TORTURE Volume 25, Number 1, 2015 17 more time each method was used, the better used, more time each method was The majority were of patients the outcome. assignments and this able to make homework with better treatment associated was no Correlation analysis showed outcome. of symptoms at severity between association baseline and the observed change. CBT The study suggests that Conclusion: incorporatingtreatment mindfulness and acceptance and commitment therapy is refugees and promising for traumatized this group that of punctures the myth are unable to participatepatients fully in treatment However, structured CBT. methods must be adapted to the special needs of refugees and trauma exposure should be further investigated. PTSD, CBT, trauma, Refugee, Keywords: depression Introduction Introduction Although evidence-based interventions exist for PTSD in the general population, of PTSD among refugees is much treatment At the trauma clinic for less researched. confronted with are regularly we refugees, other issues of central importance to our somatoform such as depression, patients, pain and chronic psychosis, disorders, Cultural differences personality disorders. and western refugee populations between *) Competence Center for Transcultural Psychiatry Transcultural *) Competence Center for the Mental Health Psychiatric Center Ballerup, (CTP), Services of the Capital Region of Denmark of Copenhagen University **) Institute for Public Health, the Mental Health ***) Psychiatric Center Copenhagen, Services of the Capital Region of Denmark [email protected] Correspondence to: description and evaluation description Abstract behavioural Introduction: Cognitive most therapy (CBT) with trauma focus is the evidence supported psychotherapeutic few CBT treatments but of PTSD, treatment been described refugees have for traumatized in detail. a describe and evaluate To Purpose: therapy for behavioral manualized cognitive refugees incorporatingtraumatized exposure and mindfulness and acceptance therapy, commitment therapy. Material received and methods: 85 patients a Copenhagen at treatment six months’ completed Clinic for Refugees and Trauma The before and after treatment. self-ratings was administered to each patient treatment in mentalThe changes monitored in detail. components associated and the treatment state analyzed statistically. were with change in state of functioning level Results: Despite the low 42% and high co-morbidity of patients, which was highly structuredreceived CBT, with all treatment associated positively The more methods used and the outcomes. psychiatric trauma clinic for refugees: refugees: clinic for trauma psychiatric Mortensen, MSc**, Lykke MD, PhD*, Ida Andersen, MSc*, Erik Cæcilie Buhmann, MD, PhD* DrMSc***, Morten Ekstrøm, Nordentoft, Merete Jasmina Ryberg, MD*, psychotherapeutic treatment at a at treatment psychotherapeutic Cognitive behavioral behavioral Cognitive ARTICLE SCIENTIFIC 18 TORTURE Volume 25, Number 1, 2015 treatment ofCambodianrefugees. therapy hasbeensuccessfullyappliedinthe culturally adaptedcognitive-behavioural effective inthetreatment ofPTSD. stress managementandgroup TFCBT are desensitization andreprocessing(EMDR), ioural therapy(TFCBT), eye movement individual traumafocusedcognitive-behav- in thegeneralpopulation concludesthat forPTSD based psychotherapyinterventions Rwanda. used withrefugeesfromSudan, Somaliaand narrative exposuretherapy, whichhasbeen there seemstobesomesuccessintheuseof been foundinseveral studies. ioural therapyandexposurehave ly positive resultsofbothcognitive-behav- proaches seempromising. Firstly, significant- firmly supported. firmly iscurrently form ed that nointervention conclud- among refugeesandasylumseekers oftreatments forPTSD controlled trials treatment. tions aredesigned, complicate the further - populations forwhichmostPTSDinterven described. psychotherapy hasalsobeenevaluated and treatment theyreceived inadditionto indetailelsewhereandthe described treatments. The population inthisstudyis more effective thannon-traumafocused highlights that traumafocusedtreatments are choose parts ofthetreatment that can choose parts offered toother patient populations andto to compareourtreatment withtreatment of description, itwillbepossibleforreaders implementation. Because ofthedetailedlevel ing futuretreatment development and ofstimulat- methods usedwiththepurpose We have includeddetailedanalysisofthe nents were associated withbetteroutcomes. the treatment andtoanalyzewhichcompo- thepsychotherapycomponentof describe A systematic reviewofrandomized

