present in all studied therapies. As noted by the authors: “This overlap in mechanisms could indicate that, although protocols stem from different theoretical backgrounds and apply partially different techniques, they address similar mechanisms” (Kooij et al., 2022). A meta-analysis (Gillies et al., 2016) found cognitive behavior therapy effective in reducing post-traumatic stress symptoms in youngsters. More recently, Xian-Yu et al. (2022) conducted a meta-analysis into the effects of cognitive behavior therapy in children and adolescents (15 on the Pediatric Symptom Scale (PSC-17) were included in the study. The intervention was delivered by trained and supervised lay workers. On the total score of the primary outcome measure (PSC-17), the Early Adolescent Skills for Emotions intervention was not more effective than care as usual; only on the subscale internalizing problems was the active intervention slightly more effective than usual care at the posttest, but not at 3-month follow-up. The Early Adolescent Skills for Emotions intervention did not result in better outcome with respect to externalizing behavior problems, attentional problems, overall severity, post-traumatic stress symptoms, or functioning.

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8.14.2 Internet-Based Interventions Regarding Internet-based intervention studies, a few studies have investigated Internet-based cognitive interventions in adolescents. There is some evidence that Internet-based cognitive behavioral therapy may be effective in reducing anxiety symptoms in comparison with no-treatment control conditions, but with respect to depressive symptoms, effects are less clear (Christ et al., 2020). In a small study of Lindegaard et  al. (2022), an Internet-based cognitive behavioral intervention for Dari- and Farsi-speaking refugee youth from Afghanistan and Syria residing in Sweden was developed and evaluated. The treatment was an adapted version of a previously developed intervention for adult Arabic-speaking immigrants and refugees in Sweden. The intervention for youth consists of a number of modules targeting various problem areas, including anxiety, depression, post-traumatic stress, grief, worry and rumination, stress management, emotion regulation, and insomnia and includes homework assignments. Based on the first session, specific modules which were thought to be relevant were chosen per patient. Patients had weekly contact through a messaging system with a clinical psychologist proficient in Dari and Farsi. Unfortunately, only 20% of the patients who started the Internet intervention completed the posttreatment assessment. Clearly, the Internet system is not yet ready for use with refugee youth.

8.15 Concluding Remarks Few studies have investigated “evidence-based” interventions in refugee youth. This is not surprising, given that conducting good-quality studies in refugee camps is difficult not only because of the lack of resources, lack of mental health workers, and lack of culturally and linguistic adapted process and outcome measures for children, but also because of ethical reasons. In addition, specific regions affected by war and conflict and specific home countries where refugee children are residing limit the generalizability of research findings to these specific settings (Bosqui & Marshoud, 2018). In a review on the effects of cognitive behavioral therapy for mental health symptoms (internalizing disorders) in child refugees in most studies, symptoms of post-­ traumatic stress, anxiety, and depression were reduced to subclinical levels (Lawton & Spencer, 2021). Clinical improvement was greatest in children with the most severe symptoms at the pretest. In a recent meta-analysis (Rafieifar & Macgowan, 2022) of group interventions for trauma and depression among immigrant and refugee children, cognitive behavioral interventions were the most effective interventions for reducing post-traumatic stress and depressive symptom; the intervention Mein Weg (Pfeiffer et al., 2018) was found to be the most effective. These results are promising, but there is a clear need for studies investigating which treatment dealing with post-traumatic stress and other mental disorders including externalizing disorders is the most effective in both accompanied and unaccompanied refugee minors.

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Matthijssen, S. J., Lee, C. W., de Roos, C., Barron, I. G., Jarero, I., Shapiro, E., et al. (2020). The current status of EMDR therapy, specific target areas, and goals for the future. J EMDR Pract Res, 14(4), 241–284. https://doi.org/10.1891/EMDR-­D-­20-­00039 Mavranezouli, I., Megnin-Viggars, O., Daly, C., Dias, S., Stockton, S., Meiser-Stedman, R., et al. (2020). Psychological and psychosocial treatments for children and young people with post-traumatic stress disorder: A network meta-analysis. Journal of Child Psychology and Psychiatry, 61(1), 18–29. https://doi.org/10.1111/jcpp.13094 McMullen, J., O’Callaghan, P., Shannon, C., Black, A., & Eakin, J. (2013). Group trauma-focused cognitive-behavioural therapy with former child soldiers and other war-affected boys in the DR Congo: A randomised controlled trial. Journal of Child Psychology and Psychiatry, 54(11), 1231–1241. https://doi.org/10.1111/jcpp.12094 Mendenhall, T. J., & Berge, J. M. (2010). Family therapists in trauma-response teams: bringing systems thinking into interdisciplinary fieldwork. Journal of Family Therapy, 32, 43–57. Michelson, D., & Sclare, I. (2009). Psychological needs, service utilization and provision of care in a specialist mental health clinic for young refugees: a comparative study. Clinical Child Psychology and Psychiatry, 14(2), 273–296. https://doi.org/10.1177/1359104508100889 Mitra, R., & Hodes, M. (2019). Prevention of psychological distress and promotion of resilience amongst unaccompanied refugee minors in resettlement countries. Child: Care, Health and Development, 45, 198–215. Morina, N., Koerssen, R., & Pollet, T.  V. (2016). Interventions for children and adolescents with posttraumatic stress disorder: a meta-analysis of comparative outcome studies. Clinical Psychology Review, 47, 41–54. Müller, L. R. F., Büter, K. P., Rosner, R., & Unterhitzenberger, J. (2019). Mental health and associated stress factors in accompanied and unaccompanied refugee minors resettled in Germany: a cross-sectional study. Child and Adolescent Psychiatry and Mental Health, 13(1), 1–13. Murray, L. K., Familiar, I., Skavenski, S., Jere, E., Cohen, J., Imasiku, M., et al. (2013). An evaluation of trauma- focused cognitive behavioral therapy for children in Zambia. Child Abuse & Neglect, 37(12), 1175–1185. Murray, L.  K., Skavenski, S., Kane, J.  C., Mayeya, J., Dorsey, S., Cohen, J.  A., et  al. (2015). Effectiveness of trauma-focused cognitive behavioral therapy among trauma-affected children in Lusaka, Zambia: a randomized clinical trial. JAMA Pediatrics, 169, 761–769. https://doi. org/10.1001/jamapediatrics.2015.0580 National Institute for Health and Clinical Excellence (NICE). (2018). Post-traumatic stress disorder. NG116. Management of PTSD in children, young people and adults (1.6.13). Retrieved from https://www.nice.org.uk/guidance/ng116/chapter/Recommendations Neuner, F., Schauer, M., Klaschik, C., Karunakara, U., & Elbert, T. (2004). A comparison of narrative exposure therapy, supportive counseling, and psychoeducation for treating posttraumatic stress disorder in an African refugee settlement. Journal of Consulting and Clinical Psychology, 72(4), 579–587. https://doi.org/10.1037/0022-­006X.72.4.579 Neuner, F., Schauer, M., Roth, W. T., & Elbert, T. (2002). A narrative exposure treatment as intervention in a refugee camp: a case report. Behavioural and Cognitive Psychotherapy, 30(2), 205–209. https://doi.org/10.1017/S1352465802002072 Nocon, A., Eberle-Sejari, R., Unterhitzenberger, J., & 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(sup2), 1388709. O’Callaghan, P., McMullen, J., Shannon, C., Rafferty, H., & Black, A. (2013). A randomized controlled trial of trauma-focused cognitive behavioral therapy for sexually exploited, war-affected Congolese girls. Journal of the American Academy of Child and Adolescent Psychiatry, 52, 359–369. Onyut, L. P., Neuner, F., Schauer, E., Ertl, V., Odenwald, M., Schauer, M., et al. (2005). Narrative exposure therapy as a treatment for child war survivors with posttraumatic stress disorder: two case reports and a pilot study in an African refugee settlement. BMC Psychiatry, 5(1), 1–9. https://doi.org/10.1186/1471-­244X-­5-­7 Ooi, C. S., Rooney, R. M., Roberts, C., Kane, R. T., Wright, B., & Chatzisarantis, N. (2016). The efficacy of a group cognitive behavioral therapy for war-affected young migrants living in

