Teaching Recovery Techniques: evaluation of a group intervention for unaccompanied refugee minors with symptoms of PTSD in Sweden

In 2015, nearly 90,000 refugee children arrived in Europe without their families [1]. Sweden alone received over 35,000 (40%) of these children, followed by Germany (16%). A substantial majority of these children were males (91%), mainly aged between 16 and 17 (57%). About half (51%) were Afghans.

Unaccompanied refugee minors (URM) are the most vulnerable of all immigrant and refugee groups [2]. Many of them have experienced multiple traumas including exposure to armed conflict, displacement, loss of close relationships, loss of security, eyewitnessing violence, as well as experiencing personal violence such as physical aggression, torture, and rape [3, 4]. The asylum-seeking process with the related feelings of uncertainty about the future is an additional stressor with further mental health implications [5]. Therefore, it is not surprising that trauma-related problems such as posttraumatic stress disorder (PTSD), anxiety and depression are particularly common among URMs. For instance, a recent study in Norway and Belgium [6] showed that 53% of URMs reported high levels of PTSD symptoms which did not change over an 18-month period [7]. Another study in Norway, that followed up URMs who had received residence, indicated that even several years after resettlement, more than 40% of them continued to show high levels of PTSD symptoms [8]. Thus, PTSD seems to be both prevalent and persistent in asylum seeking children [9].

There are several theoretical frameworks with accompanying empirical studies that can be used to understand how people exposed to severe negative events can cope, enhance positive outcomes and avoid negative ones [10]. Within a resilience and mental health model, good or adaptive outcomes can include both higher levels of positive psychological and social outcomes, such as pro-social behaviour or school results, and lower levels of mental health symptoms [11]. Important factors that affect mental health outcomes are found on all levels of social context, i.e. individual, family, peer and community level. These factors or processes can be generally grouped into protective and promotive, but are not universal and vary within the sociocultural context and over time [12]. Nevertheless, it seems that interpersonal and sociocultural factors, such as parental support and monitoring, as well as community acceptance, affect outcomes more than static factors, such as parental education or school retention per se. Silove’s theory of adaptation and development after trauma is another important theory which emphasises the importance of safety, attachment, justice, identity-role, and existential meaning [13]. Importantly, Silove distinguishes between the “survival risk group” with severe impairment and the much larger “adaptive risk group”, where mental health problems, mainly PTSD, imply ongoing, but not specialised mental health service needs [14]. This latter group is or should be the focus of mental health initiatives for post-conflict societies or subgroups of migrants who arrive in host societies after armed conflict.

Finally, Antonovsky’s Sense of Coherence theory has been very useful in developing the science around coping and resilience in the face of extremely adverse events. The theory’s three dimensions have been found relevant in a wide range of sociocultural settings. On the intrapersonal level, the dimensions of meaningfulness, comprehensibility and manageability seem central to people’s ability to cope and adapt after trauma [15]. Hence, there is a need for interventions that can address the needs of the “adaptive risk group” on the community level, while taking into account our knowledge of the importance of inter- and intrapersonal promotive and protective factors. In addition, we need knowledge about the specific techniques that might be used to teach people the necessary skills for symptom reduction.

According to the NICE guidelines [16] children who suffer from posttraumatic stress symptoms should primarily be offered trauma-focused cognitive behavioural therapy (TF-CBT), adjusted to suit their age, circumstances, and level of development. However, studies that support the effectiveness of TF-CBT have mainly been conducted on sexually abused children [16, 17, 18] with studies on refuge children being scarce, especially considering the large number of affected children [19, 20]. In Sweden, the prevailing model of PTSD is long-term individual therapy which is costly and unfortunately not accessible timely or equally. At the beginning of this study, the waiting time for therapy at Red Cross Centres for trauma victims was 6–12 months in the region. Similar waiting times were reported by Child and Adolescent Psychiatry units around the country, many of whom refusing to treat children and youth while in the asylum process, due to lack of stability, claimed necessary for successful PTSD treatment. Ironically, instability is the very hallmark of many of these children’s existence. From a public health point of view, it is simply not acceptable that large groups in society suffer from mental health problems that have long-term consequences for their health and well-being, without being offered adequate and timely support.

