Trauma-focused therapy for refugees: meta-analytic findings.

High levels of trauma-related psychological distress have been documented among ethnically diverse refugees. As the number of refugees worldwide continues to grow, determining the efficacy of established methods of trauma-focused therapy for this population is crucial. This meta-analysis examined the results of randomized controlled trials of psychotherapeutic intervention for traumatized adult refugees. Comparisons of 13 trauma-focused therapies to control groups from 12 studies were included in the analysis. The aggregate effect size for the primary outcome, posttraumatic stress disorder (PTSD), was large in magnitude, Hedge's g = .91, p < .001, 95% CI [.56, 1.52]. The aggregate effect size for depression, assessed in 9 studies, was also large g = .63, p < .001, 95% CI [.35, .92]. We used metaregression to evaluate potential moderators of the PTSD effect size. Number of sessions significantly predicted magnitude of the effect size, and studies that utilized an active control group (e.g., supportive counseling) had significantly smaller effect size than those with a passive control group. There was no difference in outcome for studies where an interpreter was used to facilitate sessions and those where no interpreter was used. There also was no difference in outcome based on type of PTSD assessment. Results provide evidence in the efficacy of trauma-focused models for treating refugees, and also shed light on important areas for future research.

Association between parents' PTSD severity and children's psychological distress: a meta-analysis.

The authors conducted a meta-analysis of studies on the correlation between parents' PTSD symptom severity and children's psychological status. An extensive search of the literature yielded 550 studies that were screened for inclusion criteria (i.e., parent assessed for PTSD, child assessed for distress or behavioral problems, associations between parent PTSD and child status examined). Sixty-two studies were further reviewed, resulting in a final sample of 42 studies. Results yielded a moderate overall effect size r = .35. The authors compared effect sizes for studies where only the parent was exposed to a potentially traumatic event to studies where both parents and children were exposed. A series of moderators related to sample characteristics (sex of parent, type of traumatic event) and study methods (self-report vs. diagnostic interview, type of child assessment administered) were also evaluated. The only significant moderator was type of trauma; the effect size was larger for studies with parent-child dyads who were both exposed to interpersonal trauma (r = .46) than for combat veterans and their children (r = .27) and civilian parent-child dyads who were both exposed to war (r = .25). Results support the importance of considering the family context of trauma survivors and highlight areas for future research.

Unpacking gender-specific risk and protective factors for mental health status among Congolese refugees in Uganda.

Background: Research indicates refugees from the Democratic Republic of Congo (DRC), particularly females, have a higher incidence of mental health problems compared to the global norm for conflict-affected populations.Objective: This study aimed to unpack gender differences in the mental health of Congolese refugees by examining specific risk (trauma exposure, adaptation challenges, and discrimination) and protective factors (marital status, literacy, and social resources) in relation to posttraumatic stress symptoms (PTSS) and depression. Method: Utilizing systematic random sampling, we surveyed 667 adult refugees (370 females, 297 males) in the Kyaka II refugee settlement in Western Uganda. A multi-group path analysis was conducted, initially allowing for variance between genders and subsequently comparing a constrained model, where paths were set equal across groups.Results: The unconstrained model presented an excellent fit to the data. When paths were set to be equal across groups, the decline in model fit, confirmed by a chi-square difference test, indicated differences in the model for males and females. A series of Z-tests were used to compare individual paths. Experiencing discrimination was a stronger risk factor for depression among men, whereas a history of rape was more strongly associated with depression for females. Being literate and a member of a social group in the settlement were stronger protective factors for depression among men, whereas living with a partner and a felt sense of connection to their community was more important for women. Associations between risk and protective factors and PTSS were more similar across groups, only membership in a group was significantly moderated by gender; with group membership being more impactful for males.Conclusion: The results highlight similarities and differences in predictors of distress for male and female Congolese refugees and point to potential avenues for tailoring programming to be gender sensitive.