7-9 12 A Cochranereviewofevidence- The aimsofthisstudyareto 1 However, several ap- 2,3 Secondly, 4-6 10 Thirdly, It Data Protection Agency.Data ical ResearchEthics aswell asby theDanish the DanishNational Committee onBiomed- Helsinki Declaration andwas approved by study was conductedinaccordance withthe or depressionaccordingtoDSM-IV. The algorithms. All patients alsohadPTSDand/ screening andcheckedwithdiagnostic individual symptomswere recordedat the andall to theICD-10researchcriteria PTSD anddepressionwere madeaccording assessment andat follow-up. Diagnosesof ratings (outoffourpossible)frominitial they didnothave at leasttwo outcome azepines. Finally, patients were excludedif fromtheregularuseofbenzodi- abuse apart to ICD-10oriftheyhadany substance bipolar disorder(F20-29orF31)according excluded ifdiagnosedwithpsychosisor treatment intheclinic. Patients were systemwerepsychiatric excludedfrom were inneedofhospitalization inthegeneral consultations withatherapist. Patients who with antidepressantsandat leastfour four months’ duration includingtreatment had tohave received treatment ofat least related toawar-related trauma. The patients (depression orPTSD)assessedasbeing older andsufferedfromamentaldisorder June 2009. The patients were or 18years theperiod 2008to Copenhagen during April Psychiatric Trauma ClinicforRefugeesin were screenedat the All participants Participants andDesign Methods and depression. PTSD andco-morbiditieslikepain, anxiety to traumatized refugeeslivinginexilewith treatment andtheirroleintreatment offered componentsofastandardCBT various andconsiderthe tounderstand readers treatment elsewhere. enables Itfurther supplement alreadyimplementedCBT SCIENTIFIC ARTICLE TORTURE Volume 25, Number 1, 2015 19 The 20 17,18 16 If pacing, use of If pacing, 19 CTRS is used to evaluate CTRS is used to evaluate 19 and its psychometric properties 20,21 Therapist self-assessment At the beginning the end of the and at (session 4 and psychotherapeutic treatment 12) the psychologist responsible for the his/her evaluated of the patient treatment performanceown in therapy by using the Therapy Rating Cognitive Young Beck & Scale (CTRS). Level of Functioning The Sheehan Disability Scale (SDS) is a which assesses the self-report scale, rating work of functioning in termslevel of family, by using three visual and social network the analogue scales from 0-10 with 10 being The of functioning. possible level lowest score is usually reported as the total score of the three scales ranging from 0-30. Quality of Life WHO-5 used the assess quality of life we To used self-adminis- scale which is a widely with 5 questions (0-5 tered questionnaire point Likert the lowest scale with 0 being a scores have Raw score and 5 the highest). are transformedrange from 0 to 25 and into to well-being) thinkable a scale from 0 (worst higher Thus, well-being). 100 (best thinkable scores mean better well-being. are well-described. scale has been used in previous CBT research the therapist’s competences and consists of competences the therapist’s 11 items scored on a 6 point Likert type - general therapy skills (feed It covers scale. understanding, interpersonal- back, effective CBT skills (guided and collaboration), ness, focus on key cognitions and discovery, of application for change, strategy behavior, CBT techniques) and structure in therapy pacing and efficient use of time, (agenda, assignments). and use of homework homework and use of behavioral strategies and use of behavioral homework the internal consistency excluded, of were HSCL-25 is a short version of the 12-15 Symptom Checklist-90 with a focus on The first anxiety and depression symptoms. 16 questions of the symptom part (Part IV) PTSD- the used to evaluate of HTQ were diagnosis according to the ICD-10 and the both scales, For DSM-IV diagnostic systems. a 1-4 Likertindividual questions have format with 4 being the highest symptom level. Symptom ratings The Hopkins Symptom Check List-25 Trauma (HSCL-25) and the Harvard Questionnaire (HTQ) are internationally self-reportused and validated rating scales. Data collection data Outcomes and baseline collected duringData the initial assessment and one hour hours(two with a physician self-report included with a social worker) the a clinical assessment of scales, rating current psychiatric and a structured status interview collecting information on trauma, previous mental socioeconomic situation, current treatment, health problems and and diagnosis health problems physical At research criteria. according to the ICD-10 