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cents in high-income countries. Cochrane Database of Systematic Reviews, 5, CD013657. https://doi.org/10.1002/14651858.CD013657.pub2 Ugurlu, N., Akca, L., & Acarturk, C. (2016). An art therapy intervention for symptoms of post-­ traumatic stress, depression and anxiety among Syrian refugee children. Vulnerable Children and Youth Studies, 11(2), 89–102. https://doi.org/10.1080/17450128.2016.1181288 Unterhitzenberger, J., Sachser, C., & Rosner, R. (2020). Posttraumatic stress disorder and childhood traumatic loss: a secondary analysis of symptom severity and treatment outcome. Journal of Traumatic Stress, 33, 208–217. https://doi.org/10.1002/jts.22499 Unterhitzenberger, J., Wintersohl, S., Lang, M., König, J., Rosner, R., et  al. (2019). Providing manualized individual trauma-focused CBT to unaccompanied refugee minors with uncertain residence status: a pilot study. Child and Adolescent Psychiatry and Mental Health, 13, 22. https://doi.org/10.1186/s13034-­019-­0282-­3 van der Oord, S., Lucassen, S., Van Emmerik, A. A., & Emmelkamp, P. M. (2010). Treatment of post-traumatic stress disorder in children using cognitive behavioural writing therapy. Clinical Psychology & Psychotherapy, 17, 240–249. van Es, C. M., Sleijpen, M., Velu, M. E., Boelen, P. A., van Loon, R. E., Veldman, M., et al. (2021). Overcoming barriers to mental health care: multimodal trauma-focused treatment approach for unaccompanied refugee minors. Child and Adolescent Psychiatry and Mental Health, 15, 53. https://doi.org/10.1186/s13034-­021-­00404-­3 Vervliet, M., Lammertyn, J., Broekaert, E., & Derluyn, I. (2014). Longitudinal follow-up of the mental health of unaccompanied refugee minors. European Child & Adolescent Psychiatry, 23(5), 337–346. von Werthern, M., Grigorakis, G., & Vizard, E. (2019). The mental health and wellbeing of unaccompanied refugee minors (URMs). Child Abuse & Neglect, 98, 104146. Votruba-Drzal, E., Coley, R.  L., Collins, M., & Miller, P. (2015). Center-based preschool and school readiness skills of children from immigrant families. Early Education and Development, 26(4), 549–573. https://doi.org/10.1080/10409289.2015.1000220 Wadaa, N.  N., Zaharim, N.  M., & Alqashan, H.  F. (2010). The use of EMDR in treatment of traumatized Iraqi children. Digest of Middle East Studies, 19(1), 26–36. https://doi. org/10.1111/j.1949-­3606.2010.00003.x Weiland, C., & Yoshikawa, H. (2013). Impacts of a prekindergarten program on children’s mathematics, language, literacy, executive function, and emotional skills. Child Development, 84(6), 2112–2130. https://doi.org/10.1111/cdev.12099 Weine, S., Kulauzovic, Y., Klebic, A., Besic, S., Mujagic, A., Muzurovic, J., et  al. (2008). Evaluating a multiple family group access intervention for refugees with PTSD. Journal of Marital and Family Therapy, 43, 149–164. Woollett, N., Bandeira, M., & Hatcher, A. (2020). Trauma-informed art and play therapy: pilot study outcomes for children and mothers in domestic violence shelters in the United States and South Africa. Child Abuse & Neglect, 107, 104564. https://doi.org/10.1016/j.chiabu.2020.104564W World Health Organization. (2013). Guidelines for the management of conditions specifically related to stress. WHO. Xian-Yu, C.-Y., Deng, N.-J., Zhang, J., Li, H.-Y., Gao, T. Y., Zhang, C., & Gong, Q.-Q. (2022). Cognitive behavioral therapy for children and adolescents with post-traumatic stress disorder: meta-analysis. Journal of Affective Disorders, 308, 502–511. https://doi.org/10.1016/j. jad.2022.04.111 Yule, W., Dyregrov, A., Neuner, F., Pennebaker, J. W., Raundalen, M., & Emmerik, A. V. (2005). Writing for Recovery: A manual for structured writing after disaster and war. Children and War.

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Substance Abuse, Personality Disorders, and Severe Mental Illness

9.1 Introduction Most research on mental health disorders in refugees and asylum seekers has focused on common mental disorders as depression, anxiety disorders, and post-­ traumatic stress disorder. However, other types of mental health problems warrant attention as well among refugees and asylum seekers, such as alcohol or substance use disorders, personality disorders, and psychosis, which may be associated with severe disability (Charlson et al., 2019; Kane et al., 2014). There is increasing evidence that in addition to these common mental disorders, other mental disorders such as alcohol or substance use disorders (e.g., Abbas et al., 2021; Fine et al., 2022; Bapolisi et al., 2020; Luitel et al., 2013; Weaver & Roberts, 2010) and psychotic disorder (e.g., Anderson et al., 2015; Duggal et al., 2020; Fine et al., 2022; Jones et al., 2009; Hollander et al., 2016; Llosa et al., 2014) are also prevalent among refugees and asylum seekers. Hardly any research has been done on personality disorders among refugees and asylum seekers, but given the high prevalence of personality disorders worldwide (Emmelkamp & Meyerbröker, 2020; Volkert et al., 2018; Winsper et al., 2020), the prevalence among refugees and asylum seekers may be even higher among refugees and asylum seekers given the stressors they have to deal with. Sen et  al. (2018) screened mental disorders in detainees in immigration removal centers in the United Kingdom. The prevalence of screen-positive personality disorder (35%) was higher than that found in community samples using the same screening instrument (Standardised Assessment of Personality Abbreviated Scale, SAPAS).

9.1.1 Psychosis As discussed in Chap. 1, refugees have a significantly higher risk of developing schizophrenia and non-affective psychoses compared with the native population © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 P. M. G. Emmelkamp, Mental Health of Refugees, https://doi.org/10.1007/978-3-031-34078-9_9

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and compared with non-refugee migrants (e.g., Brandt et al., 2019). There is increasing evidence that migration may be a risk factor for developing psychosis, including schizophrenia (Blázquez et al., 2015; Cantor-Graae & Selten, 2005; Selten et al., 2007; Devylder et  al., 2013; Nielssen et  al., 2013; Nygaard et  al., 2017; Veling et al., 2008). In a review and meta-analysis of studies conducted in Canada, Denmark, Norway, and Sweden among refugees and asylum seekers, prevalence of psychotic disorders was compared with the prevalence of psychotic disorders among non-refugee migrants or among the native population (Brandt et al., 2019). Diagnoses had to be based on ICD-9 or ICD-10 or DSM. The prevalence of non-affective psychoses in refugees and asylum seekers was higher compared with the native population as well as compared with non-refugee migrants. In a very large study in Sweden, unaccompanied and accompanied young refugees had an elevated risk of mental care due to schizophrenia or other non-affective psychotic disorders when compared to Swedish-born youth (Björkenstam et  al., 2022), confirming that traumatic events experienced prior to migration are a risk factor for the development of psychosis. In a study of Duggal et al. (2020), the risk of developing psychosis was much higher among male refugees who had lived in refugee camps for prolonged periods of time compared to refugees who had received residence status.

9.1.2 Asylum Seekers Asylum seekers are vulnerable for mental health problems due to the uncertainty of the asylum process (Kleinert et al., 2019; Posselt et al., 2020). In contrast to earlier years where the emphasis was on pre-migratory trauma, more recently, there has been more emphasis on problems in the resettlement phase and mental problems (see Chap. 1). In addition to premigration trauma, asylum seekers or individuals with temporary resident status often experience substantial stress related to insecurity with respect to their legal status, which also affects the mental health of asylum seekers (Carswell et  al., 2011; Hajak et  al., 2021). Factors affecting the mental health of asylum seekers include continuing uncertainty regarding the outcome of one’s asylum request; fear of being sent back to one’s home country; prolonged worrying about children, partner, and other family members who are still in the country of origin; prolonged feelings of insecurity; unemployment; and financial problems (see Alim et al., 2021; Gleeson et al., 2020; Li et al., 2016; Phillimore & Cheung, 2021). In a study of Bogner et al. (2007), high levels of dissociation were reported during asylum interviews. In a study of Schock et al. (2015), asylum seekers who had experienced high-impact trauma in the past were assessed for mental health problems before the asylum interview and again after the interview. Results revealed that in a number of cases, asylum interviews among traumatized refugees triggered post-traumatic intrusions. Thus, asylum seekers are particularly vulnerable for mental health problems and have higher prevalence rates of mental health problems compared to resettled refugees (van Eggermont Arwidson et al., 2022).

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Recent research in European countries revealed that asylum systems may actually enhance post-migration stressors by keeping refugees and asylum seekers in precarious conditions often leading to reliving of traumatic experiences, which may enhance the risk of developing severe mental health disorders (e.g., Hvidtfeldt et al., 2020, 2022; Jannesari et al., 2022). A number of studies showed that socially disadvantaged migrants with social difficulties had a higher risk to develop schizophrenia in European countries (see Eaton & Harrison, 2000), but few studies investigated the prevalence of psychotic disorders in refugees and asylum seekers (e.g., Dapunt et al., 2017; Hollander et al., 2016; Llosa et al., 2014; Patanè et al., 2022). In addition to the stress experienced before and during the flight, the asylum process for refugees in the host country, in a number of cases including detention, may have additional negative impact on mental health (e.g., Kinzie, 2006; Schock et al., 2015; von Werthern et al., 2018) and may increase the vulnerability to psychoses.