This research identified key differences in how specific traumatic experiences and social factors correlate with psychological distress for male and female Congolese refugees, underscoring the need for tailored support strategies.The study reveals that while discrimination is a stronger predictor of depression in men, experiences of rape are more closely linked to depression in women. Conversely, social factors like literacy and group membership offer more protection to men, whereas relationship status and community connection are more protective for women.The findings shed light on the importance of gender-sensitive mental health and psychosocial support interventions.

Refugee posttraumatic growth: A grounded theory study.

In response to the unprecedented refugee crisis around the world, a growing body of research has focused on psychological distress among individuals and families forced to flee their homelands. Less attention has been directed toward understanding resilience, adaptation, and growth among this population. This grounded theory study explored the posttraumatic growth experiences of Middle Eastern and Afghan refugees resettled in the United States. The principal researcher conducted 23 interviews with seven couples and 16 individuals aged 25 to 67 years, from Afghanistan, Iraq, Iran, and Syria. This study aimed to explore how refugees understand, process, overcome, and grow from the trauma and adversity they have experienced. Findings were used to delineate a model of the process through which refugees experience posttraumatic growth. The overarching theme of moving forward had five specific growth themes: increased awareness of context; tolerating uncertainty; spiritual/religious attunement; consideration of others; and integrating into society. Findings shed light on the complex process of growth and adaptation in the aftermath of war and forced migration. The model can serve as a tool for clinicians to facilitate more empowering posttraumatic narratives with refugee clients rooted in growth experiences.

Posttraumatic stress and depression among women in Kenya's informal settlements: risk and protective factors.

Background: Approximately 56% of Kenya´s population resides in informal settlements (UN-Habitat, 2016). Female residents experience a range of psychosocial stressors including chronic poverty and high rates of interpersonal violence. Despite evidence that this population has some of the worst physical health outcomes in the country (APHRC, 2014), few studies have evaluated their mental health status and its correlates. Objective: The purpose of this study was to identify risk and protective factors associated with mental health problems (posttraumatic stress & depression) among women living in informal settlements in Kenya. Hypothesized risk factors included economic stress, a history of experiencing childhood abuse and sexual violence, as well as partner-perpetrated psychological and physical abuse. Hypothesized protective factors were supportive relationships with family members and friends and having a sense community connection. Method: Local community health workers were trained to collect data via individual interviews using validated measures. Participants were recruited using systematic random sampling in two informal settlements in Nakuru County. We used path analysis to test the hypothesized model among a sample of 301 women. Results: The model had an excellent fit (χ2 = 13.391, df = 8, p =.099; GFI =.99; CFI =.99; RMSEA =.05) and explained 25% of the variance in PTSS and 28% of the variance in depression. All predictor variables except support from friends were statistically significant in the expected direction. Specifically, economic stress, childhood abuse, sexual violence, as well as physical and psychological abuse from one´s partner had significant positive associations with PTSS and depression. Having supportive family members and a sense of being part of the community had significant negative associations with symptoms. Conclusions: Results highlight the importance of addressing intimate partner and other forms of interpersonal violence in these settings and hold implications for tailoring interventions for this marginalized population.

