School-based Psychosocial Interventions' Effectiveness in Strengthening Refugee and Migrant Adolescents' Mental Health, Resilience, and Social Relations: A Four-country Cluster Randomized Study.

School-based psychosocial interventions are increasingly put forward as a way to support young refugees' and migrants' well-being and mental health in resettlement. However, the evidence on these interventions' effectiveness remains scarce and scholars denounce particular gaps in the evidence to date, pointing to a lack of large-scale, controlled studies and studies including social outcome measures. This cluster randomized study aims to strengthen the evidence base on school-based psychosocial interventions for refugee and migrant youth by assessing the effect of two interventions, Classroom Drama and Welcome to School, on youth's mental health, resilience, and social relations in Belgium, Denmark, Norway, and the United Kingdom. Multilevel analyses were conducted separately for the two interventions (Classroom Drama, n = 307, ages 11-19; Welcome to School, n = 251, ages 11-23), using separate no-treatment control groups. Our analyses indicated a significant main, positive effect of Classroom Drama on perceived family support, and an effect on perceived support from friends that was moderated by country: in the United Kingdom, the intervention group reported an increase in perceived friend support, whereas the control group reported a decrease. Furthermore, baseline resilience moderated the effect of the Classroom Drama intervention on behavioral difficulties and well-being. No effects of Welcome to School on any of the outcome variables were found. Overall, this study provides novel, nuanced evidence on school-based psychosocial interventions for refugee and migrant adolescents.

Cada vez se proponen más las intervenciones psicosociales centradas en la escuela como ayuda al bienestar de jóvenes refugiados y migrantes en su realojamiento. No obstante hay pocas pruebas sobre la eficacia de tales intervenciones y los expertos denuncian fallas en dichas pruebas hasta el momento debido a la falta de estudios controlados a gran escala que incluyan medidas de los resultados sociales. El presente estudio de grupos aleatorizados pretende potenciar la base de pruebas sobre intervenciones psicosociales centradas en la escuela con jóvenes refugiados y migrantes analizando el efecto de dos intervenciones, "El drama en el aula" y "Bienvenido al colegio", en la salud mental, la resiliencia y las relaciones sociales de los jóvenes en Bélgica, Dinamarca, Noruega y el Reino Unido. Se efectuaron análisis multinivel por separado para las dos intervenciones ("El drama en el aula", n = 307, edad entre 11 y 19 años; "Bienvenido al colegio", n = 251, edad entre 11 y 23 años) con grupos de control sin tratamiento separados. Los análisis mostraron un efecto positivo principal significativo de "El drama en el aula" en el apoyo familiar percibido y un efecto en el apoyo percibido de los amigos moderado por el país: en el Reino Unido el grupo de intervención presentó un aumento del apoyo percibido de los amigos, mientras que en el grupo control disminuyó. Además la resiliencia básica moderaba el efecto de la intervención de "El drama en el aula" en las dificultades conductuales y en el bienestar. No se apreció efecto de "Bienvenido al colegio" en ninguna de las variables resultado. En términos generales el estudio supone un inédito y detallado aval de las intervenciones psicosociales centradas en la escuela en el caso de adolescentes refugiados y migrantes.

School-based Psychosocial Interventions’ Effectiveness in Strengthening Refugee and Migrant Adolescents’ Mental Health, Resilience, and Social Relations: A Four-country Cluster Randomized Study / [La eficacia de las intervenciones psicosociales centradas en la escuela para potenciar la salud mental, la resiliencia y las relaciones sociales de adolescentes refugiados y migrantes: un estudio de grupos aleatorizados en cuatro países]