Teaching Recovery Techniques (TRT) [21] is a manualised intervention based on TF-CBT, developed by the Children and War Foundation in Norway. It was explicitly built to meet the needs of low-resource settings where large numbers of children needed intervention. TF-CBT includes both stress-management skills that help children to better process their trauma-related emotions and thoughts, as well as gradual exposure to traumatic experiences that assist children to gain mastery over trauma reminders. TF-CBT intervention has some common components [22, 23]. Psychoeducation about PTSD symptoms helps to normalise children’s reactions to traumatic experiences. Parenting skills give parents the necessary tools to ensure a positive parent–child relationship. Relaxation skills such as controlled breathing help children alleviate the stress-related physiological changes. Affective modulation skills such as positive self-talk and positive imagery encourage children to express and regulate their feelings and emotions. Cognitive coping and processing, i.e. recognising the interrelation between thoughts, feelings, and behaviours and offering ways to change inaccurate and unhelpful thoughts promote better affective regulation. Trauma narrative helps children to correct their cognitive distortions about these experiences, and reduces their negative impact. In vivo mastery of trauma reminders helps children to overcome their avoidance behaviour. Conjoint child–parent sessions help facilitating parent child communications about children’s traumatic experiences and addressing other family issues. Finally, enhancing future safety and development prevents future trauma and helps children return to a normal developmental trajectory. The blend and dosage of components used in each TF-CBT intervention varies depending on the target population and type of trauma.

TRT is a group intervention based on the principles of TF-CBT that includes five sessions for young people and two for their caregivers/guardians. The sessions for children incorporate the following components of TF-CBT: psychoeducation, relation skills, affective modulation skills, cognitive coping and processing, trauma narrative, in vivo mastery of trauma reminders and enhancing future safety and development. Therefore, TRT enables normalisation of reactions to trauma, offers children emotional support, and provides them with strategies to cope with intrusive thoughts and memories, regulate their arousal, and expose themselves to avoided thoughts and situations. These strategies and techniques are modelled and practiced during the sessions. The two sessions for caregivers are held without the children. Caregivers are provided with psychoeducation about traumas and receive information about what children learn during their sessions and how caregivers can help youth to cope with past and ongoing traumas. It is hypothesised that by learning and using the coping strategies presented in TRT, children are able to assume control over their minds and bodies and therefore experience a reduction in their PTSD and depression symptoms. Normalisation is assumed to relieve children from shame and fear, whereas the safe environment provided by caring adults is geared to rebuild youth’s trust in the adult world and provide social support. The intervention can be provided by staff without previous therapeutic experience, but requires a 3-day structured training program where group leaders learn how to use the manual.

TRT has been tested in a number of settings. High acceptability and large-to-moderate effect sizes were reported for posttraumatic stress measures, depression and grief in Palestine and Gaza [24, 25] and in Thailand after the tsunami [26]. Another study in Gaza reported a modest reduction in PTSD symptoms and no change in depression [27]. The authors argued that the modest effects might be due to the imminent threat of war and the high level of ongoing stress. A study in the UK on refugee youth demonstrated short-term effects, that were not maintained at the follow-up [28]. Implementation problems, high rates of dropout at follow-up, as well as instability were reported as possible explanations for the long-term null findings in this study. In sum, there is some evidence to support the usefulness of TRT in youths with PTSD symptoms, but studies in the Scandinavian context and on the target group of URMs are needed.

The current study aimed to [1] evaluate the effectiveness of TRT in reducing the symptoms of PTSD and depression in URMs when offered in a community setting in Sweden; and [2] examine participants’ experiences of the program based on theories of posttraumatic adaptation.

Significant differences between pre- and post-measures on depressive and PTSD symptoms were seen. The analyses of reliable clinical change showed that 33% of the participants recovered based on depression symptoms and 22% recovered based on PTSD symptoms. These findings occurred despite 62% of participants experiencing negative life events during the six weeks of the program, and being in the middle of their asylum-seeking process. The qualitative interviews resulted in six overall categories: social support, normalisation, valuable tools, comprehensibility, manageability, and meaningfulness.

Our results are in accordance with the program theory of TRT, where sharing experiences in a safe and supportive environment and learning tools for coping, including trauma-specific exposure and behavioural activation, are expected to increase youth’s sense of coherence and decrease symptom burden of depression and PTSD. Specifically, we found through our qualitative interviews that the TRT program components enabled normalisation of reactions to trauma (normalisation), offered participants emotional support (social support), provided them with strategies to cope with intrusive thoughts and memories (valuable tools), regulate their arousal (manageability), and expose themselves to avoided thoughts and situations (manageability). In addition, Antonovsky’s dimensions of meaningfulness and comprehensibility clearly appeared in the narratives of youth during the interviews. In terms of Silove’s theory of adaptation and development after trauma, our participants belonged to the “adaptive risk group” where mental health problems, mainly PTSD and depression meant they needed help, even though they seemed to function to a certain extent in their everyday lives [14].

