Asylum seekers often suffer from high levels of mental distress. However, as a result of a lack of knowledge about mental health and health care, as well as cultural and language barriers, the utilization of mental health care in Western host countries is often difficult for these individuals. Reducing these barriers may thus be a crucial first step towards appropriate mental health care. Previous research showed that psychoeducation may be helpful in this regard.
The current manuscript describes a short, low-threshold and transdiagnostic intervention named ‘Tea Garden (TG)’. The TG aims to increase specific knowledge about mental health problems and available treatments, and may improve psychological resilience and self-care. In this manuscript, we specifically focus on culturally sensitive facets, following the framework proposed by Heim and colleagues (2021, https://doi.org/10.32872/cpe.6351), and lessons learned from three independent pilot evaluations (Ns = 31; 61; 20).
The TG was found to be feasible and quantitative results showed that it was helpful for male and female asylum seekers from different countries of origin (e.g., Afghanistan, Syria, Pakistan, Iraq) and with different educational levels. Interestingly, even asylum seekers who had already been in Germany or Austria for three or more years benefited from the TG.
The TG specifically aims to be culture-sensitive rather than culture-specific, to be transdiagnostic rather than focused on specific mental disorders, and to be suitable for asylum seekers who are still in the insecure process of applying for asylum. It may also be helpful for distressed asylum seekers who do not fulfill the criteria for a mental disorder, and for healthy asylum seekers who could use the knowledge gained in the TG to help others.
There is a lack of short, low-threshold, and culture-sensitive interventions for asylum seekers. A transdiagnostic intervention, named ‘Tea Garden’ (TG), is described and findings of pilot evaluations are reported. The TG aims to increase knowledge about mental health (care), and improve resilience and self-care. The TG was found to be helpful for refugees from different origins and with different educational levels.
The prevalence of mental disorders in refugees and asylum seekers
Systematic reviews have revealed that psychoeducation improves specific knowledge about mental disorders (e.g., about possible causes, typical symptoms of a disorder, factors influencing the symptoms) and psychosocial functioning, including coping with symptoms, and reduces distress for people suffering from mental disorders (
Our main aim (I) in this paper is to describe the TG with a specific focus on culturally sensitive facets, following the framework proposed by
The TG was developed as part of the project ‘Psychotherapeutic first aid for asylum seekers living in Hesse’ funded by the European Refugee Fund, EFF-12-775 (
The developing team comprised members from different countries of origin and different cultural backgrounds (e.g., Persian, Arabic, Kurdish, Turkish), some of them with a refugee background, psychotherapists working with asylum seekers, and researchers in the field of intercultural psychology.
The target group for the TG consists of asylum seekers who have recently arrived in a host country (e.g., max. 18 months), are still in the process of applying for asylum, and may suddenly be transferred to other cities or Federal states during their asylum procedure. Participants may be mentally distressed or suffer from a mental disorder, but this is not mandatory for participation. The TG is transdiagnostic and may even be helpful for healthy asylum seekers who could use the knowledge gained in the TG to help others.
With the aid of interpreters, the TG is provided in a group format to provide help to several asylum seekers simultaneously. The TG consists of four modules (A-D): Module A) establishing trust and confidence; Module B) symptoms of mental disorders; Module C) resources and self-care, and Module D) treatment options. These modules are interactively presented in two 90-minute sessions delivered one week apart in groups of approximately six participants (detailed information can be found in the German manual,
A group setting is applied to enhance social support and mutual exchange, and to take into account the mainly collectivistic background of the main groups of asylum seekers (in Western host countries) as well as shared pre-, peri-, and postmigration experiences (
Tea and food are offered to promote a relaxing and welcoming atmosphere. In addition, the TG uses images/ illustrations, symbols (e.g., rope, flowers, stones, spinning top) and familiar metaphors in order to facilitate communication and to adapt to different educational levels. Its material is free of written language or complicated figures, and operates best in gender- and language-homogenous groups of five to seven participants.
Based on a literature review and our own work (
In order to consider relevant
In line with trials offering psychoeducation interventions for persons with serious mental illnesses (e.g.,
For the three pilot studies reported below, a questionnaire developed by our work group was used (
Three independent pilot evaluations were conducted with a focus on acceptance, feasibility, first hints of possible effectiveness, as well as lessons learned (mainly based on anecdotal reports of the researchers, and the therapists who conducted the TGs, and written and verbal feedback of participants). Two pilot evaluations were conducted in Germany (
To facilitate recruitment, potential participants needed to be educated in detail about the program, and it was necessary to establish trust, be patient, and build a network of contact persons.
The outcome assessment was too complex and unfamiliar for some participants, and was simplified by only using smileys.
Some participants erroneously expected to learn about asylum procedures. Therefore, flyers and invitations should be phrased very clearly and highlight the content of the TG.
Even asylum seekers with longer durations of stay (e.g. three years and more) appreciated the TG.
The illustrations used in the TG were complemented by new illustrations in order to enhance the variety of shown human appearances and the fit for different groups of asylum seekers.
The larger the size of the group the more likely conflicts between participants may emerge. We thus suggest to limit the number of participants to eight.
In contrast to other interventions, the TG specifically aims to be culture-sensitive rather than culture-specific, to be transdiagnostic rather than focusing on specific mental disorders, and to be suitable for asylum seekers who are still in the insecure process of applying for asylum. The three independent pilot evaluations demonstrated the feasibility of the TG and its acceptance with regard to different countries of origin, spoken languages, educational levels, and durations of stay in the host countries. Moreover, they provided us with important lessons for the future recruitment of potential participants, appropriate designs for the outcome assessment, the materials used, and the recommended group size. In general, our findings suggest that the TG may be a useful first step to improve mental health care for asylum seekers. However, the generalizability and explanatory power of the presented results is limited by the single-group designs, and the lack of pre-post comparisons as well as follow-up assessments that would provide information about the sustainability of possible benefits. These limitations will now be tackled by the multicenter randomized controlled trial ‘Efficacy of Low-threshold, Culturally Sensitive Group Psychoeducation in Asylum Seekers’ (LoPe; DRKS00020564), where the participants will be randomized to either the TG or a waitlist control group and changes in knowledge will be assessed pre- and postintervention as well as two and six months later.
Following the example of other projects that successfully used brief psychological interventions to reduce the treatment gap for common mental disorders in affected groups, such as the Friendship Bench project in Zimbabwe (
Parts of this study were funded by the European Refugee Fund (EFF-12-775). The LoPe study is funded by the German Ministry of Education and Research (01EF1804B).
Cornelia Weise is one of the Editors-in-Chief of
We thank Mag.a Vesna Maric Medjugorac (Caritas Vienna) for supporting the pilot evaluation 3.
'An asylum seeker' is defined as a person who is seeking international protection and whose claim for asylum has not yet been finalized. If protection is granted according to the 1951 Refugee Convention, the person is recognized as a 'refugee'. Accordingly, all refugees were initially asylum seekers. Many of the studies cited investigated both asylum seekers and refugees. Because of the current study's focus, we primarily use the term 'asylum seekers' and speak of refugees only if they are specifically addressed.
The Supplementary Materials contain suggestions for the measures of the aims two and three of the Tea Garden and more detailed information about findings from the first evaluations of the Tea Garden and lessons learned (incl. two Tables) (for access see