School-based psychosocial interventions are increasingly put forward as a way to support young refugees’ and migrants’ well-being and mental health in resettlement. However, the evidence on these interventions’ effectiveness remains scarce and scholars denounce particular gaps in the evidence to date, pointing to a lack of large-scale, controlled studies and studies including social outcome measures. This cluster randomized study aims to strengthen the evidence base on school-based psychosocial interventions for refugee and migrant youth by assessing the effect of two interventions, Classroom Drama and Welcome to School, on youth’s mental health, resilience, and social relations in Belgium, Denmark, Norway, and the United Kingdom. Multilevel analyses were conducted separately for the two interventions (Classroom Drama, n = 307, ages 11-19; Welcome to School, n = 251, ages 11-23), using separate no-treatment control groups. Our analyses indicated a significant main, positive effect of Classroom Drama on perceived family support, and an effect on perceived support from friends that was moderated by country: in the United Kingdom, the intervention group reported an increase in perceived friend support, whereas the control group reported a decrease. Furthermore, baseline resilience moderated the effect of the Classroom Drama intervention on behavioral difficulties and well-being. No effects of Welcome to School on any of the outcome variables were found. Overall, this study provides novel, nuanced evidence on school-based psychosocial interventions for refugee and migrant adolescents.(AU)

Cada vez se proponen más las intervenciones psicosociales centradas en la escuela como ayuda al bienestar de jóvenes refugiados y migrantes en su realojamiento. No obstante hay pocas pruebas sobre la eficacia de tales intervenciones y los expertos denuncian fallas en dichas pruebas hasta el momento debido a la falta de estudios controlados a gran escala que incluyan medidas de los resultados sociales. El presente estudio de grupos aleatorizados pretende potenciar la base de pruebas sobre intervenciones psicosociales centradas en la escuela con jóvenes refugiados y migrantes analizando el efecto de dos intervenciones, “El drama en el aula” y “Bienvenido al colegio”, en la salud mental, la resiliencia y las relaciones sociales de los jóvenes en Bélgica, Dinamarca, Noruega y el Reino Unido. Se efectuaron análisis multinivel por separado para las dos intervenciones (“El drama en el aula”, n = 307, edad entre 11 y 19 años; “Bienvenido al colegio”, n = 251, edad entre 11 y 23 años) con grupos de control sin tratamiento separados. Los análisis mostraron un efecto positivo principal significativo de “El drama en el aula” en el apoyo familiar percibido y un efecto en el apoyo percibido de los amigos moderado por el país: en el Reino Unido el grupo de intervención presentó un aumento del apoyo percibido de los amigos, mientras que en el grupo control disminuyó. Además la resiliencia básica moderaba el efecto de la intervención de “El drama en el aula” en las dificultades conductuales y en el bienestar. No se apreció efecto de “Bienvenido al colegio” en ninguna de las variables resultado. En términos generales el estudio supone un inédito y detallado aval de las intervenciones psicosociales centradas en la escuela en el caso de adolescentes refugiados y migrantes.(AU)

Convergence in a multi-method study between Rorschach and self-report data of traumatized refugees assessed before and after psychotherapy.

Rorschach and self-report instruments represent methodologically different types of assessment, which together may yield incremental information about the test-taker. There is little evidence on whether and when results from these methods converge. OBJECTIVE: To examine possible convergences between Rorschach trauma-related personality variables and self-reported variables. METHOD: Before and after psychotherapy 22 traumatized adult refugee patients were assessed with the Rorschach Performance Assessment System (R-PAS), symptom checklists of posttraumatic stress, anxiety and depression, and a quality of life questionnaire. Correlational analyses between eight R-PAS variables and 10 self-reported variables were performed. RESULTS: The findings showed inconsistent and nonsignificant correlations pretherapy. Posttherapy, however, all R-PAS variables except Complexity correlated positively with symptoms of mental disorder, and negatively with the quality of life variables, as predicted. The R-PAS variables Mutuality of Autonomy-Pathology, Poor Human Representation, Critical Content, and Form Quality-minus%, converged significantly with most of the self-reported variables, with medium to large correlations. CONCLUSION: The finding of convergence only after psychotherapy, may tentatively suggest greater self-knowledge and internal consistency through the therapy experience, and increased trust and self-disclosure through the repeated meetings with the researchers. The findings represent a promising contribution to a cumulative validation process of convergence between Rorschach and self-report data.