methods treatment every consultation, dose of pharma - (topics in psychoeducation, record- cotherapy and CBT methods) were The same self-report were ratings ed. the initial assessment and at completed at translation If necessary, end of the treatment. during provided assessment and was All self-report consultations. treatment in the six most available questionnaires were Bosnian / Farsi, common languages (Arabic, and Danish Russian, Serbo-Croatian, If which addressed 86% of patients. English), gave a translator available, was no translation version from the official translation a verbal in the language he/she felt most comfortable with. ARTICLE SCIENTIFIC 20 TORTURE Volume 25, Number 1, 2015 tion andtreatment alliance. The scalehas intherapy,participation empathy, introspec- es 6items: motivation, mentalflexibility, where 5isthebestscore. - The scalecompris typescaleof1-5,session 12usingaLikert suitability fortherapyat session4and The therapistevaluated thepatient’s Patient suitabilityratings in patient condition. ofchange used intheanalysisofpredictors score oftheremaining8items, whichwas 0.87). We thereforemadeanaggregated the scalewas acceptable(coefficientalpha= Figure 1:Standardtreatment model Week 9-24 Week 3-8 Week 1-2

pharmaco-therapy and pharmaco-therapy pharmaco-therapy and pharmaco-therapy Monthly adjustmentof Weekly adjustmentof psychoeducation by psychoeducation by Baseline assessment by physician physician physician further analysis(alpha=0.92).further for the6itemsandthiswas usedinthe and consequentlywe calculated atotalscore The itemsonthescalearehighlycorrelated Figure 1). (see sessions withaclinicalpsychologist consultations withamedicaldoctorand16 ofsixmonthsincludes10 standard period follow.cians andclinicalpsychologists A inmanualswhichallphysiand described - The treatment at theclinicisstandardized The intervention been adapted to various clinicalsettings.been adaptedtovarious session (45min)with Baseline assessment Weekly CBTtherapy by socialworker psychologist SCIENTIFIC ARTICLE 22,23

TORTURE Volume 25, Number 1, 2015 21 It consists of CBT including 10 The psychotherapeutic treatment treatment The psychotherapeutic manual at PTF manual treatment The psychotherapeutic and June 2008 between developed was on evidence-based March 2009 and draws of trauma and approaches to treatment PTSD. always show up for appointments, the time up for appointments, show always sometimes longer. was consultations between treatment the overall This could increase number of period the average and reduce The duringconsultations course. a treatment by a social least once seen at were patients during period. worker the treatment elements of acceptance and commitment elements of acceptance and commitment than Rather and mindfulness. therapy (ACT) focusing intensely on the trauma of the the methods in the individual refugee, manual encourage a focus on the patient’s current and future development situation anxiety and wellbeing with regards to stress, 21 can include Treatment in everyday life. 1. Table described in more detail in methods, Description and their degree overview of of main life events Provides distress. cause. Standard CBT map of problems and their and goals for the therapy. problems Lists the patient’s and behaviour. bodily sensations feelings, Links thoughts, Is a tool for restructuring dysfunctional thoughts. others with basic assumptions about the self, and Working the world. imaginesThe patient feared person approaching the or situation. actually performsExposure where the patient the feared tasks. The standard medical treatment of the medical treatment The standard Name of method Life line Case formulation Problem identification diamond Cognitive Thought records Assumptions Visualized Exposure exposure In vivo ARTICLE SCIENTIFIC patient included the SSRI Sertraline, which which SSRI Sertraline, included the patient the antidepressant supplemented by was Mianserin had sleeping patients if the a week. four days problems for more than other psychophar- any possible, Whenever macological reduced or was treatment the consultations In addition, terminated. about the illness, include psychoeducation the role of life in exile, the treatment, life-style including relaxation- sleep, religion, pain, activities, and social physical exercises, and the influence of the functions, cognitive The psychotherapeutic illness on the family. intervention of consisted of 16 sessions Therapy (CBT) Behavioural Cognitive administered by six clinical psychologists in training ten days who had all received