9.2 Use of Mental Health Service In a number of countries, only permanent refugees have access to mental health and psychological support services provided by specialist refugee agencies (Silove, 2021). In a very large study, Fine et al. (2022) examined mental service usage within 175 refugee camps in 24 low- and middle-income countries across 10  years including Bangladesh, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, the Democratic Republic of Congo, Djibouti, Eritrea, Ethiopia, Ghana, Kenya, Liberia, Namibia, Nepal, Republic of the Congo (Congo-Brazzaville), Rwanda, South Sudan, Sudan, Thailand, Tanzania, Uganda, Yemen, and Zambia. Thus, data from Iran, Iraq, Jordan, Lebanon, Pakistan, and Turkey, which host the most refugees from Afghanistan, Iraq, and Syria and from Europe, North America, South America, and Australia, are not included. Data were collected within each refugee camp through outpatient primary health care facilities. This study revealed that most visits for mental health problems were for epilepsy/seizures (44.4%) and psychotic disorders (21.8%). Mental health care service utilization rates were particularly low for common mental disorders, including anxiety, post-traumatic stress disorder, and depression. The smallest number of visits was due to alcohol and or substance use disorder. One should realize that care providers in refugee camps in these countries have often minimal training in the recognition of mental disorders, given that mental health training is often limited to identification of traumatic stress. In addition, a number of care providers are inclined to prioritize medical acute conditions and may ignore people with mental illness (Jones et al., 2009). It should be noted, however, that efforts to integrate mental health into primary health care facilities for refugees are already underway. In 2021, over 1300 primary health care workers in refugee camps across the Democratic Republic of Congo, Ethiopia, Jordan, Kenya, Niger, Rwanda, Sudan, and Uganda were trained in mental health recognition and assessment, and mental health professionals were trained to provide treatment for patients with complex conditions or to provide supervision to primary health care workers (Fine et al., 2022).

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A number of studies revealed that demographic characteristics including income, proficiency of the language of the home country, cost of services, and formal citizenship of the home country are related to the mental health service use of refugees and asylum seekers (Derr, 2015). Access and use of mental health services include, in addition to demographic characteristics and language barriers, stigma around mental illness, cultural interpretations of mental illness, and fear of negative repercussions when living with a mental illness (e.g., Salami et al., 2019). Mental health stigma can have a negative effect on psychopathology in immigrants (Chen et al., 2016). According to the Health Belief Model, individuals are likely to engage in mental health care when they believe that the problem could have serious consequences for daily living activities (Henshaw & Freedman-Doan, 2009). This model, however, has not yet been evaluated with refugees and asylum seekers. A few studies have investigated the role of stigma and acculturation with refugees and asylum seekers (e.g., Galvan et al., 2022; Giacco et al., 2014; Pumariega et al., 2005) and found that these factors were involved in the willingness to use mental health care. Culturally and religiously based mental health beliefs may have an impact on the use of mental health service by refugees and asylum seekers from the Middle East and North Africa (Galvan et al., 2022). In these cultures, the preservation of family honor is of utmost importance (Amri & Bemak, 2013). This often results in reliance on family members to support their mental health problems (Aloud & Rathur, 2009). Especially females with a Muslim background may be reluctant to make use of mental health service, given that doing so can be perceived by male Muslim husbands as deviation from the Islamic faith and threatening their authority, eventually leading to interpersonal violence for the female partner (Phillips & Lauterbach, 2017). According to Galvan et al. (2022), among sub-Saharan African immigrants, one of the most frequently cited attitudinal factors associated with their underutilization of mental health support is a mistrust of the mental health system. This is due to mistrust of European ideologies as a result of the colonization in the past and the still difficult race relations, which in a number of individuals may lead to fear that they may receive a mental health diagnosis when one is not warranted (Omenka et al., 2020). In a study of Adekeye et al. (2018), African immigrants’ religiosity was associated with how they dealt with mental health. Not only Muslims but also Christians considered mosque/church attendance important in coping with stress and challenges in daily life.

9.3 Alcohol and Substance Abuse Generally, refugees have a high risk of alcohol and substance abuse (e.g., Horyniak et al., 2016a; Weaver & Roberts, 2010). There is some evidence that alcohol and substance use rates are lower among recently settled refugees compared with refugees who stayed longer in the European host country (Abbas et  al., 2021). In a recent study of Diese et al. (2022), the onset of alcohol abuse in the United States

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by Babembe refugees from the Eastern Democratic Republic of Congo was associated with war in their home country and forced migration and was later enhanced by loss of cultural identity in the United States. Generally, risk factors for substance abuse among refugees and asylum seekers include increased re-experiencing of trauma, social and economic disadvantage, uncertainty with respect to being formally accepted as citizen in the host country, stigma, family conflict, religious norms, and acculturation stress (Douglass et  al., 2022a; Douglass et  al., 2022b; Horyniak et al., 2016b; Lindert et al., 2016; Posselt et al., 2014). Refugees’ living conditions (e.g., living in camps) can increase distress and substance availability, whereas on the other hand, separation from family may increase the risk for substance abuse (Hertner et al., 2023). There is some evidence that especially young refugees and asylum seekers are inclined toward heavy alcohol consumption and drug use to cope with boredom, trauma, homelessness, and family conflict (e.g., Horyniak et  al., 2016a, 2016b; Mwanri & Mute, 2021; Posselt et al., 2014), which enhances morbidity and mortality in young refugees (Degenhardt et al., 2013). There is also some evidence that refugees and asylum seekers are less willing than natural inhabitants to apply for treatment to deal with substance abuse (Drummond et  al., 2011; McCann et  al., 2016; McCann et al., 2018). Given that the use of alcohol in Islam is strictly forbidden according to the Sharia law, it is generally held that Arab people and Muslims do not use alcohol and drugs. Research conducted in the Arabian Gulf region (in Bahrain, Kuwait, Oman, Saudi Arabia, the United Arab Emirates, and Qatar) has shown, however, that alcohol and drug abuse problems exist among the inhabitants of Arabian Gulf countries despite the religious and legal constraints. Results reveal that alcohol, hashish, and/or heroin were the dominant drugs of choice (AlMarri & Oei, 2009). In a number of Arab countries, alcohol use has become increasingly accepted over the past years (Mauseth et al., 2016). Overall, two-thirds of the world’s refugees originate from the Eastern Mediterranean Region, most of them coming from Afghanistan, Iraq, Libya, Somalia, Sudan, Syrian Arab Republic, and Yemen (Al-Mandhari et al., 2021). In a recent review, it was estimated that 67% of the adult population in the Eastern Mediterranean region which has a majority Muslim population used an illicit drug in the past year. This figure is primarily due to opioid use in the South Asian subregion, khat use in the East African subregion, and cannabis use in the North African subregion (Rostam-Abadi et al., 2023).

9.4 Substance Abuse and Intimate Partner Violence It is important to realize that alcohol abuse and use of illicit drugs are connected to interpersonal violence perpetration (e.g., Foran & O’Leary, 2008; Kraanen et al., 2014). Alcohol and drug use is not only common on perpetrators of intimate partner violence, but also common as “self-medication” among interpersonal violence-­ exposed victims, which may lead to severe substance abuse in victims, which may