Predictors of the 10 year course of mental health and quality of life for trauma-affected refugees after psychological treatment.

Background: Trauma-affected refugee patients benefit from psychological treatment to different degrees. Only a handful of studies has investigated potential predictors of treatment outcome that could throw light on the great variability in outcomes reported for this group. Such knowledge may be vital to better tailor prevention and treatment efforts to the needs of different individuals and subgroups among these patients. Objective: In a naturalistic and longitudinal study, the aim was to analyse demographics and traumatic exposure as potential predictors of the participants' long-term trajectories of mental health symptoms and quality of life. Method: A group of 54 multi-origin adult refugee patients with complex traumatic exposure, such as armed conflicts, persecution, torture, and childhood adversities, were interviewed face to face over up to 10 years; at therapy admittance, and at varying points in time during and after psychotherapy. Checklists of war-related and childhood trauma, mental health symptoms, and quality of life were included in the interviews. In linear mixed effects analyses, interaction was analysed with potential predictors included separately because of the sample size. Time was modelled as continuous from inclusion into the study. Results: Gender predicted the course of symptoms of post-traumatic stress, anxiety, and depression, and of quality of life in physical health and social relationships. Childhood family violence and experiences of torture predicted the course of depression, whereas the extent of exposure to war-related trauma events and having experienced torture predicted the course of anxiety. Conclusions: The results indicated greater chronicity in male refugees, in refugees who had experienced domestic violence during childhood, in refugees who had experienced torture, and in refugees with more numerous types of potentially traumatic war-related experiences. The findings highlight the need for gender-sensitive research, rehabilitative efforts, and treatment. HIGHLIGHTS In a 10 year longitudinal and naturalistic therapy follow-up study of traumatized refugees, female gender, childhood trauma, war trauma, and torture predicted mental health and quality of life outcomes.Male participants responded less than females to therapy.

Antecedentes: Los pacientes refugiados afectados por el trauma se benefician del tratamiento psicológico en diferentes grados. Sólo un puñado de estudios han investigado los posibles predictores del resultado del tratamiento que podrían arrojar luz sobre la gran variabilidad de los resultados registrados en este grupo. Este conocimiento puede ser vital para adaptar mejor los esfuerzos de prevención y tratamiento a las necesidades de los diferentes individuos y subgrupos de estos pacientes.Objetivo: En un estudio naturalista y longitudinal, el objetivo fue analizar los datos demográficos y la exposición traumática como posibles predictores de las trayectorias a largo plazo de los síntomas de salud mental y la calidad de vida de los participantes.Método: Un grupo de 54 pacientes adultos refugiados de múltiples orígenes con exposición traumática compleja, como conflictos armados, persecución, tortura y adversidades en la infancia, fueron entrevistados cara a cara durante un período de hasta 10 años; al ingreso en la terapia, y en diferentes momentos durante y después de la psicoterapia. En las entrevistas se incluyeron listas de comprobación de traumas relacionados con la guerra y la infancia, síntomas de salud mental y calidad de vida. En los análisis lineales de efectos mixtos, se analizó la interacción con los posibles predictores incluidos por separado debido al tamaño de la muestra. El tiempo se modeló como continuo desde la inclusión en el estudio.Resultados: El género predijo la evolución de los síntomas de estrés postraumático, ansiedad y depresión, y de la calidad de vida en cuanto a salud física y relaciones sociales. La violencia familiar en la infancia y las experiencias de tortura predijeron el curso de la depresión, mientras que el grado de exposición a eventos traumáticos relacionados con la guerra y el haber experimentado la tortura predijeron el curso de la ansiedad.Conclusiones: Los resultados indicaron una mayor cronicidad en los refugiados varones, en los refugiados que habían sufrido violencia doméstica durante la infancia, en los refugiados que habían sufrido tortura y en los refugiados con más tipos de experiencias potencialmente traumáticas relacionadas con la guerra. Los resultados ponen de manifiesto la necesidad de realizar investigaciones, esfuerzos de rehabilitación y tratamientos que tengan en cuenta el género.