Antecedentes: Aproximadamente, el 56 % de la población de Kenia vive en asentamientos informales (Naciones Unidas, 2015). Las mujeres que viven en estos asentamientos experimentan un amplio espectro de estresores psicosociales, incluyendo a la pobreza crónica y a altos niveles de violencia interpersonal. Pese a que existe evidencia respecto a que esta población tiene los peores indicadores de salud física (Centro de Investigación sobre la Población y Salud Africanas, 2012), son muy pocos los estudios que han evaluado el estado de su salud mental y factores relacionados.Objetivo: El objetivo de este estudio fue el de identificar factores protectores y de riesgo asociados a problemas de salud mental (estrés postraumático y depresión) en mujeres que viven en asentamientos informales en Kenia. Los factores de riesgo hipotéticos fueron el estrés económico, el antecedente de haber experimentado abuso infantil y violencia sexual, así como el haber experimentado abuso psicológico y físico por parte de la pareja. Los factores protectores hipotéticos fueron las relaciones interpersonales de soporte con familiares y amigos y el tener una sensación de conexión con la comunidad.Métodos: Se capacitó a los trabajadores de salud mental comunitaria locales en la recolección de datos a través de entrevistas individuales y el uso de escalas validadas. Se reclutó a las participantes mediante un muestreo por aleatorización sistemática realizado en dos asentamientos informales en el condado de Nakuru. Se realizaron análisis de ruta para evaluar el modelo hipotetizado en una muestra de 301 mujeres.Resultados: El modelo mostró un encaje excelente (χ2 = 13.391, df = 8, p = .099; GFI = .99; CFI = .99; RMSEA = .05) y explicó el 25 % de la varianza en los síntomas de estrés traumático (PTSS) y el 28 % de la varianza en los de depresión. Todas las variables predictivas, a excepción del soporte por parte de los amigos, resultaron ser estadísticamente significativas en la dirección esperada. De manera específica, el estrés económico, el abuso infantil, la violencia sexual y el abuso físico y psicológico por parte de la propia pareja mostraron asociaciones positivas significativas con los PTSS y de la depresión. El tener soporte por parte de los miembros de la familia y el tener un sentido de pertenencia a la comunidad mostraron asociaciones negativas significativas con los síntomas.Conclusiones: Los resultados enfatizan la importancia de abordar la violencia ejercida por la pareja y otras formas de violencia interpersonal en estos escenarios, además de tener implicancias para el diseño de intervenciones específicas para estas poblaciones excluidas.

The treatment of mental illness in faith-based and traditional healing centres in Ghana: perspectives of service users and healers.

BACKGROUND: The maltreatment of people with mental illness in Ghana's traditional and faith-based healing centres, including shackling, flogging, and forced fasting, has been documented by numerous sources. Such treatment is potentially traumatising and may exacerbate mental health problems. Despite widespread use, few studies have focused on experiences and characteristics of people who seek traditional healing for mental illness or healers' perspectives treatment of these conditions. METHOD: Purposeful sampling was used to recruit 82 individuals who were treated in healing centres and 40 traditional healers; all took part in semi-structured interviews. Those treated were asked about experiences in centres and assessed for prior trauma exposure, posttraumatic stress, and functional impairment. Healers were asked about beliefs and practices related to the treatment of mental illness. RESULTS: Individuals treated in centres and healers generally believed that mental illness has a spiritual cause. Approximately 30.5% of those treated in centres were exposed to maltreatment; despite this, half would return. Individuals with a history of trauma were more likely to report maltreatment in the centre and had higher symptoms of posttraumatic stress. Most participants had impaired functioning. Healers who used practices like shackling believed they were necessary. Most healers were willing to collaborate with the official health structure. CONCLUSION: Results provide insight into the treatment of mental illness by traditional healers in Ghana and the need for trauma-informed mental health services. Findings also highlight the importance of considering cultural beliefs when attempting to implement mental health interventions in the region.

Subjective reactions to international research participation: An illustration of ethical considerations with women heading households in Sri Lanka.

There are unique ethical considerations in conducting international research with war and disaster-affected populations that are important for ensuring adequate protection of participants. Of particular importance is the distress that participants may experience as a result of being asked about traumatic stressors, psychological symptoms, and life problems. In this study, trauma-affected Tamil women in Eastern Sri Lanka were asked to report on their research-participation experience after taking part in a larger study on risk and resiliency. Results indicated that most participants experienced emotional upset as a result of taking part in the study. However, the degree of distress was generally not more than they anticipated, and most participants reported they would have participated had they known in advance how they would feel. Most participants perceived some benefit as a result of participating and agreed that items were personally relevant. Emotional distress from participation positively correlated with culturally specific symptoms of anxiety and depression. Contextual stressors and social support were not associated with participation-related distress. We discuss these findings as well as general issues that might arise in international research with trauma-affected populations. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Toward understanding posttraumatic stress and depression among trauma-affected widows in Sri Lanka.