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eventually result in severe mental and physical health consequences, including brain injury (Mehr et al., 2023; Oram et al., 2022). There are cultural factors involved in the application of intimate partner violence. In the Multi-Country Study on Domestic Violence and Women’s Health, rates of psychological abuse between countries varied substantially (GarcíaMoreno et al., 2005; Oram et al., 2022), which may be relevant for refugee populations. Although there are no hard figures, interpersonal violence is also prevalent among refugee populations. Presumably, different routes lead from alcohol use, use of opium or cocaine, and cannabis use to interpersonal violence perpetration. For example, for cocaine, it is hypothesized that its psychopharmacological effects directly increase aggressive behavior, whereas for cannabis, it is assumed that irritability as a result of withdrawal may lead to committing interpersonal violence. A large study (Kraanen et al., 2014) demonstrated that almost one-third of the patients in substance abuse treatment were involved in any interpersonal violence, either perpetration, victimization, or both in the year before treatment started. Almost a quarter of patients severely abused their partner in the past year. For males, an alcohol use disorder in combination with a cannabis and/or cocaine use disorder significantly predicted any interpersonal violence (perpetration and/ or victimization) as well as severe interpersonal violence perpetration. For females, however, alcohol and cocaine abuse predicted both interpersonal violence perpetration and victimization and severe interpersonal violence perpetration. Results from this study emphasize the importance of routinely assessing interpersonal violence in patients with substance abuse problems and demonstrate that clinicians should be particularly alert for interpersonal violence in patients with specific substance use disorder combination. There is a clear need of studies with refugees addressing these issues. Specific (cognitive behavioral) interventions have been developed to treat intimate partner violence (see Nesset et al., 2019; Stephens-Lewis et al., 2021; Tarzia et al., 2020), but it is important in comorbid cases of substance abuse and interpersonal violence to treat substance abuse as well (Easton et al., 2018; Kraanen et  al., 2013; Murphy & Ting, 2009). Patients who relapsed to substance abuse after successful substance use disorder treatment were much more likely to relapse to interpersonal violence than patients who abstained from alcohol (e.g., Mignone et al., 2009). Generally, starting with motivational interviewing will prevent dropout and enhance treatment effectiveness (Murphy et al., 2018; Pinto e Silva et al., 2022) and may be especially important with refugee people from different cultural backgrounds. There is hardly any evidence of effective interventions for interpersonal violence and substance abuse in low-resource contexts. In a randomized controlled trial, the cognitive behavioral Common Elements Treatment Approach was evaluated among couples living in low-socioeconomic neighborhoods in Lusaka (Zambia) (Murray et al., 2020). The Common Elements Treatment Approach was more effective than an enhanced control condition, in reducing interpersonal violence and male alcohol use at 12-month follow-up.

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9.5 Substance Abuse and Comorbid Post-traumatic Stress Disorder Many patients with common mental disorders have substance use disorder as well; this is especially the case with post-traumatic stress disorder. Prevalence estimates for post-traumatic stress disorder in patients with substance use disorder vary from 20 to 30% (Kimerling et  al., 2006; van Dam et  al., 2010). The co-occurrence of substance use disorder and post-traumatic stress disorder is highly prevalent among (female) victims of interpersonal violence (McKee & Hilton, 2019). Also, in youngsters, there is an association between substance abuse and post-traumatic stress disorder (e.g., Welsh et  al., 2017). Of youngsters aged 11–18  years old, residing at refugee centers in the Republic of Serbia, more than a half of the participants displayed post-traumatic stress symptoms, which was often associated with substance abuse (Vasic et al., 2021). Patients with comorbid post-traumatic stress disorder and substance use disorder show higher symptom severities and worse treatment outcomes compared to patients with either disorder alone (see van Dam et al., 2012). The “self-medication hypothesis” suggests that concurrent post-traumatic stress disorder and substance use disorder are caused by trauma survivors’ excessive use of substances as self-medication for painful and disturbing post-traumatic stress symptoms (Stewart & Conrod, 2003). Repeated “self-medication” by using alcohol or other substances may eventually lead to an association between post-traumatic stress symptoms and substance use, so that exposure to trauma reminders and experience of post-traumatic stress symptoms can trigger craving and substance use. Patients with concurrent post-­ traumatic stress disorder and substance use disorder may then end up in a vicious circle, where post-traumatic stress symptoms trigger substance abuse, and substance abuse in turn increases the risk for future traumatic experiences. In a study of McGovern et  al. (2011), the majority of patients first reported trauma and then substance use, which again was followed by additional traumatic experiences leading to further substance use. Thus, a reciprocal relationship between both disorders appears to be the most likely explanation for the high comorbidity between post-traumatic stress disorder and substance use disorder (van Dam et al., 2012). Given that refugees and asylum seekers have often experienced many traumas and are often exposed to stressors for a rather long time in the host country, it is plausible that the “self-medication” model certainly also applies to refugees and asylum seekers, but this has not yet been investigated.

9.6 Psychological Interventions for Comorbid Post-­traumatic Stress and Substance Use Disorders People with comorbid post-traumatic stress disorder and substance use disorder have more severe problems such as violent behavior, suicidal ideation, and financial and social problems (Blakey et al., 2022; Straus et al., 2018), and a higher incidence

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of childhood trauma (Schäfer et al., 2010). A number of studies have investigated whether trauma-focused therapy for post-traumatic stress disorder would enhance the effects of treatment for substance abuse in patients with both comorbid disorders. In a study of van Dam et al. (2013), an evidence-based trauma-focused intervention (structured writing therapy; van Emmerik et al., 2008) for post-traumatic stress disorder was added on a regular intensive cognitive behavioral program for severe patients with substance use disorder. Structured writing therapy uses specific writing assignments to reprocess painful trauma memories, and it encourages cognitive reappraisal of trauma-related thoughts and social sharing of the traumatic event. Results showed a general reduction of substance abuse symptoms for both treatment conditions. Improvements for post-traumatic stress severity over time were only significant within the combined treatment condition. More recently, a number of studies investigated the additional value of trauma-focused therapy in people with comorbid post-traumatic stress disorder and substance use disorder. Generally, trauma-focused therapy plus therapy for substance abuse was (slightly) more effective than treatment for substance abuse only both for post-traumatic symptoms and for substance abuse (see Roberts et al., 2022). In a study of Schäfer et  al. (2019) with women with comorbid substance use disorder and post-traumatic stress disorder, an integrated group treatment for substance abuse and post-traumatic stress disorder (“Seeking Safety”) led to a significantly greater reduction in psychological distress in patients that received integrative intervention compared to patients on the wait list up to 6-month follow-up. However, compared against substance use interventions as stand-alone treatment, “Seeking Safety” conducted in groups was not found to be more effective, neither was it more effective in a few other studies with patients with comorbid post-traumatic stress symptoms and substance abuse (see Roberts et al., 2022). Thus, a few studies based on trauma-focused therapy provide some evidence that adding a trauma-focused treatment on to standard treatment for substance abuse may be beneficial. Whether a combination of trauma-focused therapy and substance abuse treatment would also be effective in refugees and asylum seekers with comorbid post-traumatic stress symptoms and substance abuse has not yet been investigated. Actually, hardly any study investigated the effects of interventions targeting substance abuse in refugees and asylum seekers. Somali people are inclined to chew khat to cope with adversity (Odenwald et  al., 2009; Widmann et  al., 2014). In a randomized controlled trial (Widmann et al., 2017, 2022) among Somali refugees living in large refugee camps in Kenya, the effect of substance abuse intervention for khat users was investigated. In this study, 330 male Somali khat users were assigned to either “screening and brief intervention” or no-treatment control. A single session reduced khat use frequency and amount in the following month. The intervention group showed a greater reduction than control condition, but effect sizes were small. Khat use, depression, and khat-related psychotic symptom decreased. In participants without comorbid psychopathology, more khat use reduction after the intervention was found.

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In another randomized controlled trial, the effects of the “Common Elements Treatment Approach,” a trans-diagnostic intervention for comorbid disorders, were investigated in refugees in Thailand (Bolton et  al., 2014). The Common Elements Treatment Approach was designed to treat symptoms of common mental health disorders including post-traumatic stress, depression, and anxiety and consisted of nine elements that focused on torture- and violence-exposed people. All participants received the components engagement, psychoeducation, cognitive coping/restructuring, imaginal gradual exposure, and safety. The intervention was adapted to the culture and situation of the refugees. The active treatment was delivered by trained and supervised lay workers (all Burmese refugees themselves) and compared with wait list control. Results revealed clear symptom reductions for post-traumatic stress symptoms, anxiety, and depression, but—surprisingly—not for substance abuse (alcohol). The Common Elements Treatment Approach resulted in large effect sizes for depression (d = 1.16) and post-traumatic stress symptoms (d = 1.19), and zero for alcohol use. In sum, there is hardly any evidence on the efficacy of interventions for refugees and asylum seekers with substance abuse. A study of Kane et al. (2014) in 90 refugee camps revealed that there were very few consultations for alcohol or substance use in primary health care facilities. The refugee camps were in 15 countries in Central Africa, East and Horn of Africa, Southern Africa, West Africa, the Middle East, South Asia, and Southeast Asia. Utilizing surveillance data from the Health Information System of the United Nations High Commissioner for Refugees, this study found that most visits of refugees to health centers were associated with epilepsy and psychotic disorders. Very few visits concerned substance use, which suggests that many alcohol and substance abuse problems remain unattended by refugee health services.

9.7 Practical Recommendations Guidelines for the provision of humanitarian assistance recommend actions to address substance misuse in conflict-affected areas (IASC, 2007), but hardly anything has changed over the past few years to prevent and treat substance use problems among refugees and asylum seekers (Roberts & Ezard, 2015; Kane & Greene, 2018).