Posttraumatic stress symptoms significantly decreased from pre- to post-assessment which is in line with previous research investigating the effects of TRT [36] and other TF-CBT programs [37] in traumatised children. As we did not have a control group, we conducted analyses comparing the natural remission seen in previous publications to the observed outcomes in this study. Even when assuming double the natural remission rate calculated for a 6-week period observed in previous studies, our results show a significant likelihood of the program having an effect compared to natural remission. Our results are also in accordance with those reported by Berkowitz et al. [38] on an individual intervention for children with risk of developing PTSD, the Child and Family Traumatic Stress Intervention. This intervention is very similar to TRT, but allows greater individual adjustment and has more additional specific focus on depressive symptoms and withdrawal. Even without a focus on depressive symptoms and although not the primary target of TRT, symptoms of depression significantly decreased from pre- to post-assessment. This is also in line with previous research on TRT after the Athens earthquake [36]. Reasons why TRT might have had a positive effect on depressive symptoms include strategies, such as the “safe inner place” (arousal control) technique, and tools, such as set time for thoughts/concerns, that might have promoted youth to break the vicious cycle of negative thoughts and feelings and being out of control. In addition, getting involved in more activities and activating support networks by talking to trusted people when feeling sad might also have contributed to less depressive symptoms. Some youth reported better sleep as a consequence of relaxation techniques, and better sleep can clearly contribute to symptom improvement in depression. Finally, the presence of meaningfulness described by several participants might have contributed to improved depressive symptoms: meaningfulness is the very contradiction of the feeling of everything being meaningless, at the core of depression. The qualitative interviews confirmed the program theory regarding the use of the group setting as a safe environment to normalise experiences and contribute to meaning creation in addition to behavioural activation components.

Our subgroup analyses indicate that suicidal ideation at baseline markedly increased the odds for symptom reduction. This is all the more interesting as we had an initial ethical discussion whether we should include youth with such serious symptom burden in this light-touch intervention. The reason we decided to do so was twofold. There was no other viable option for help, given waiting times of 6–12 months to regular services that not even always took on youth during the asylum process, referring to the instability of their situation. The other reason was the advice of our international advisory board, namely that a structured program with established safety protocols and a supportive climate, although conducted by personnel outside child psychiatry services, had potential benefits, widely offsetting potential risks, given the current situation. Although we did not find empirical support in the qualitative interviews for the categories of safety and identity creation stemming from Silove’s theory, it is quite plausible that creating social support through the groups addressed needs related to the category of safety/security. Indeed, Silove recommends social and family support as a means to provide safety and security to the group who shows an adaptive response, albeit with symptoms. Similarly, Silove proposes terminating isolation, skills development, and offering counselling as a means to enhance role identity. Thus, our findings of reduction in both depressive and PTSD symptoms are well in line with the program theory of TRT and what we know about factors that affect posttraumatic adaptation and growth from other theories.

Yet, although caution in interpreting results from this observational study is required, the reduction of PTSD symptoms is remarkable considering the context in which the youths were living. First, they were enduring an ongoing asylum process; the majority of them had been in Sweden since 2015 and still did not know whether they would be granted asylum. Second, more than half of the children (62%) had been exposed to new stressful life events during the time of the intervention, something which probably added to their mental health burden. Additionally, parental support has in previous studies been shown to mitigate the consequences of trauma [9], but for unaccompanied refugee minors no parental support was available (many had no contact at all with their parents) and we do not know to what extent they were supported by caring adults to handle their new stressful experiences. For trauma-focused CBT to have optimal effect, regular practicing and homework completion are required. Although inclusion criteria said that an adult would have to participate in the parallel sessions, the youths did not turn out to have adequate and regular support in practicing the strategies included in the program.

Significant differences between pre- and post-measures on depressive and PTSD symptoms were seen, despite 62% of participants experiencing negative life events during the program, and being in the middle of their asylum process. The qualitative interviews resulted in six overall categories: social support, normalisation, valuable tools, comprehensibility, manageability, and meaningfulness. Our results are in accordance with the program theory of TRT, where sharing experiences in a safe and supportive environment and learning tools for coping, including trauma-specific exposure and behavioural activation, are expected to increase youth’s sense of coherence and decrease symptom burden of depression and PTSD. Overall, results indicate that TRT is a promising indicated preventive intervention for URMs with PTSD symptoms. Nevertheless, this is not to say that TRT should be the treatment of choice for URM with PTSD symptoms, depression and suicidal ideation or plans. What it may be, is the first stage in a stepped care model.