OBJECTIVE: In this study, we applied conservation of resources theory (Hobfoll, 1989) to explain high rates of depression and posttraumatic stress symptoms (PTSS) among war- and disaster-affected Tamil widows in the Eastern Province of Sri Lanka. We hypothesized exposure to potentially traumatic events and severity of current contextual problems would influence PTSS and depressive symptoms directly and indirectly through loss of psychological (view of self), environmental (sense of community), and energy (physical health) resources. METHOD: Trained research assistants interviewed a convenience sample (N = 381) of women, using established measures of the constructs of interest. Data were analyzed using path analysis in MPlus. The significance of the indirect effects was tested using bootstrapping. RESULTS: The model had an acceptable fit (χ2 = 4.06, df = 1, p < .05; Log Likelihood = -3344.26*; AIC = 6760.59; BIC = 6894.64; RMSEA = 0.09; CFI = .99; TLI = .91; SRMR = .02) and explained approximately 38% of the variance in both PTSS and depression. Contextual problems were significantly associated with PTSS and depression both directly and indirectly through deleterious effects on view of self, health status, and sense of community. Degree of trauma exposure was directly associated with indicators of distress. CONCLUSION: Results support the utility of COR theory in this context and hold implications for research and program development. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Relationship of differentiation of self to adult clients' perceptions of the alliance in brief family therapy.

The authors examined differentiation of self, a multidimensional construct in Murray Bowen's (1976, 1978) family systems theory, as a predictor of clients' perceptions of the therapeutic alliance. Adult clients (N=38) in brief family therapy completed the Differentiation of Self Inventory-Revised (Skowron & Schmitt, 2003) during prescreening and the self-report version of the System for Observing Family Therapy Alliances (Friedlander & Escudero, 2002) after Session 3. More differentiated adults reported significantly more positive overall alliances. In a canonical correlation analysis, four roots were extracted that together accounted for 56% of the shared variance. Interpretation of the single significant canonical root suggested that clients reporting less emotional reactivity were more likely to have strong feelings of safety in the family therapy context.

How do therapists enhance family alliances? Sequential analyses of therapist-client behavior in two contrasting cases.

To identify alliance-related behavior patterns in more and less successful family therapy, the authors intensively analyzed two cases with highly discrepant outcomes. Both families were seen by the same experienced clinician. Results showed that participants' perceptions of the alliance, session impact, and improvement at three points in time were congruent with the families' differential outcomes and with observer-related alliance behavior using the System for Observing Family Therapy Alliances. In this measure, therapist behaviors contribute to the alliance and client behaviors reveal the strength of the alliance on four dimensions: Engagement in the Therapeutic Process, Emotional Connection with the Therapist, Safety within the Therapeutic System, and Shared Sense of Purpose within the Family. In the poor outcome case, observer ratings and self-reported alliance scores revealed a persistently "split" alliance between family members; this family dropped out midtreatment. Only in the good outcome case did the clients follow the therapist's alliance-building interventions with positive alliance behaviors; sequential analyses showed that therapist contributions to Engagement significantly activated client Engagement behavior, and therapist Emotional Connection interventions significantly activated client Emotional Connection. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Stories of the Accused: A Phenomenological Inquiry of MFTs and Accusations of Unprofessional Conduct.

Interviews were conducted with 10 MFTs (six females and four males) who had received a formal accusation of unprofessional conduct and went before state licensure boards in three different states. Accusations included dual relationships, financial fraud/errors, receiving DUIs, sexual misconduct, and emotionally harming a client. Utilizing Moustakas' (1994, Phenomenological research methods, Thousand Oaks, CA: Sage) transcendental phenomenology, five essential themes emerged: (a) The experience of being formally accused of unprofessional conduct is life-changing, (b) state MFT licensing boards are more punitive than rehabilitative, (c) obtaining support is vital, (d) making accusations creates stigma, (e) therapists were unprepared to handle accusations of unprofessional conduct. Clinical implications include the importance of supervision, personal therapy, and strategies for prevention and rehabilitation with this population.

