“Same Same or Adapted?” Therapists’ Feedback on the Implementation of Trauma-Focused Cognitive Behavioral Therapy With Unaccompanied Young Refugees

Unaccompanied refugee minors (URMs) constitute a vulnerable population, firstly due to their various traumatic experiences before, during and after their flight (Reed et al., 2012; Steel et al., 2017), and secondly in terms of severe post-migration stressors (Keles et al., 2018) on their arrival in the host country. It comes as no surprise that the prevalence rates of trauma- and stress-related mental health conditions are higher among URMs compared to youth without a migration background, immigrant samples (Betancourt et al., 2017) or accompanied refugee minors (Bean et al., 2007). A recent meta-analysis on mental illness among refugee minors revealed that 23% report posttraumatic stress disorder (PTSD) (Blackmore et al., 2020).

Current treatment guidelines for treating trauma-related disorders, especially PTSD, recommend trauma-focused cognitive behavioral approaches (International Society for Traumatic Stress Studies [ISTSS], 2019; Rosner et al., 2019) for traumatized children and adolescents. In this context, trauma-focused cognitive behavioral therapy (TF-CBT, e.g. the specific manual by Cohen et al., 2017) has been identified as a gold standard treatment for children and adolescents with PTSD across guidelines and meta-analyses (Gutermann et al., 2016). Experts claim, however, that yet child trauma guidelines focus too little on children’s cultural background and possible adaptations (Alisic et al., 2020).

Most evidence-based treatments for PTSD were developed in western societies. They were then increasingly widely implemented and found to be effective in samples with cultures outside of western societies (Ennis et al., 2020). Only a very small number of interventions have been specifically developed and tailored to the needs of URMs, for example the trauma-focused group intervention “Mein Weg” (English “My Way”) (Pfeiffer et al., 2018), which is based on TF-CBT but re-modeled into a group-based low-level intervention for refugees in child welfare programs. The development of this intervention adopted a theory-driven approach for cultural adaptation (Heim & Kohrt, 2019). The theory-driven changes focused mostly on delivery in a group format (e.g. additional group discussions), the language barrier (e.g. changes in materials) and the inclusion of flight and migration specific content (flight route as part of narrative). More commonly, evidence-based trauma-focused treatments are adapted to cultural characteristics of study populations in a data-driven, so-called “bottom-up” approach. These approaches are especially favorable if the question is whether there is a good fit between the evidence-based treatment itself and the new target group, and whether cultural adaptations are necessary to some or all aspects of that specific therapy.

A recent review (Ennis et al., 2020) systematically reviewed research articles on cultural adaptations in trauma-focused CBT approaches with children and adults. The results highlight the complexity of cross-cultural adaptations of psychotherapy due to several reasons such as heterogeneous sources of information (e.g. stakeholders, therapists or patients), the usage of different frameworks for cultural adaptations (if used at all) and different levels of efficacy evaluation. Seven out of the 17 included studies were on cultural adaptations in TF-CBT. They either implemented the treatment with immigrant samples in western countries (e.g. Schottelkorb et al., 2012) or delivered the treatment abroad in the cultural context of the country itself (DRC: McMullen et al., 2013; Jordan: Damra et al., 2014; Zambia: Murray et al., 2013; Tanzania: O’Donnell et al., 2014). One study involved local therapists (Murray et al., 2013) as main source of information for assessing potentially necessary changes to the treatment protocol during treatment delivery, while others used focus groups, surveys, or expert panels ahead of treatment implementation. The most often used source in the studies described in the review by Ennis et al. (2020), which focused on data-driven approaches, were (local) therapists as they might function as a direct mediator between high adherence in the implementation of the manual on the one hand and the individual needs of their patients on the other hand.

There are only two studies on cultural adaptations to the TF-CBT protocol delivered to refugee minors (Schottelkorb et al., 2012; Unterhitzenberger et al., 2019). The refugee population might throw up specific challenges as it represents a heterogeneous population that originates from different countries and cultures. Consequently, this makes an oftentimes preferred “one size fits all” approach even more challenging. The authors of both studies gave only a brief description of marginal changes to the protocol (e.g. translation when needed, tailored psychoeducation, more sessions on trauma narrative). This leaves a gap in the literature on the need for cultural adaptations in TF-CBT for this vulnerable cohort. Especially so-called “on the fly” adaptations of experienced therapists (Heim & Kohrt, 2019) might be crucial to increasing understanding of necessary adaptations to evidence-based trauma-focused treatments such as TF-CBT for URMs.