Mental Health of Refugee and Non-refugee Migrant Young People in European Secondary Education: The Role of Family Separation, Daily Material Stress and Perceived Discrimination in Resettlement.

While scholarly literature indicates that both refugee and non-refugee migrant young people display increased levels of psychosocial vulnerability, studies comparing the mental health of the two groups remain scarce. This study aims to further the existing evidence by examining refugee and non-refugee migrants' mental health, in relation to their migration history and resettlement conditions. The mental health of 883 refugee and 483 non-refugee migrants (mean age 15.41, range 11-24, 45.9% girls, average length of stay in the host country 3.75 years) in five European countries was studied in their relation to family separation, daily material stress and perceived discrimination in resettlement. All participants reported high levels of post-traumatic stress symptoms. Family separation predicted post-trauma and internalizing behavioral difficulties only in refugees. Daily material stress related to lower levels of overall well-being in all participants, and higher levels of internalizing and externalizing behavioral difficulties in refugees. Perceived discrimination was associated with increased levels of mental health problems for refugees and non-refugee migrants. The relationship between perceived discrimination and post-traumatic stress symptoms in non-refugee migrants, together with the high levels of post-traumatic stress symptoms in this subsample, raises important questions on the nature of trauma exposure in non-refugee migrants, as well as the ways in which experiences of discrimination may interact with other traumatic stressors in predicting mental health.

Traumatized Refugees in Psychotherapy: Long-Term Changes in Personality, Mental Health, Well-Being, and Exile Life Functioning.

ABSTRACT: This pre- and posttreatment study of 22 severely traumatized adult refugees spanned a mean of 6.5 years. Changes in personality functioning, mental health, and well-being were examined using the Rorschach Performance Assessment System, Harvard Trauma Questionnaire, Hopkins Symptom Checklist-25, and the World Health Organization's Quality of Life-BREF questionnaire. A paired samples t-test revealed significant improvement after psychotherapy in traumatic ideation and initial severe disruptions in thought processes, reality testing, perception, self and other representations, and relational capacity (Cohen's d = 0.46-0.59). Symptoms of anxiety, depression, and posttraumatic stress were significantly reduced (d = 0.54-0.84), quality of life in the physical health and psychological health domains increased significantly (d = 0.87 and 0.97), and percentage of participants with exile language proficiency and work/study status increased significantly. The findings demonstrate the potential of psychotherapy to contribute to normalizing perceptual, cognitive, and relational capacities in severely traumatized refugees, paramount to well-being and functioning in exile.

The 10-year course of mental health, quality of life, and exile life functioning in traumatized refugees from treatment start.

Refugee patients with severe traumatic experiences may need mental health treatment, but treatment results vary, and there is scarcity of studies demonstrating refugees' long-term health and well-being after treatment. In a 10-year naturalistic and longitudinal study, 54 multi-origin traumatized adult refugee patients, with a background of war and persecution, and with a mean stay in Norway of 10.5 years, were recruited as they entered psychological treatment in mental health specialist services. The participants were interviewed face-to-face with multiple methods at admittance, and at varying points in time during and after psychotherapy. The aim was to study the participants' trajectories of symptoms of post-traumatic stress, anxiety and depression, four aspects of quality of life, and two aspects of exile life functioning. Linear mixed effects analyses included all symptoms and quality of life measures obtained at different times and intervals for the participants. Changes in exile life functioning was investigated by exact McNemar tests. Participants responded to the quantitative assessments up to eight times. Length of therapy varied, with a mean of 61.3 sessions (SD = 74.5). The participants improved significantly in symptoms, quality of life, and exile life functioning. Improvement in symptoms of posttraumatic stress, anxiety, and depression yielded small effect sizes (r = .05 to .13), while improvement in quality of psychological and physical health yielded medium effect sizes (r = .38 and .32). Thus, long-time improvement after psychological therapy in these severely traumatized and mostly chronified refugee patients, was more notable in quality of life and exile life functioning than in symptom reduction. The results imply that major symptom reduction may not be attainable, and may not be the most important indication of long-term improvement among refugees with long-standing trauma-related suffering. Other indications of beneficial effects should be applied as well.