trauma-focused cognitive-behavioural individu- weekly Therapists received therapy. al and group supervision by certified supervi- sors with experience with traumatized Psychotherapy sessions were refugees. did not since patients but offered weekly, Methods included in the treatment manual 1: Methods included in the treatment Table 22 TORTURE Volume 25, Number 1, 2015 of thoughtrecords, useofvalues, mean suitability score, useofcaseformulation, use included thefollowing predictors: patient HTQ andHSCL-25multivariate models models.included inmultivariate regression significant variables were subsequentlyall baseline rating.the corresponding The modelsadjustingfor identified inregression treatment outcome(p-value <0.05)were the data set: of significantpredictors first two-step processduetothelimitedsizeof assessments. The analysiswas madeina tion ofthepatient andscoresontherapist changesinthecondi- py withself-reported associations ofmethodsusedinpsychothera- was usedtoinvestigateregression possible In additiontodescriptive statistics, linear Statistical analysis Homework Relapse prevention skills Interpersonal Avoidance Committed action Values Defusion Control andacceptance Creative hopelessness Body scan Breathing exercises Focusing onthepresent Interoceptive exposure

Is integrated in all of the methods described above. inallofthemethodsdescribed Is integrated larly useful. Sums upthemethodsandtechniquesthat- proved particu Focuses oncommunication skillsandangermanagement. functioning. oftheavoidanceDiscovery andhow itinhibits pattern The patient actively engagesinactionbasedontheirvalues. our life. Discovering whichvalues create meaninganddirectionin them. ourthoughtswe candistanceourselves from By observing situation. Different toolsallowing thepatient toaccepttheircurrent situation. The patient isencouragedtoacceptaseeminglyhopeless another.Moving attention fromonebodypart Using breathing asananchortothepresentmoment. freeshimselffromrumination.The patient momentarily sensations. In traumarecalltheclientisconfrontedwithhisbodily Corp LP,Corp CollegeStation, TX, USA). analyses were madeinSTATA 11(Stata- therapists’ evaluation ofthepatient. All change over timeinCTRSscoreandthe Paired t-testswere used toevaluate the between therapistassessmentsandoutcome. cients were usedtoevaluate thecorrelations compliance. Pearson’s coeffi- correlation records, relapseprevention andhomework included useofmindfulness, thought compliance, whereasthe WHO-5 model psychoeducation intherapyandhomework of breathing techniques, useofvalues, useof self-evaluation, patient suitabilityscore, use model includedscoreonthetherapist’s with apsychologist. The SDSmultivariate compliance andthetotalnumberofsessions number oftherapymethodsused, homework SCIENTIFIC ARTICLE TORTURE Volume 25, Number 1, 2015 23 The therapy lasted on average 5.6 average The therapy lasted on Psychotherapy Psychotherapy CBT manualized received All of the patients 3). Table (see as described above 13.5 of on average months and consisted the 21 11 of On average therapy sessions. included in the possible CBT-methods and in patient used with each manual were number of methods each session the mean In analyses adjusting for 2.4. used was a significant was baseline scores there the mean between association positive number of methods used per session and Did not have ratings N=24 ratings Did not have full Did not receive N=21 treatment Excluded with bipolar or psychosis (N=19) or no inclusion diagnosis (N=17) N=85 Included criteria N=130 Screened N=166 Fulfilled inclusion For a description at of the patients For Complete data N=106 Complete data baseline see Table 2. Of all ratings, only Of all ratings, 2. Table baseline see with a mean HSCL-25 differed significantly, who completed score for those patients of 3.0 for those who did of 3.2 and treatment (p=0.05), not complete the treatment suggesting marginally less depression and in non-completersanxiety symptom intensity compared with completers. Results screened and were 166 patients At the clinic, analysis (Figure included in the final 85 were 2). ARTICLE SCIENTIFIC Figure 2: Inclusion 24 TORTURE Volume 25, Number 1, 2015 Table 2: Treatment ofallincludedpatients (N=85) andpatient background Medicines in addition toantidepressants Treatment Mean no. trauma ofyears sincefirst Age Mean no. ofyears inDenmark Translator needed Others Libanon /Palestinian Iranian Iraqi Main EthnicGroups Male Female Sex Been subjectedtotorture war Experienced Trauma Permanent resident status Working at assessment Any education Previous treatment includingPsychotherapy treatment Previous psychopharmacological (excluding painandheadache) Untreated physical symptomsat assessment Treated physical symptomsat assessment psychotic episodesat assessment hallucination,Describes delusionsor previous pain Reports Depression (moderate orsevere) PTSD Health at baseline Background