In our recent pilot study (Unterhitzenberger et al., 2019) on TF-CBT with URMs, we implemented the TF-CBT protocol without prior theory-driven adaptations. The aim was to evaluate the feasibility of TF-CBT for this specific target group. Therapists were instructed to provide the treatment according to the manual, however, also to implement and document any “on the fly” adaptations they made in order to successfully treat the refugee patient. The present study, which was part this pilot study (Unterhitzenberger et al., 2019), aims to increase knowledge on how to adapt TF-CBT to the specific needs of URMs by examining therapists’ self-reported cultural adaptations in implementing TF-CBT with URMs in a qualitative study design.

Method

This study is part of a recently published pilot study conducted in Germany between March 2015 and July 2017. For details on the procedure please refer to the main publication (Unterhitzenberger et al., 2019). The participants treated in this pilot study were 26 male URMs (M_age = 17.1; SD = 1.0; range 15-19) who had been in Germany for an average of 9.8 months (SD = 3.9) and who originated from eight different countries in the Middle East and Africa. 22 of them completed treatment. Uncontrolled effect sizes were high for PTSD symptoms at post (d = 1.08) and follow-up assessments (d = 1.23).

Results

Discussion

This is the first study to investigate “on the fly” adaptations by practitioners implementing TF-CBT with an especially vulnerable and diverse population. As one of the first studies, we present qualitative findings from therapists’ adaptations during TF-CBT, which is a valuable addition to the research field. The overall results suggest that the implementation of TF-CBT is feasible without a tremendous amount of adaptation. In line with other studies on cultural adaptations to trauma-focused treatments, therapists also made changes in the conceptualization of the trauma’s effects such as spiritual approaches (Ennis et al., 2020), and tailored materials and language (e.g. usage of metaphors) to the target group.

The additional content or techniques described were mostly TF-CBT components. Consequently, therapists had to repeat some components in later sessions (like psychoeducation before starting the trauma narrative) or brought components forward that were supposed to be carried out later (like affective modulation in the first session to enable some self-efficacy in dealing with PTSD symptoms). This is an approach that is typical for TF-CBT, which is meant to be flexible in the use of its components (Cohen et al., 2017). It is not surprising that dealing with the ‘crisis of the week’ was the content added most often. In addition to their trauma history, URMs have to deal with daily stressors and post-migration stressors (Keles et al., 2018) such as an unsecure asylum status, discrimination, or language and cultural barriers in the acculturation process. Therefore, we recommend that enhanced problem management related to post-migration stressors should be added as an additional component in TF-CBT (‘crisis of the week’) for this population.

There were reports of obstacles related to TF-CBT in only one third of cases. Language was named as the only problem in treatment, the other responses referred to components of little help for the respective treatment case. Relaxation was named most often. We recommend, however, to retain this content as part of the treatment as it is considered to be an important part of stabilization ahead of the trauma confrontation and suitable for use across different cultures.

The cultural adaptations named by the therapists were rather diverse. Looking at the data, we can see that most adaptations named were techniques that we would use irregularly throughout treatment, like the meaning of pride, strength or respect that can be included in the cognitive work, trauma narrative or future safety. The use of pride or respect and culture-specific grief rituals could be discussed in the TF-CBT training in order to enable therapists to deliver culturally sensitive treatment for URMs. This specific content might not be necessary for all URMs in treatment though, which means that therapists need to evaluate the inclusion of such culture-specific rituals and concepts for each individual patient independently. Therapists need to be trained to maintain a balance between cultural considerations and an overestimation of cultural aspects as this might lower manual adherence. In addition, suitable metaphors should be provided for different modules.

Even though trauma confrontation with asylum seekers is discussed in a controversial manner in the literature (ter Heide et al., 2016), the therapists named the trauma narrative as the most helpful component for their patients. The factor named most helpful for therapists was “having an agenda” which is not a TF-CBT component, but a characteristic of manualized CBT approaches. The agenda for every session seems especially helpful when the “crisis of the week” is a very dominant part of the treatment sessions.

There are several limitations which might limit the generalizability of the findings. Unfortunately, Question 3 about cultural adaptations was phrased as a closed, two-stepped question (“Did you consider cultural factors in this treatment case? If so, which ones?”). This might have forced a “yes” or “no” answer and might therefore have biased the results. Furthermore, we were not able to calculate interrater reliability scores for the coding of categories. In addition, there was a lack of objective ratings (e.g. independent raters of videos from treatment sessions). Lastly, we did not assess the therapists’ cultural competence or prior experience in transcultural work. Therefore, we cannot rule out that the level of cultural knowledge influenced the actual cultural adaptations.