9.7.1 Screening for Substance Abuse As a first step, it is important to screen for alcohol and substance use in refugees and asylum seekers. Given that refugees/asylum seekers come from diverse cultures, religions, and ideologies, there is no standard screening measure which can be recommended. This diversity of background impacts a person’s understanding and perception of substance use, which limits the ability of health care providers to comprehensively screen for alcohol and substance abuse. Although the Alcohol Use Disorders Identification Test (AUDIT) can be used (Babor et al., 2001), results of

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use of this scale (and a variant for drug use: WHO ASSIST Working Group, 2002) are mixed. Equipping health care providers with training on how to identify factors that are associated with alcohol and substance abuse in refugee populations increases the likelihood that appropriate care can be provided.

9.7.2 Which Intervention? A number of cognitive behavioral interventions to address substance abuse have been found to be evidence based in Western countries (see Emmelkamp & Vedel, 2006), but these have hardly been investigated in non-Western countries. These evidence-based interventions include motivational interviewing, coping skill training, cue exposure, and contingency management. Very few treatment studies have been published which evaluated substance abuse treatments in refugees (see Greene et  al., 2018), and hardly any study evaluated one of the evidence-based Western psychological interventions described above. In their review, Greene et al. (2018) could not find information on the effectiveness of skill-based stigma reduction interventions for populations using substances in low- and middle-income countries or conflict-affected populations. An intervention which may be promising in the context of refugee camps is Brief Intervention for Alcohol Problems. This intervention consists of a number of methods that aim to motivate behavior change of alcohol use including feedback on the person’s risky alcohol use; information on the harms associated with risky alcohol use; motivational enhancement; analysis of high-risk situations for drinking; and development of an individual plan to reduce alcohol consumption (Beyer et  al., 2019). This Brief Intervention for Alcohol Problems may be useful for refugees, while it can be easily adapted to different behavioral variants and health settings and hence can involve a number of various approaches. Unfortunately, there is very limited evidence for both efficacy and effectiveness of Brief Intervention for Alcohol Problems in low- and middle-income countries (Greene et al., 2018; Nadkarni et al., 2022). In a recent meta-analysis (Ghosh et  al., 2022), the Brief Intervention for Alcohol Problems did better than controls, but the effects did not persist at 6- and 12-month follow-up. There was hardly any evidence that Brief Intervention did reduce the frequency of heavy drinking. Taken together, there is a clear need to investigate Western substance abuse interventions in refugees, but these interventions need to be culturally adapted before use with refugees (Wechsberg et al., 2022).

9.8 Personality Disorder A personality disorder can be referred to as an enduring pattern of inner experiences and specific behaviors that deviates to a significant extent from the expectations of the individual’s culture. People diagnosed with “personality disorder” are unable to react flexibly and appropriate to life’s challenges and experience severe distress

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from adolescence or early adulthood onward, affecting a number of aspects of their life, including social functioning and mental health (APA, 2013). Currently, the term complex emotional needs is also used as a working description of the difficulties experienced by people who may receive a “personality disorder” diagnosis (Ledden et al., 2022). Trauma may affect the personality development (Berman et  al., 2020; Emmelkamp & Meyerbröker, 2020; Pagura et al., 2010), and young refugees may be particularly at risk of developing personality disorders (e.g., Huemer et  al., 2013). The adverse life events they have experienced in their home country during the flight and the post-migration stressors during the resettlement process may affect their personality development. Personality traits in adolescence predict mental disorders and poor functioning in the future (e.g., Krueger, 1999; Shiner, 2009), but research on the development of personality pathology and the prevalence of personality disorders among refugees is scarce.

9.9 Personality Traits During adolescence, a number of changes in personality traits and identity are normal (e.g., Bleidorn, 2015; Chung et al., 2014; Kroger et al., 2010), but may also be the result of negative major life events (e.g., Laceulle et  al., 2015; Shiner et  al., 2017), including refugee-related adversity for adolescent refugees. There is some evidence that major stressors such as migration or health impairment may affect identity development in adolescence and young adulthood (e.g., Fadjukoff et  al., 2016). According to Kernberg (2006), identity impairment is characteristic of personality pathology, which is now included in the Alternative Model for Personality Disorders in DSM-5. In the Alternative Model for Personality Disorders, it is assumed that personality disorders are characterized by problems in self-­functioning (identity) and problems in interpersonal functioning (APA, 2013). Similarly, in ICD-11, personality disorders are defined as well as problems in functioning of aspects of identity (self-worth, accuracy of self-view, self-direction) and/or interpersonal dysfunction (World Health Organization, 2021). In a study of Ertorer (2014), the identity formation of Karen refugees who were resettled in Canada was investigated. This study showed that the resettlement process impaired the sense of temporal sameness and continuity and was associated with crisis in identity and distress concerning personal and social identity issues such as loyalty with the group, work, and social values. In another study (Guler & Berman, 2019) among adolescent refugees resettled to the United States from a number of different conflict areas (e.g., Iraq, Jordan, Haiti, and Venezuela), results revealed that native cultural identity was a significant protective factor against identity distress. A few studies have investigated (change in) personality traits in young refugees and asylum seekers. Laceulle et  al. (2022) investigated changes in dispositional compassion in Syrian adolescents and young adults resettling in the Netherlands over a 13-month period. Dispositional compassion is regarded as a facet of the

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personality trait agreeableness. Results revealed that dispositional compassion in Syrian young adults with refugee backgrounds decreased over time. A study by Latzman et al. (2016) revealed that adolescent refugees who had lived in a refugee camp reported higher callous and unemotional trait levels and detachment than migrants. Zettl et al. (2022) investigated the development of maladaptive personality traits in young refugees and migrants from 22 countries who were settled in Germany. Maladaptive personality traits were assessed with the Personality Inventory for DSM-5-Brief Form. Results revealed that young refugees reported significantly higher levels of identity diffusion, negative affectivity, detachment, antagonism, and disinhibition compared to migrants. Refugees reported higher overall expression of maladaptive personality traits and had higher scores in four of the five DSM-5 personality domains. The higher levels of detachment in refugees confirm earlier findings among adolescent refugees (Latzman et al., 2016) and are interpreted by Zettl et al. as a coping mechanism to deal with negative experiences during migration, eventually resulting in a tendency to avoid interpersonal interactions and to express restricted affective experiences. The higher levels of antagonism (e.g., callousness, deceitfulness, hostility, and manipulativeness) and disinhibition (e.g., impulsivity, irresponsibility, and risk-taking) are personality traits of antisocial personality disorder (see Emmelkamp & Meyerbröker, 2020). Results of this study are certainly interesting, but given that only German-speaking immigrants were included in this study, generalizability of the results may be limited. Nevertheless, diagnosing personality disorders by clinical interviews may be particularly important in adolescent refugees since personality disorders usually develop during this developmental period. Early detection of personality impairments and providing evidence-based psychological interventions for this at-risk group of adolescent refugees may prevent the development of one or more personality disorders. As Zettl et al. (2022) conclude: “... This may be in addition to classic mental health care by allowing refugees to share their cultural heritages with the hosting cultures, exchange and discuss cultural norms, and by relieving them of the impression that they would need to give up cultural identity if they want to remain in the hosting country.”

9.10 Treatment of Personality Pathology Generally, personality pathology is associated with worse psychotherapy outcomes in common mental disorders (e.g., Carter et al., 2011; Huibers et al., 2015; Zeeck et al., 2020), but whether personality pathology affects the outcome of psychotherapy in refugees and asylum seekers has hardly been investigated. In a study of Bernardsdottir et al. (2023), personality functioning did not predict the outcome of 16–20 sessions of cognitive behavioral interventions for post-traumatic stress disorder in refugees resettled in Denmark. Personality functioning was measured with the Levels of Personality Functioning Scale, an observer rating scale from the alternative model for personality disorders in DSM-5 (Morey, 2017). Psychotherapy consisted of a combination of trauma-focused cognitive behavioral therapy,

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acceptance and commitment therapy, mindfulness, and/or stress management, which renders results difficult to interpret. There is a consensus that psychological interventions are the first-line treatment for people diagnosed with personality disorder (Cristea et al., 2017; Emmelkamp & Meyerbröker, 2020; Katakis et al., 2023; Storebø et al., 2020), especially cognitive and behavioral therapies and psychodynamically oriented therapies. Although there is now considerable evidence that there are a number of evidence-based psychological therapies for personality disorders especially for borderline personality disorder, these have not yet been investigated in refugees or asylum seekers. Several promising psychosocial interventions have been developed, some of which fared rather well in controlled research: cognitive therapy (Beck et al., 2004), dialectical behavior therapy (Linehan, 1993), schema-focused therapy (Young et al., 2003), transference-focused therapy (Clarkin et al., 1999), and mentalization-based therapy (Bateman & Fonagy, 2004). Most studies evaluating these therapies have been conducted with patients with borderline personality disorder.

