Cognitive behavioral psychotherapeutic treatment at a psychiatric trauma clinic for refugees: description and evaluation
Keywords:Refugee, trauma, CBT, PTSD, depression, psychotherapeutic treatment, mindfulness, acceptance, commitment
Introduction: Cognitive behavioural therapy (CBT) with trauma focus is the most evidence supported psychotherapeutic treatment of PTSD, but few CBT treatments for traumatized refugees have been described in detail.
Purpose: To describe and evaluate a manualized cognitive behavioral therapy for traumatized refugees incorporating exposure therapy, mindfulness and acceptance, and commitment therapy.
Material and methods: 85 patients received six months’ treatment at a Copenhagen Trauma Clinic for Refugees and completed self-ratings before and after treatment. The treatment administered to each patient was monitored in detail. The changes in mental state and the treatment components associated with change in state were analyzed statistically.
Results: Despite the low level of functioning and high co-morbidity of patients, 42% received highly structured CBT, which was positively associated with all treatment outcomes. The more methods used and the more time each method was used, the better the outcome. The majority of patients were able to make homework assignments and this was associated with better treatment outcome. Correlation analysis showed no association between severity of symptoms at baseline and the observed change.
Conclusion: The study suggests that CBT treatment incorporating mindfulness and acceptance and commitment therapy is promising for traumatized refugees and punctures the myth that this group of patients are unable to participate fully in structured CBT. However, treatment methods must be adapted to the special needs of refugees and trauma exposure should be further investigated.
2. Paunovic N, Ost LG. Cognitive-behavior therapy vs exposure therapy in the treatment of PTSD in refugees. Behav Res Ther. 2001 Oct;39(10):1183-97.
3. Basoglu M, Salcioglu E, Livanou M, Kalender D, Acar G. Single-session behavioral treatment of earthquake-related posttraumatic stress disorder: a randomized waiting list controlled trial. J Trauma Stress. 2005 Feb;18(1):1-11.
4. Hinton DE, Chhean D, Pich V, Safren SA, Hofmann SG, Pollack MH. A randomized controlled trial of cognitive-behavior therapy for Cambodian refugees with treatment-resistant PTSD and panic attacks: a cross-over design. J Trauma Stress. 2005 Dec;18(6):617-29.
5. Hinton DE, Pham T, Tran M, Safren SA, Otto MW, Pollack MH. CBT for Vietnamese refugees with treatment-resistant PTSD and panic attacks: a pilot study. J Trauma Stress. 2004 Oct;17(5):429-33.
6. Otto MW, Hinton D, Korbly NB, Chea A, Ba P, Gershuny BS, et al. Treatment of pharmacotherapy-refractory posttraumatic stress disorder among Cambodian refugees: a pilot study of combination treatment with cognitive-behavior therapy vs sertraline alone. Behav Res Ther. 2003 Nov;41(11):1271-6.
7. Neuner F, Kurreck S, Ruf M, Odenwald M, Elbert T, Schauer M. Can asylum-seekers with posttraumatic stress disorder be successfully treated? A randomized controlled pilot study. Cogn Behav Ther. 2010;39(2):81-91.
8. Neuner F, Onyut PL, Ertl V, Odenwald M, Schauer E, Elbert T. Treatment of posttraumatic stress disorder by trained lay counselors in an African refugee settlement: a randomized controlled trial. J Consult Clin Psychol. 2008 Aug;76(4):686-94.
9. Neuner F, Schauer M, Klaschik C, Karunakara U, Elbert T. A comparison of narrative exposure therapy, supportive counseling, and psychoeducation for treating posttraumatic stress disorder in an african refugee settlement. JConsult ClinPsychol. 2004;72(4):57987.
10. Bisson J, Andrew M. Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database Syst Rev. 2007 Jul 18;(3).
11. Buhmann CB, Mortensen, EL, Ryberg J, Nordentoft M, Ekstroem M. Follow-up study of the treatment outcomes at a psychiatric trauma clinic for refugees. Torture. 2015;25(1): pp.
12. Mollica RF, Caspi-Yavin Y, Bollini P, Truong T, Tor S, Lavelle J. The Harvard Trauma Questionnaire. Validating a cross-cultural instrument for measuring torture, trauma, and posttraumatic stress disorder in Indochinese refugees. J Nerv Ment Dis. 1992 Feb;180(2):111-6.
