This article is the second part of a two-part series. The first article, Refugee Youth Traumatized by War: Overwhelmed, Understudied, examined research on the mental health of traumatized youth.
Psychologists and researchers have developed evidence-based treatments to help those who are trying to improve the mental health of traumatized young refugees.
But a shortage of mental-health professionals working with refugees makes these methods difficult to roll out.
There are a number of practical things that volunteers, government workers and those at non-governmental organizations can do. The most immediate step is to stabilize the child’s environment by establishing safety and basic routines, research has found. Comprehensive treatment is, of course, the ultimate goal, but experts say it is important not to rush the process, because some patients need time to gain the strength to relive their experiences during therapy. Some psychologists also stress the need for trained individuals to carry out treatment, limiting the number of ways that a general volunteer can help.
A treatment that works for displaced populations has to meet multiple conditions. “It has to be universal and work for all,” says Elisabeth Schauer-Kaiser, a psychotraumologist at the University of Konstanz, in Germany. “It has to be able to be done in the field without a hospital or complex medical equipment,” she continues. “You have to be able to sit under a tree with the patient and do it. It has to be easily scaled up and it has to be cost effective.”
The established best practice is to take an incremental approach, says Ken Curl, a senior mental health program analyst at the Substance Abuse and Mental Health Services Administration, an agency within the U.S. Department of Health and Human Services.
“You have to be careful and not delve into treatment too quickly; instead you must first stabilize things,” he explains. “For some children it might take a very long time and so you have to assess individually.” To this, Curl says bringing routine back into a child’s life can work wonders and says attending school is especially effective. So at this stage, ensuring children have access to lessons in camps and host countries is important.
“Once there’s a sense of stability and security, we can get on with the process without fear it’s going to have an adverse effect,” he says. “It’s not nice to remember the things these children have experienced.”
After making children feel safe, the next stage is to assess them and find out if they’re likely to be suffering from a mental-health problem such as post-traumatic stress disorder or depression.
Ideally, well-trained professionals would carry out this screening process, but the short supply of specialists makes this nearly impossible. Fadi Maalouf, a child psychiatrist at the American University of Beirut, says that general volunteers can help in screenings by handing out surveys and collating the data, if they have some basic training.
Then those children who are flagged during the screenings need to be treated. “Our experience is that the children get better faster when the underlying problems are identified and dealt with,” says Curl.
Experts emphasize that mental-health problems can’t be ignored.
“Many people say there’s no point dwelling on the past and say instead they should look to the future,” says Frank Neuner, a psychotherapist at Bielefeld University, in Germany, who has studied and treated young people suffering from violence-related trauma in Uganda. “But those suffering can’t do that because they haven’t processed their past.”
In one study, Neuner and a team of other psychotherapists went to refugee camps in Uganda, where they pioneered a treatment called Narrative Exposure Therapy during four to six sessions with six Somali youth between the ages of 12 and 17 who suffered from post-traumatic stress and depression. Their symptoms were measured before treatment began, immediately after and then nine months later.
During this treatment the patient, with the help of a therapist, recalls their life from their earliest memory through to the present day, paying particular attention to the negative experiences of war. The first session is often distressing for the child, but it gets easier as the process unfolds, and research has shown that the therapy works.
Neuner’s results showed that the treatment significantly decreased symptoms, a finding that has subsequently been replicated in follow-up studies.
“NET is evidence-based,” says Maalouf. He adds that there are other therapies such as trauma-focused Cognitive Behavior Therapy, in which therapists challenge a patient’s harmful and negative thinking and try to replace it with more realistic and effective thinking. “Sessions help the child to make sense of their traumatic experience,” he explains.
Testimony therapy, in which a patient and therapist produce a written record of what happened, is also backed up by research. For some patients, the act of creating something physical like a testimony is less daunting than talking to a psychiatrist, says Neuner.
In a few cases, drugs can be helpful, but that’s rarely the advised course of action for minors. “While there is some evidence that drugs like antidepressants can help, it’s extremely limited for children. In fact there is hardly any evidence that it is effective in children. It may even increase suicide risk in adolescents,” warns Neuner.
All experts interviewed for this article stressed that to determine which therapy is best, each patient needs to be considered as an individual. “But most of the evidence out there is for Cognitive Behavior Therapy and Narrative Exposure Therapy,” says Maalouf.
Psychiatrists disagree about who is able to provide therapy. Some psychiatrists say that a medical professional should carry out any serious treatment. Others say a general volunteer with fairly limited training can serve as an effective therapist.
Verena Ertl, a psychotherapist at Bielefeld University who has collaborated with Neuner, says one of the biggest selling points of Narrative Exposure Therapy is that almost anyone can do it with a relatively small amount of training. Although she cautions that “the therapist has to be a reliable person because the patient needs a stable point of contact.”
Maalouf disagrees, and says the therapy must be done by a thoroughly trained professional. “It is a form of psychotherapy and includes probing for thoughts and feelings and discussing stories that may be very distressing. I don’t see that it can be safely implemented by a layperson with no mental-health background,” he says.
Some Narrative Exposure Therapy training programs exist for psychologists in the Arab region, notably the “Back to Life” program conducted by the Danish Institute Against Torture and the Noor Al Hussein Foundation’s Institute for Family Health in Jordan.
The National Child Traumatic Stress Network advises in its manual that therapists begin their Cognitive Behavior Therapy training with an online course before an intensive in-person series of lessons. It is not something that can be swiftly learned and applied, the network says.
Still, at a certain point those trying to serve refugees have to face up to the realities of caring for a large population of displaced children, Maalouf acknowledges, and one of those realities is a lack of fully qualified psychiatrists. Even Lebanon only has four child psychiatrists, he says.
“We don’t want to make it sound like anyone can treat these kids, but we also need to respond to the lack of mental-health professionals,” he says. “General volunteers could learn some stress-management techniques, which have been shown to prevent anxiety—but it doesn’t deal with ADHD or PTSD.”
Overall, the best way to help young refugees suffering from mental health problems, experts agree, is to improve their access to therapists who can treat them.