Mean (min-max) 43.4 (21-57) 22.6 (4-46) 14.5 (2-30) SCIENTIFIC ARTICLE 49 38 15 11 36 47 53 54 86 90 10 76 88 80 77 23 13 99 98 87 %

Standard deviation 8.9 6.4 8.0 42 32 13 31 40 45 46 72 65 58 75 68 63 19 11 83 83 74 N

9 8 TORTURE Volume 25, Number 1, 2015 25 - - 5 8 84 2.3 1.7 1.5 4.2 75 (26) 50 (31) 2 (0 - 9) 0 (0 - 3) 1 (0 - 4) 5.6 (1.2) 7.9 (5.0) 2.4 (0.9) 3 (0 - 12) 13.5 (3.5) 11.0 (3.2) deviation Standard Mean (sd) Median (range) 6 9 99 -

5.7 (0-10) 8.7 (4-14) 92 (78) 82 (70) 99 (84) 21 (18) 75 (64) 94 (80) 99 (84) 22.3 (11-38) 8.2 (5.4-13.1) Mean (min-max) % Patients where where % Patients % Patients where where % Patients method was used (N) method was method was used (N) method was Life line Case formulation Problem identification The cognitive diamond The cognitive Cognitive (no. of sessions) (no. Cognitive The use of psychotherapy components in the study The use of psychotherapy 3: Table Individualization (no. of sessions) (no. Individualization Homework Handed out compliance 8%) Patient Duration of Psychotherapy (months) Duration Sessions with psychologist Mean no. of methods per session Mean no. of methods used (of 25) No. Benzodiazepines as part psychoeducation - Received of treat ment covered topics Psychoeducation Session with doctor (months) of treatment duration Total number of sessions Total Psychotherapy Antipsychotics ARTICLE SCIENTIFIC 26 TORTURE Volume 25, Number 1, 2015 Exposure (no. ofsessions) Mindfulness (no. ofsessions) ACT (no. ofsessions) Other methods(no. ofsessions) and identification ofbehavioural patterns. Of ofthoughts ofproperrestructuring than part ofpsychoeducation more likelytobepart diamond orthoughtrecordsonce ortwiceis avoidance). However, theuseofcognitive diamond, thought records, assumptionsand of thefourcorecognitive methods(cognitive Only onepatient received therapywithoutany Cognitive methods ate analysis. WHO score(ß=11.77,- p=0.02)inunivari positively associated withanimprovement in wasthe therapeutictreatment course discussion ofrelapseprevention at theendof HSCL-25 (ß=-0.17, p=0.02)scores. The reduction inHTQ(ß=-0.12, p=0.03)and

Focusing onthepresent Interoceptive exposure Control &acceptance Creative hopelessness Visualized exposure Breathing excercise Relapse prevention Interpersonal skills Interpersonal Committed action In vivo exposure Thought record Assumptions Body Scan Avoidance Defusion Values received cognitive therapyusingthecoreCBT measurements between that had thegroup in baselinescoreonany oftheoutcome p =0.03). There was nosignificantdifference p =0.05)andon WHO-5 (difference =10.6, significantly largeronHTQ(difference =0.2, t-tests were performed, thechangewas comes thantheremainingpatients. When positive changeonallfourtreatment out- ofthoughtsgenerallyhadalarger turing received therapyinvolving- theuseofrestruc used 2-5timeseach. The 42%who had at leastonce. The fourmethodswere typically therapy includedtheuseofallfourmethods more thantwiceandfor30%ofpatients the cognitive diamondorthoughtrecordsused the patients, 42%received therapywiththe 80 (68) 47 (40) 85 (72) 36 (31) 27 (13) 21 (18) 92 (78) 13 (11) 74 (63) 74 (63) 38 (32) 88 (75) 12 (10) 69 (59) 35 (30) 66 (56) 82 (70) 46 (39) 68 (58)

SCIENTIFIC ARTICLE 2 (0-13) 3 (0-14) 1 (0-12) 2 (0-11) 3 (0-16) 0 (0-10) 0 (0–5) 0 (0-9) 0 (0-5) 0 (0-5) 0 (0-5) 2 (0-9) 0 (0-5) 1 (0-7) 0 (0-6) 1 (0-6)

- - - TORTURE Volume 25, Number 1, 2015 27 - - was associated with a positive change in change in with a positive associated was SDS p < 0.01) and HTQ score (ß = -0.30, p < 0.01) in univariate score (ß = -1.47, analysis. Homework home- used to evaluate variables were Two given who were patients many how work; and the compliance with the homework handed out was Homework given. homework compli- in 75% of the sessions and patient The patients 50%. was ance with homework sion) and SDS. Individualisation of therapy had a case formulaOnly 21% of the patients - tion identifying a pattern of negative thoughts and basic assumptions automatic in made and central problems to focus on identified not systematically the therapy were one to On average for 18% of the patients. spent on planning indi- sessions were two of therapy in the beginningvidualization of a case formulation