Veteran PTSS and spouse relationship quality: The importance of dyadic coping.

Research with combat veterans and their spouses has documented the harmful impact of posttraumatic stress symptoms (PTSS) on relationships, yet few studies have evaluated theoretically based models of relational processes among these couples. In this study, the authors tested 2 moderators of the association between male combat veterans' PTSS and their female spouses' reported relationship quality based on Bodenmann's (1997, 2005) systemic transactional theory of dyadic coping. We hypothesized that supportive dyadic coping and common dyadic coping would moderate the association of PTSS and spouses' relationship quality. Hypotheses were supported. The degree to which a veteran's PTSS was negatively associated with his spouse's relationship quality depended on whether she perceived him as supportive when she experiences stress (i.e., supportive dyadic coping) and the degree to which she perceived the couple as working together to manage difficulties (i.e., common dyadic coping). The significant interactions of PTSS with supportive and common dyadic coping accounted for 11.95% and 10.58% of the variance, respectively. Tests of conditional effects showed veterans' PTSS was only significantly negatively associated with spouses' relationship quality when supportive and common dyadic coping were low. Findings highlight the importance of adaptive dyadic coping behaviors as a protective factor for spouses of veterans and hold implications for research and practice.

The firefighter coping self-efficacy scale: measure development and validation.

The authors evaluated the psychometric properties of the Firefighter Coping Self-Efficacy (FFCSE) Scale, a new measure developed to assess firefighters' perceived competence in managing stressful and traumatic experiences encountered on the job. Two samples of firefighters completed the FFCSE Scale at two different time points. Exploratory factor analysis yielded a unidimensional structure, which was further supported with confirmatory factor analysis using a second sample. Internal consistency of the measure was excellent. Analysis of cross-sectional data indicated FFCSE was positively associated with measures of psychological well-being and social support, and negatively associated with work-related stress and psychological distress. FFCSE also uniquely contributed to the variance in psychological distress, over and above variables previously shown to be associated with distress among this population. Implications and suggestions for future research are discussed.

Problematic within-family alliances in conjoint family therapy: a close look at five cases.

We intensively analyzed five sessions in which the within-family alliance was manifestly problematic and family members reported discrepant perceptions of the family's sense of purpose about working together in therapy. Triangulation of observer ratings with (a) session content, (b) participants' post-session perceptions, (c) therapists' alliance-related interventions, and (d) clients' pretreatment target complaints and problem descriptions suggested three essential, interrelated aspects of the within-family alliance: family members (a) agreeing on the problem(s) and goals for treatment, (b) feeling connected in coping with their concerns ("a felt unity"), and (c) seeing conjoint therapy as valuable. Within-family disagreements on any of these aspects seemed to account for the observed in-session struggles. The analysis also suggested several missed opportunities for strengthening the within-family alliance.

Impact of posttraumatic stress disorder on the relationship quality and psychological distress of intimate partners: a meta-analytic review.

The authors conducted a meta-analysis of the literature on associations between trauma survivors' PTSD symptoms and the (a) relationship quality and (b) psychological distress of intimate partners. Results yielded a small combined effect size (r = -.24) for the association between PTSD and partners' perceived relationship quality. Gender and military status moderated this association with a larger effect size for female partners of male trauma survivors than for male partners of female trauma survivors and a larger effect size for military samples than for civilians. The effect size of the association between PTSD and partners' psychological distress was moderate in magnitude (r = .30). Analysis of hypothesized moderators indicated this association was stronger among military than civilian samples. The association was also stronger among samples of survivors who experienced traumatic events in the more distant past compared with those who experienced more recent events. Results support the systemic impact of one family member's PTSD symptoms and highlight areas for future research.