9.10.1 Cognitive Therapy Cognitive therapy (Beck et  al., 2004) aims to identify and modify core dysfunctional beliefs that automatically organize biased perceptions of self, others, and the future. For example, patients hold highly negative and polarized core beliefs that include extreme helplessness, distrust, fears of abandonment and rejection, mistrust/abuse, social isolation, and emotional deprivation (e.g., Barazandeh et  al., 2016). Despite the fact that cognitive therapy has become rather popular among clinicians, few controlled studies are available that have demonstrated its effectiveness in the treatment of patients with severe personality disorders. Given the emphasis on cognitions in therapy, cognitive therapy may be less suited for refugees and asylum seekers.

9.10.2 Dialectical Behavior Therapy Dialectical behavior therapy was specifically developed for chronically suicidal and severely dysfunctional individuals, including patients with borderline personality disorder (Linehan, 1993). Given its roots in Eastern contemplation and dialectical philosophy, this treatment may be particularly suited for refugees and asylum seekers with an Eastern background. Dialectical behavior therapy is based on principles of cognitive behavior therapy combined with acceptance, mindfulness, and dialectics. Dialectical behavior therapy differs from cognitive behavior therapy in that it is directed to teaching new skills rather than emphasizing cognitive restructuring. It consists of a combination of individual sessions and group skill training, which is organized in modules that specifically target core features of (borderline) personality psychopathology. Patients receive a practical training in ways of more effective coping with their critical functional deficits. The personal situation is addressed in

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the individual therapy sessions, where the emphasis is on integrating the skills into their daily functioning. Noteworthy is also the “packaging” of dialectical behavior therapy. The model takes a nonpejorative stance toward these “notoriously difficult” patients. Patients are not considered “manipulative” but treated with respect.

9.10.3 Schema-Focused Therapy Schema-focused therapy or schema therapy overlaps with other models of psychotherapy, but has distinctive features in its theoretical approach, technique, and use of the therapeutic relationship. Change is achieved through a range of behavioral, cognitive, and experiential techniques, focusing on the therapeutic relationship, life outside therapy, and past traumatic experiences. Young et al. (2003) proposed that psychotherapists should primarily focus on the Early Maladaptive Schema in individuals with personality disorder, and therapy focusing on schema modes was developed for treating shifting emotional states in patients with complex personality disorders such as borderline personality disorder. Schemata are complex phenomena, involving memories, physical sensations, emotions, and dysfunctional cognitions. They are broad, deep-seated beliefs and themes about the self and the world. According to Young et al. (2003), core emotional needs include: –– –– –– –– ––

The development of secure attachments to others The development of autonomy, competency, and sense of identity The freedom to express valid needs and emotions Spontaneity and play Realistic limits and self-control

Young et al. also propose four types of early-life experience that foster the acquisition of schemata: toxic frustration of needs (leading for example to the schema of deprivation), traumatization (leading to mistrust and abuse schemata), overindulgence (leading to entitlement and dependence schemata), and selective internalization (leading for example to a subjugation schema).

9.10.4 Transference-Focused Therapy Transference-focused therapy (Clarkin et al., 1999) is an individual psychotherapy, usually on a twice-a-week basis, lasting between 2 and 5 years. It requires active therapist involvement and focuses on the here and now transactions in the therapeutic relationship, with the aim of understanding issues that originated in childhood. The core issue in transference-focused therapy is to learn to accept and tolerate conflicting feelings both in self and in others. The assumption is that the important childhood conflicts will surface in the therapeutic relationship, hence the label transference-focused therapy. The interpersonal relationship between the therapist

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and patient is consistently explored for affect-laden themes that may recapitulate dominant object relational patterns (see also Clarkin & Levy, 2006). Issues are addressed in a fixed hierarchy: first, containment of suicidal and self-destructive behaviors, then treatment interfering behaviors, and subsequently identification of the dominant object relational themes. Given the long duration of transferencefocused therapy (2–5 years), this treatment is less suited for refugees and asylum seekers.

9.10.5 Mentalization-Based Treatment Mentalization-based treatment (Bateman & Fonagy, 2004) is based on psychodynamic theory, attachment theory, and cognitive theory. Mentalizing is the capacity by which people can make sense of themselves and of each other, in the way that we are attentive to our own and other’s feelings, thoughts, desires, and intentions. The capacity to do this develops through a process of having experienced oneself in the mind of another during childhood within an attachment context, and only matures adequately within the context of a secure attachment (Luyten et al., 2020). As such, mentalization is seen as a developmental achievement; that is, in the context of a secure attachment, an intersubjective process can take shape centered around observing, labeling, and communicating feelings, thoughts, and desires, and to link these internal states in a meaningful way to the actions of self and others. The treatment aims to improve the capacity to mentalize, especially under stressful circumstances and in attachment relationships, in order to improve agency, reflection, and interpersonal relationships, and to stimulate more effective ways to manage vulnerability and difficulties. To enhance mentalization, strategic use of transference is sought, working in the here and now with current mental states, bearing in mind the patient’s deficits. The therapeutic task is to assist the patient to link affects to representation and to develop a capacity for symbolic representation (see also Fonagy & Bateman, 2006). Although mentalization-based treatment is a psychodynamic treatment, it emphasizes working in the “here and now” rather than focusing on the past.

9.10.6 Which Intervention Is the Most Effective? Reviews conclude that these treatments described above are more effective than treatment as usual achieving clinical improvements in self-harm and “borderline symptoms,” although no single intervention type has emerged as the most effective (Emmelkamp & Meyerbröker, 2020; Ledden et al., 2022). While most patients with personality disorders receive treatment in outpatient settings, a number of more severe cases are treated in day hospitals or are treated as inpatients which may be needed in severe cases with repeated self-harm or suicide attempts (e.g., Bartak et al., 2009, 2011a, 2011b; Choi-Kain et al., 2016; Mehlum, 2018). Inpatient treatment is often difficult to realize for refugees/asylum seekers. Although antidepressants are often prescribed, there is little evidence that antidepressants are effective

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with respect to personality psychopathology (Stoffers-Winterling et al., 2022). Most clinical guidelines agree that pharmacotherapy should not be considered as the primary intervention for personality disorders, but may be needed for treating comorbid disorders (e.g., severe depression, impulsivity; Stoffers et al., 2010) and in a few patients may be used briefly during times of crisis (Simonsen et al., 2019). In outpatient treatment settings, mentalization-based therapy (Bateman & Fonagy, 2009; Khabir et  al., 2018), dialectical behavior therapy (Khabir et  al., 2018), and schema-focused therapy (Bamelis et al., 2014; Farrell et al., 2009) were found to be effective in reducing “personality pathology” in adults. It is not clear, however, which of these therapies work better for whom (Oud et al., 2018). Patients involved in studies evaluating psychosocial treatment for personality disorder are largely White and female with hardly any study focusing on other ethnicities (Ledden et al., 2022). There is a clear need of studies investigating which of these therapies is most effective in refugees and asylum seekers.

9.11 Treatment of Personality Pathology in Non-Western Cultures Both mentalization-based therapy and dialectical behavior therapy have been investigated in people from Arabic culture. In the study of Khabir et al. (2018), the effects of group mentalization-based treatment and group dialectical behavior therapy were compared in young people (age 18–27 years), all residing in Shiraz (Iran). Patients fulfilled the criteria of borderline personality disorder, based on a structured interview. Results revealed that the two treatments were effective in improving avoidant and ambivalent attachment styles, mentalization, and social cognition. Thus, both treatments developed for personality disorders in Western cultures were also effective in young people in Iran. As far as I know, no studies have been reported which investigated the cross-­ cultural validity of schema therapy in non-Western patients. One case study (Barbieri et  al., 2022) was reported investigating the effectiveness of schema therapy in a three phase-based approach, with a 38-year-old male refugee from Yemen with other specified dissociative disorder, post-traumatic stress disorder, and borderline personality disorder with narcissistic and histrionic traits. The patient also suffered from sexual abuse by adults during his childhood. The diagnoses were based on the Structured Clinical Interview for DSM-5 (SCID-5) and the SCID-5 for Personality Disorders (SCID-5-PD). Schema therapy was chosen given its effectiveness in the treatment of personality disorders (Emmelkamp & Meyerbröker, 2020) and preliminary evidence that schema therapy may also be effective in dissociative identity disorder (Huntjens et  al., 2019). The treatment was provided in a cross-cultural clinic in Rome, Italy (host country), by two Italian therapists who were assisted by an Arabic interpreter. The therapy sessions occurred once a week. The cultural adaptation of the schema therapy was not limited to language translation; cultural values and contextual stressors were taken into account as well. The therapists choose for schema therapy given its emphasis on the consequences of early

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childhood neglect and abuse, and the explanation within the therapeutic model of the patient’s experience of drastic shifts between personality states. Posttreatment and follow-up reliable change analyses showed significant improvements not only in relevant cognitive schemas, but in post-traumatic stress and dissociative symptoms as well. Although results are positive in this case study, there is a clear need of research based on larger samples and specific cross-cultural focused designs before recommendations can be made.