13. Mollica RF, Wyshak G, de Marneffe D, Khuon F, Lavelle J. Indochinese versions of the Hopkins Symptom Checklist-25: a screening instrument for the psychiatric care of refugees. Am J Psychiatry. 1987 Apr;144(4):497-500.
14. Oruc L, Kapetanovic A, Culhane M, Lavelle J, Miley K, Forstbauer S, et al. Screening for PTSD and depression in Bosnia and Herzegovina: validating the Harvard Trauma Questionnaire and the Hopkins Symptom Cheklist. Int J Culture Ment Health. 2008 Dec;1(2):105-116.
15. Kleijn WC, Hovens JE, Rodenburg JJ. Posttraumatic stress symptoms in refugees: assessments with the Harvard Trauma Questionnaire and the Hopkins symptom Checklist-25 in different languages. Psychol Rep. 2001 Apr;88(2):527-32.
16. WHO. Info package; mastering depression in primary care Frederiksborg, Denmark: World Health Organisation, Regional Office for Europe, Psychiatric Research Unit; 1998 [updated 1998]. Available from: http://www.who-5.org.
17. Sheehan KH, Sheehan DV. Assessing treatment effects in clinical trials with the discan metric of the Sheehan Disability Scale. Int Clin Psychopharmacol. 2008 Mar;23(2):70-83.
18. Lam RW, Michalak EE, Swinson RP. Assessment scales in depression, mania and anxiety. London: Taylor & Francis; 2005. p. 152-3.
19. Vallis TM, Shaw BF, Dobson KS. The Cognitive Therapy Scale: psychometric properties. J Consult Clin Psychol. 1986 Jun;54(3):381-5.
20. Simons AD, Padesky CA, Montemarano J, Lewis CC, Murakami J, Lamb K, et al. Training and dissemination of cognitive behavior therapy for depression in adults: a preliminary examination of therapist competence and client outcomes. J Consult Clin Psychol. 2010 Oct;78(5):751-6.
21. Shaw BF, Elkin I, Yamaguchi J, Olmsted M, Vallis TM, Dobson KS, et al. Therapist competence ratings in relation to clinical outcome in cognitive therapy of depression. J Consult Clin Psychol. 1999 Dec;67(6):837-46.
22. Valbak K. Suitability for psychoanalytic psychotherapy: a review. Acta Psychiatr Scand. 2004 Mar;109(3):164-78.
23. Valbak K, Rosenbaum B, Hougaard E. Suitability for psychoanalytic psychotherapy: validation of the Dynamic Assessment Interview (DAI). Acta Psychiatr Scand. 2004 Mar;109(3):179-86.
24. Kinzie JD. Psychotherapy for massively traumatized refugees: the therapist variable. Am J Psychother. 2001;55(4):475-90.
25. Kinzie JD. A cross-cultural treatment of PTSD. In: Wilson JP, Friedman M, Lindy JD, editors. Treating Psychological Trauma and PTSD. New York: The Guilford Press; 2001.
26. Foa EB, Hembree EA, Rothbaum BO. Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences, Therapist Guide. Oxford: Oxford University Press; 2007.
27. Pitman RK, Altman B, Greenwald E, Longpre RE, Macklin ML, Poire RE, et al. Psychiatric complications during flooding therapy for post-traumatic stress disorder. J Clin Psychiatry. 1991 Jan;52(1):17-20.
28. Drozdek B, Bolwek N. Evaluation of group therapy with traumatized asylum seekers and refugees - the Den Bosch Model. Traumatology. 2010 Dec;16(4):117-27.
29. Toneatto T, Nguyen L. Does mindfulness meditation improve anxiety and mood symptoms? A review of the controlled research. Can J Psychiatry. 2007 Apr;52(4):260-6.
30. Fjorback LO, Arendt M, Ornbøl E, Fink P, Walach H. Mindfulness-based stress reduction and mindfulness-based cognitive therapy: a systematic review of randomized controlled trials. Acta Psychiatr Scand. 2011 Aug;124(2):102-19.
How to Cite
We accept that some authors (e.g. government employees in some countries) are unable to transfer copyright. The Creative Commons Licence Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) covers both the Torture Journal and the IRCT web site. The publisher will not put any limitation on the personal freedom of the author to use material contained in the paper in other works which may be published, provided that acknowledgement is made to the original place of publication.