Relationship of Pretreatment Rorschach Factors to Symptoms, Quality of Life, and Real-Life Functioning in a 3-Year Follow-Up of Traumatized Refugee Patients.

Response to mental health treatment varies highly among refugee patients. Research has not established which factors relate to differences in outcome. This study is a follow-up of Opaas and Hartmann's (2013) Rorschach Inkblot Method (RIM; Exner, 2003) pretreatment study of traumatized refugees, where 2 RIM principal components, Trauma Response and Reality Testing, were found descriptive of participants' trauma-related personality functioning. This study's aims were to examine relationships of the RIM components with measures of anxiety, depression, posttraumatic stress, quality of life (QOL), employment, and exile language skills throughout 3 years. We found that impaired Reality Testing was related to more mental health symptoms and poorer QOL; furthermore, individuals with adequate Reality Testing improved in posttraumatic stress symptoms the first year and retained their improvement. Individuals with impaired Reality Testing deteriorated the first year and improved only slightly the next 2 years. The results of this study imply that traumatized refugee patients with impaired Reality Testing might need specific treatment approaches. Research follow-up periods should be long enough to detect changes. The reality testing impairment revealed by the RIM, mainly perceptual in quality, might not be easily detected by diagnostic interviews and self-report.

Relationships of Childhood Adverse Experiences With Mental Health and Quality of Life at Treatment Start for Adult Refugees Traumatized by Pre-Flight Experiences of War and Human Rights Violations.

Adverse and potentially traumatic experiences (PTEs) in childhood were examined among 54 adult refugee patients with pre-flight PTEs of war and human rights violations (HRVs) and related to mental health and quality of life at treatment start. Extent of childhood PTEs was more strongly related to mental health and quality of life than the extent of war and HRV experiences. Childhood PTEs were significantly related to arousal and avoidance symptoms of posttraumatic stress disorder (PTSD) and to quality of life, whereas pre-flight war and HRV experiences were significantly related to reexperiencing symptoms of PTSD only. Within childhood adversities, experiences of family violence and external violence, but not of loss and illness, were significantly related to increased mental health symptoms and reduced quality of life. These results point to the importance of taking childhood adverse experiences into account in research and treatment planning for adult refugees with war and HRVs trauma.

Rorschach assessment of traumatized refugees: an exploratory factor analysis.

Fifty-one multitraumatized mental health patients with refugee backgrounds completed the Rorschach (Meyer & Viglione, 2008), Harvard Trauma Questionnaire, and Hopkins Symptom Checklist-25 (Mollica, McDonald, Massagli, & Silove, 2004), and the World Health Organization Quality of Life-BREF questionnaire (WHOQOL Group, 1998) before the start of treatment. The purpose was to gain more in-depth knowledge of an understudied patient group and to provide a prospective basis for later analyses of treatment outcome. Factor analysis of trauma-related Rorschach variables gave 2 components explaining 60% of the variance; the first was interpreted as trauma-related flooding versus constriction and the second as adequate versus impaired reality testing. Component 1 correlated positively with self-reported reexperiencing symptoms of posttraumatic stress (r = .32, p < .05). Component 2 correlated positively with self-reported quality of life in the physical, psychological, and social relationships domains (r = .34, .32, and .35, p < .05), and negatively with anxiety (r = -.33, p < .05). Each component also correlated significantly with resources like work experience, education, and language skills.