9.12 Interventions for Adolescents with Personality Pathology There is now considerable evidence that personality disorders are already prevalent in young people (e.g., Ha et al., 2017; Zanarini et al., 2017) and are associated with future mental health and social adjustment (Moran et al., 2016). The occurrence of personality pathology in young adolescents is associated with emergency admissions and substance abuse (Bozzatello et al., 2021; Hutsebaut et al., 2020; Moran et  al., 2015) and with deviant sexual behavior both in young male and female patients (Bégin et al., 2022; Penner et al., 2019; Thompson et al., 2019). Internalizing symptoms in childhood (e.g., anxiety, depression, dissociative symptoms, suicidal ideation) and externalizing symptoms in childhood (e.g., ADHD, conduct disorder, impulsive-aggressive behavior, and substance use disorder) are associated with the occurrence of borderline personality pathology in adolescence (see Bozzatello et al., 2021). Considering the high prevalence and the adverse consequences of borderline symptoms in adolescence, there is an urgent need for early interventions, which is particularly relevant for adolescent refugees and asylum seekers. However, few interventions have been developed for youth with personality pathology. Some of the aforementioned interventions for adults with severe personality pathology have been adapted to adolescents, but little research has been done to investigate the effectiveness with youth. Early interventions could lessen the suffering of both adolescents and their environment and may prevent the development of full-blown personality pathology in adulthood, which is important for young refugees and unaccompanied minors. The adolescent version of dialectical behavior therapy consists of weekly individual cognitive behavioral therapy and weekly group skill training with participation of one of the parents in the skill training. A few studies with adolescents revealed a decrease in borderline pathology, impulsivity, anxiety, depression, and self-harming and suicidal behavior (see Hunnicutt Hollenbauch & Lenz, 2019). The adolescent version of mentalization-based treatment consists of a combination of group therapy and individual therapy and focuses on five targets: to stimulate commitment, to reduce psychiatric symptoms, to decrease self-destructive behavior, to improve interpersonal functioning, and to resume age-specific developmental tasks. In a study of Rossouw and Fonagy (2012), mentalization-based treatment was more effective than treatment as usual in 80 adolescents with self-harm, of whom three-quarters had borderline personality disorder. More recently, however, results

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of a randomized controlled trial revealed that 1-year mentalization-based treatment in groups was not more effective than treatment as usual on any of the outcome measures (Jørgensen et  al., 2021). Remission rates were rather modest and even slightly higher in treatment as usual (39%) than in the mentalization-based therapy (35%) at a follow-up of 2 years after the pretest. As noted by the authors, although improvement was observed equally in both interventions over time, the patients continued to exhibit prominent borderline personality characteristics, general psychopathology, and decreased functioning in the follow-up period, which suggests that mentalization-based treatment should not be considered for adolescent refugees and asylum seekers. Emotion Regulation Training is a skill training for adolescents with borderline pathology symptoms and is based on the Systems Training for Emotional Predictability and Problem Solving (STEPPS) program (Blum et al., 2008). This course for adolescent borderline personality pathology patients combines cognitive behavioral elements and skill training and may involve family members and important others in the training. As in dialectical behavior therapy, the core symptom addressed in emotion regulation training is emotional dysregulation. Emotion regulation training—consisting of 17 weekly sessions—involves three phases. The first phase provides psychoeducation, combined with instruction on behavioral chain analyses and problem-solving techniques. The second phase is focused on “knowing yourself.” Youth are asked to take a close look at their character and temperament in relation to their emotions and behaviors. In the third phase, youth learn to make better lifestyle choices including eating, sleeping, substance use, mental hygiene, and personal relationships and they learn to implement better coping mechanisms in their daily life. The effectiveness of emotion regulation training was examined in two randomized controlled trials in five mental health centers in the Netherlands (Schuppert et al., 2017). In the first study (Schuppert et al., 2009), adolescents with borderline personality traits were randomly assigned to emotion regulation training plus treatment as usual or to treatment as usual alone. Both groups showed equal reductions in borderline pathology symptoms over time. Treatment resulted in less severe borderline symptoms after 6 months, regardless of whether they received emotion regulation training or treatment as usual. In a large randomized controlled trial (Schuppert et al., 2012) conducted in general mental health institutes, the majority of adolescents (73%) fulfilled full borderline personality disorder criteria according to DSM-IV. At the end of the treatment, there were no significant differences between emotion regulation and treatment as usual on any of the measures. Both groups improved from baseline to post-intervention on all measures. However, at 6-month follow-up, 67% of youth still fell in the normative range of borderline personality symptomatology. Adolescents with a history of physical and/or sexual abuse reported less reduction of complaints. These studies suggest that recovery of borderline pathology symptoms might need a more intensive intervention. Emotion regulation training may be too fragmented, just touching the core symptoms (such as emotional dysregulation), and not being able to bring about more fundamental changes. The results of these randomized controlled trials suggest that Emotion

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Regulation Training is not the treatment of choice for young refugees and asylum seekers. Taken together the results of studies evaluating the effectiveness of interventions for personality pathology in adolescents, presumably the best candidate for treatment of young refugees and asylum seekers, including unaccompanied minors, is dialectical behavior therapy. There is considerable evidence that psychological interventions addressing common mental disorders, including post-traumatic stress disorder, depression, and anxiety, can be applied by well-trained and supervised lay workers (Ryan et al., 2021). However, treatment for personality pathology provided by lay or specialized providers must be feasible in the local context and is more realistic in Western countries where refugees and asylum seekers live than in situations where no such services have been available historically.

9.13 Personality Disorder and Substance Abuse There is considerable evidence that personality disorders, especially borderline personality disorder, are often associated with alcohol and drug abuse (e.g., Emmelkamp & Meyerbröker, 2020; Köck & Walter, 2018; Tomko et al., 2014), but prevalence studies have been conducted in Western cultures only. Generally, patients with borderline personality disorder and comorbid substance use disorder have more severe psychopathology and more social problems than patients with either substance use disorder without comorbid borderline personality disorder or borderline personality disorder without comorbid substance use disorder (Heath et al., 2018). Research with respect to the impact of comorbid borderline personality disorder and substance abuse on treatment outcome has not yet led to clear clinical guidelines. Effectiveness of treatments of patients suffering from substance abuse disorder with comorbid personality disorder is worse than that of patients with substance abuse disorder without personality disorder (Emmelkamp & Vedel, 2006).

9.14 Psychosis Migrants are on average two times more likely to develop a psychotic disorder than the native population, and refugees and asylum seekers are even three times more likely to be diagnosed with psychotic disorder than the native population in the host country (Hollander et al., 2016; Katsampa et al., 2021; Selten et al., 2020). The risk of psychotic disorder among people who migrate prior to age 18 is twice as high as the native-born population (Anderson & Edwards, 2020) and is even higher in young refugees (Liu & Chowdhary, 2020). Young males who came as refugee child to Denmark had higher rates of psychotic disorders compared with Danish-born children (Barghadouch et al., 2018). Another study in Denmark revealed that unaccompanied minors had significantly higher rates of psychotic disorders than accompanied minors (Norredam et al., 2018). In Italy, a substantial increase is observed

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among young male asylum seekers who have to be hospitalized for a psychotic disorder (Aragona et al., 2020). In a 22-year longitudinal cohort study including all refugees in Denmark, the length of asylum-decision waiting periods was associated with refugees’ risk of being diagnosed with a psychiatric disorder. Resettled asylum seekers from Afghanistan, Iraq, Syria, and Somalia had an increased risk of developing a psychotic disorder during the first 3  years of stay in the host country (Hvidtfeldt et al., 2020). Experienced discrimination and social exclusion may be associated with increased rates of psychotic experiences in refugees and asylum seekers (Henssler et al., 2020). A substantial number of asylum seekers and refugees are exposed to multiple stressors and violations before, during, and after their flight, but they are often not screened for psychotic disorders and if they receive mental health treatment it is often substandard compared to patients from the host country.