Getting was treatment. of symp- with an improvement associated p = 0.05) in toms on HSCL-25 (ß = -0.31, In terms of baseline analysis. univariate with a case the patients outcome scores, formulation did not differ from those without. Exposure methods Exposure was used with the of 47% patients and the majority of patients were only treated with one of thethree possible exposure Interoceptive exposure methods. was used the least and visualized exposure the most. Exposure was on average per formed once or twice with each patient. significant no association There was between the use of exposure and change in any of the outcome measures. The use of with significantly associated exposure was lower scores on HSCL-25 part 2 (depres Acceptance and Commitment therapy methods the used with 88% of methods were ACT each of the methods On average patients. to four times in therapy. used two was used were Control-acceptance and values whereas defusion with 66-69% of patients used with only hopelessness was and creative The use of values 35-38% of the patients. Mindfulness methods used was At least one mindfulness exercise during and therapy with 92% of the patients focusing on the present and/or breathing Only seven used with 84%. were exercises with body scan during worked patients with all three therapy and all of those worked duringmindfulness exercises their therapy about No information available was sessions. who practisedthe number of patients Each therapy sessions. mindfulness between intro- on average of the three methods was Mindful- to three times in therapy. duced two with a decrease in quality associated ness was p = 0.03) WHO-5 score (ß = -18.24, of life on analysis and breathing in multivariate with a decrease in associated were exercises of functioning on SDS score (ß = -0.95, level The analysis. p = 0.03) in multivariate with mindfulness receiving treatment patients did not differ in baseline scores compared to treatment. those who did not receive methods several times and the group wheremethods several only been usedthe core methods had regression In univariate analysis sporadically. association positive a significant there was records and the use of thought between p = 0.02) WHO-5 (ß = 14.2, on improvement a positive p = 0.01) and and HTQ (ß = -0.31, the use of the between significant association = p (ß=-0.50, diamond and HTQ cognitive in a significant improvement was There 0.01). the use p = 0.03) with HSCL-25 (ß = -0.38, analysis. multivariate of thought records in ARTICLE SCIENTIFIC 28 TORTURE Volume 25, Number 1, 2015 multivariate analyses. SDS (ß=-0.015, p=0.03)scoresin change onHTQ(ß=-0.003, p=0.05)and univariate analysis, but onlywithapositive positive changeonalloutcomemeasuresin was significantlyassociated withamarginal those whowere not. Homework compliance patients whowere given homework and ences withregardtobaselinescorebetween p =0.04). There were nosignificantdiffer- (ß=0.01,when testedwithlinearregression lowermarginally scoreonSDSat baseline who hadlow homework compliancehada 0.03). For SDSand WHO-5 thetrend was -0.27, p =0.02)andHTQ(ß-0.24, p= outcome withregardstoHSCL-25 (ß= patient suitabilityfortherapyand changein betweensignificant correlation highscore on WHO-5 (r=-0.22, p=0.0). There was a scores onSDS(r=-0.26, p=0.02)and scores onpatient suitabilityand bad baseline significant negative between correlation (Pearson 0.6–0.9). correlations There was a of thepatient’s suitabilityfortherapy self-evaluation and thetherapist’s evaluation betweenhigh correlation thetherapist’s 0.02-0.2).correlation However, therewas a baseline assessmentbyaphysician (Pearson andmotivationpsychologist evaluated at suitability fortreatment asevaluated bya betweenwas nocorrelation thepatient’s = 0.04)scoresinmultivariate analysis. There -0.94, p=0.01)andHSCL-25(ß=-0.25, p in univariate analysis, andonSDS(ß= change onHTQscore(ß=-0.21, p=0.03) ity fortherapywas positively associated with was 3(onascalefrom1-5). Patient suitabil- paired t-tests. The average scoreforallitems second patient evaluation whentestedwith tothe changed significantlyfromthefirst for 46patients intotal. Noneofthesixitems Patient suitabilityfortherapywas evaluated Patient suitabilityratings unrelated tothebaseline conditionsofthe larger improvement andthisseemedtobe more thanonceortwice, thepatients showed measures. When thesemethods were used and thecognitive diamondandalloutcome cognitive methodssuchasthoughtrecords a positive association between theuseofcore of timesdependingonthemethod. We found one tothreetimeswiththeoptimalnumber