9.14.1 Differential Diagnosis Assessment of psychosis in refugees and asylum seekers is often easier said than done because it may be difficult to determine whether psychotic symptoms in this group of patients relate to a primary psychotic disorder or to post-traumatic stress disorder (Waterman et al., 2020). There is some clinical consensus that individuals with post-traumatic stress disorder may have secondary psychotic features, which can be understood as part of the post-traumatic stress disorder (Braakman et  al., 2009). For example, individuals may hear voices as part of a flashback to past traumatic events. Psychotic features do not emerge in isolation from traumatic stress symptoms (Frost et al., 2019), which may be relevant for recognition of psychosis symptoms as part of the broader clinical picture among trauma-exposed refugees and asylum seekers (Waterman et al., 2020). Auditory hallucinations are common among refugee people, and the frequency and the content of auditory hallucinations vary across cultures (Laroi et al., 2014; Luhrmann et al., 2015). Auditory hallucinations, however, are not only occurring in the context of psychosis, but also often associated with severe trauma (Hardy, 2017; McCarthy-Jones & Longden, 2015; Laroi et al., 2019; Luhrmann et al., 2019). Nygaard et al. (2017) investigated the prevalence of psychotic features in a clinical population of trauma-affected refugees with post-traumatic stress disorder. Results revealed that 41% of refugees with post-traumatic stress disorder suffered from secondary psychotic features. In another study (Rathke et al., 2020), the prevalence of post-traumatic stress disorder with psychotic features was 30%. Among these, 44% fulfilled the criteria for Enduring Personality Change After Catastrophic Experience. A few asylum-seeking children fell into a stuporous condition (von Knorring & Hultcrantz, 2020; Kozlowska et al., 2021), in severe cases being unable to give any response at all, unable to react to pain, or unable to stand on their feet. All these children had either experienced violence themselves or witnessed or heard about

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violence against close family members. Also, here is the clinical question whether this should be regarded as a variant of catatonia or a severe form of dissociation in the context of post-traumatic stress disorder. Another issue is the heightened incidence of psychogenic non-epileptic seizures in refugee populations (Hallab & Sen, 2021), especially among female refugees with a history of sexual violence (Kizilhan et al., 2020), but this is primarily associated with dissociation and post-traumatic stress disorder rather than with psychosis. There is a clear need of further studies into psychotic symptoms in refugees with post-traumatic stress disorder, given the difficulty for clinicians to distinguish between symptoms like flashbacks, auditory hallucinations, psychotic symptoms, and dissociative symptoms. A better understanding of this symptomatology may lead to better diagnosis of refugees, which may eventually lead to enhanced treatment options (Nygaard et  al., 2017). Further, it is important to consider cultural idioms of distress when assessing “psychotic experiences” in patients from different ethnic and cultural backgrounds (see Chap. 4). The cultural formulation interview described in DSM-5 may be useful in this regard.

9.14.2 Young People A few studies have addressed how a lack of cultural adaptation to services can act as a barrier for (parents of) children and adolescents to accessing mental health care or engaging in treatment for schizophrenia or psychosis, but these studies did not include refugees (Coelho et al., 2022). Poor access of mental health care was attributed to lack of trust in care professionals, social stigma related to severe mental illness, and cultural factors. In focus-group studies, adolescents with ethnic diverse background reported that lack of care-seeking was affected by the idea that the symptoms were due to spiritual or religious causes (Cadge et al., 2019; Islam et al., 2015). There were, however, some differences related to ethnic background: Indian adolescents were inclined to perceive upbringing as a causal factor in the development of psychosis, while Pakistani adolescents were more inclined to perceive possession by a spirit as a cause (Cadge et al., 2019). In the study of Islam et  al. (2015), ethnic minority adolescents reported that help-seeking involved support from spiritual healers, before seeking medical treatment. Finally, unaccompanied minors may have a biased perception of mental health and mental health professionals, which may prevent adequate mental health care (Demazure et al. (2022). Although early intervention for psychosis programs has taken into account cultural assessment and adaptation of therapies for psychosis (e.g., Habib et al., 2015), there is still a gap related to engaging and meeting the needs of patients and their parents/caregivers from racial-ethnic and cultural minority groups, including refugees. A large survey on providers of early intervention in young people with psychosis in Australia, Canada, Chile, the United Kingdom, and the United States revealed low levels of implementation of a variety of assessment and support practices related to cultural diversity, particularly among groups

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with non-Western explanatory frameworks (Jones et  al., 2021). Assessment of childhood adversity and cultural formulation was present in only a minority of programs. Practitioners had serious concerns with respect to the impacts of disadvantage and cultural differences of young people with early psychosis and their families.

9.15 Prevention of Mental Disorders According to the United Kingdom National Institute for Health and Care Excellence (NICE) guidelines, there is some evidence that early intervention services and intensive case management for psychosis, and a few pharmacological and psychological interventions for psychosis, may prevent crises (e.g., Drake & Bond, 2021; Johnson et al., 2022), but this has not yet been studied among refugees and asylum seekers. Given that in the general population nearly half of the mental disorders start before the age of 18, a number of studies have investigated the value of prevention strategies in young people. These primary prevention strategies may target subgroups of individuals at higher than average of developing mental disorders (Fusar-­Poli et al., 2020a, 2021). Of special interest for young refugees and asylum seekers is the Clinical High Risk for Psychosis paradigm (Fusar-Poli, 2017). This prevention strategy is directed to adolescents and young adults (usually 14–35 years) who are characterized by an increased number of risk factors for psychosis often associated with infrequent mild symptoms of psychosis. According to Gonzalo et al. (2021), young people who fulfill the criteria for the Clinical High Risk for Psychosis paradigm have a 25% increased risk of developing psychosis in the coming years. Clinical services based on the Clinical High Risk for Psychosis paradigm can be focusing on a number of social variables associated with enhanced psychosis risk, including ethnic related factors, poverty, social deprivation, exposure to traumatic events (including migration), and physical violence or emotional abuse (Estradé et  al., 2022). There is considerable evidence that psychoeducation through outreach campaigns in the general population is particularly effective to improve mental health literacy (Salazar de Pablo et al., 2020, 2021) and may help to change negative stereotypical beliefs about people with mental disorders enabling reduction of stigma. In addition, interventions typically employed by the Clinical High Risk for Psychosis paradigm services are directed at cognitive and social skills, improving family and other social relationships, and at scholastic and occupational performance (Salazar de Pablo et al., 2020). Further, improving physical health is of high importance in early psychosis (Carney et al., 2018; Coates et al., 2019; Teasdale et al., 2019). This is addressed in Clinical High Risk for Psychosis paradigm services by focusing on interventions to improve healthy eating and sleeping habits and interventions to enhance physical activity. Improving physical health is an evidence-­based approach to reduce the risk of not only depressive disorder but psychotic and bipolar disorders as well (Firth et al., 2020).

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9.16 Concluding Remarks Surprisingly few studies have investigated psychological interventions with refugees and asylum seekers with substance abuse, personality disorder, or severe mental illness. There is a clear need of focusing future research on screening and interventions for these disorders among refugees and asylum seekers, especially in high-income countries. In addition, future research should specifically refine the Clinical High Risk for Psychosis paradigm services to customize effective mental health prevention approaches to refugee and asylum-seeker populations (Salazar de Pablo et  al., 2021). Although no studies have been published specifically focusing on refugees and asylum seekers, there is considerable evidence that this approach may also be effective in areas with a high proportion of adolescents and young adults from Asian, Black, and other ethnic minority groups (e.g., Fusar-Poli et al., 2020b; Kwon et al., 2012; McFarlane et al., 2012; Ventura et al., 2021). The programs developed information materials directed to youth culture, which were adapted for service delivery to ethnically and culturally diverse populations (e.g., Fusar-Poli et  al., 2020b). Of course, further development of the Clinical High Risk for Psychosis paradigm services should be rooted in evidence, but it should be acknowledged that practical and ethical challenges in recruiting refugees and asylum seekers who are at risk of developing a psychosis will hamper research in this area. In the United Kingdom, there is some evidence that crisis centers in the community may be an interesting alternative to standard clinical approaches (Johnson et al., 2022). These services provide an informal “walk-in” assessment and immediate support for individuals experiencing a mental health crisis. This support is often delivered by volunteers who often have relevant clinical experience, including peer support workers with lived experience of mental health problems (Gillard et  al., 2017). The potential of such services for refugees and asylum seekers is clear, but research is needed to evaluate the usefulness and effectiveness. Finally, further research is needed into the role of social stressors and adverse social circumstances with which refugees and asylum seekers have to deal in the host country. Internationally well-supported comprehensive programs to reduce adversity, stigma, and inequality are also of high importance in crisis prevention.

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