of methodsbeingused, mostwere onlyused of methods. Inadditiontothehighnumber increasetheneedfor repetition may further lar. andcognitive deficits Languagebarriers - with individualtherapyandCBTinparticu of patients have noorlimitedexperience that themajority numerousconsidering fairly session,introduced inalmostevery whichis sessions, meaningthat anewmethodwas anaveragedifferent methodsduring of14 session. Therapists usedonaverage 11 actively andmakehomework fromsessionto tion ofpatients areabletoparticipate ing, CBTispromisingandalargepropor- co-morbid diseasesandlow level offunction- ofpatients withseveralcultural group The studyshows that even inthismulti- Discussion therapist’s self-evaluation from4 There was nosignificantchangeinthe Therapist’s self-assessment significant. the samealthoughtheseresultswere not measures andthetherapists’ self-evaluation. between changesinany oftheoutcome 0.36, p<0.01). We foundnocorrelation baseline scoreandself-evaluation score(r= betweensignificant correlation WHO-5 baseline (r-0.33, p<0.01). We alsofounda between self-evaluation scoreandSDSat was, however, asignificantcorrelation The totalscorewas 3.3of6possible. There session whencomparedwithpairedt-test. SCIENTIFIC ARTICLE th to12 th

TORTURE Volume 25, Number 1, 2015 29

26 It is 29,30 Many therapists Many 27 and thus other factors be may 28 Exposure was used much less than used much Exposure was Several factors- Several influence effective may use of each method could increase the method could increase use of each effect further.treatment anticipated with visualized exposure therapy with visualized anticipated In addition the patients. only used on 27% of only undertaken exposure was one to to this, suggests times although the literature two 7-12 times in the case it should be used that with PTSD patients. of trauma exposure explained that exposure was used less than exposure was explained that planned in the manual because patients refused to participate of due to high levels there may sessions, and in translated distress, visualized been too little time for proper have however, Other researchers have, exposure. applied exposure with the same patient group, therefore questionable whether the use of therefore questionable whether the use of a few times during exercises breathing effect. any therapy can be expected to have may mindfulness such as breathing Indeed, techniques been used when other CBT have This might explain why possible. not were and mindfulness were exercises breathing change in quality with a negative associated It is also of functioning. of life and level mindfulness is harmfulpossible that in suffering patients traumatized from PTSD as increase dissociation. it may got a patients Few ness of therapy sessions. case formulation and in some cases central not focus problems for the therapy were The lack of a positive outcome of the outcome The lack of a positive reflect too little use of psychotherapy might brief It is also possible that use of exposure. visualized exposure has led to sensitization than improvement. rather involved, such as a hesitation on the part on such as a hesitation of involved, Mindfulness the therapist to use exposure. more intensive research is generally involves that and it is believed than ours, treatments is the amount of daily practice by the patient important for clinical effects. However, we found a 50% com- found a 50% we However, 24,25 It has been questioned whether trauma- It has been questioned tized refugees are able to do homework or if to do homework tized refugees are able cultural Western is only useful in a homework context. patients. Several less specifically cognitive less specifically cognitive Several patients. not were times but used many methods were (focusing change with a positive associated interpersonal skills and on the present, it is not merely the Therefore, avoidance). is being used number of times a method “reverse However, which is important. is a possibility if spontaneously causality” are those who are able to patients improving methods. with the cognitive cooperate ARTICLE SCIENTIFIC pliance with homework, which is a relatively which is a relatively pliance with homework, a with and it seems to be associated high rate change in mental health small positive In clinical symptoms and social functioning. focus it has also been suggested that settings, on restructuring of thoughts and more might not be CBT methods advanced appropriate refugees because for traumatized condition and of the patients’ of the severity because of few psycho-social resources, and language including limited education unable to clearly identify a were We barriers. mostly subgroup who were of patients it is likely but receiving supportive therapy, a involve supportivethat therapy would of the occasional use of CBT combination using mindfulness when everything methods, else fails and generally using few methods. Each of these factors individually was in patient with less improvement associated no have we Consequently, condition. will some of the patients that indication benefit more from a supportive and less In summary, structured therapy than CBT. are able the patients that our results indicate to participate in and benefit from CBT and Our results on the restructuring of thoughts. it is number of methods used suggest that a more thorough applica- that possible even tion of CBT methodology and the repeated 30 TORTURE Volume 25, Number 1, 2015 therapy methods, whichenablesevaluation of possible touse a thoroughregistration However, we have demonstrated that itis always well-describedintheliterature. models whichhave beenevaluated arenot traumatized refugees, and thetreatment treatment effectofpsychotherapy for contexts. therapy mightbeausefultoolinclinical evaluation ofthepatient’s suitabilityfor patient suitabilityfortherapysuggests analysis ofthetherapist’s evaluation of ofthetherapists’importance skills. The the moreanxioustheyare, isthe thegreater chronic theproblemsofpatients are, and strated that themorecomplicated and studies ofdepressedpatients have demon - likely toberelevant inthiscontextsince competence inCBTisdebated, andCBT.patient group withthis this may reflectlimitedexperience on average rated themselves 3outof5and associated withtreatment results. Therapists patients. by problems frequentlyexperienced somatisation, chronicpainandotherurgent PTSD andhadlessfocusondepression, addition, thetherapywas developed totreat CBTtreatment. instructured Inparticipate may reflectthepatients’ limitedabilityto tions andsystematic problemidentification If thiswas thecase,- thelackofcaseformula couldbemade.meaningful caseformulation wherea basic assumptionstoadegree ofnegativepatterns automatic thoughtsand cooperate withsystematic identification of reflect that many patients were unable to islikelyto The lackofacaseformulation therapy tothepatients’ individualproblems. fortargetingthe important methods arevery identified,fact that thesetwo despitethe There is very limitedevidenceof There isvery The importance ofthetherapists’The importance The therapists’ self-evaluations were not

21 but is patients cannotrelate totheCBTmodel. indication inourdata that multi-cultural therapyandthereisno in thedescribed identifies clearpossibilitiesforimprovement limitations,methodological thisstudy ratings inadditiontoself-ratings. Despite benefitted fromtheuseofblindedobserver- medication. Finally, thestudywould have study canhardlybeexplainedbytheuseof in this CBT andbetteroutcomeobserved association between theuseofsystematic psychotherapy. Ontheotherhand, the the effectofmedication andnottheeffectof changesmay thereforebedueto observed psychotherapy andpsychoeducation. The with acombination ofantidepressants, the patients. Secondly, patients were treated to spontaneouschangesintheconditionof changesaredue the notionthat theobserved out makesitimpossibletorule control group drawn fromthedata. Firstly, thelackof a which affecttheconclusionsthat canbe follow-up studieslikethepresentstudy. are whereasothers randomized trials always available. Someofthestudiesuse andmentalhealthstate isnot background about respects andsufficientinformation studies ofrefugeepopulations differinmany cultural background. The fewavailable sis, co-morbidities, socio-economicand comparable withregardtoinclusiondiagno- treatments requiresthat thesamplesare methods fortraumatized refugees. and development ofpsychotherapeutic The study has important limitations The studyhasimportant Any ofpsychotherapeutic comparison SCIENTIFIC ARTICLE TORTURE Volume 25, Number 1, 2015 31 treatment outcomes at a psychiatric outcomes at clinic trauma treatment pp. 2015;25(1): Torture. for refugees. T, Truong Bollini P, Y, Caspi-Yavin Mollica RF, Question- Trauma The Harvard J. Lavelle S, Tor a cross-cultural instrument for Validating naire. and posttraumatic measuring trauma, torture, J Nerv refugees. stress disorder in Indochinese 1992 Feb;180(2):111-6. Ment Dis. the Hopkins Indochinese versions of J. Lavelle F, a screening instrument Symptom Checklist-25: Am J Psychia- for the psychiatric care of refugees. 1987 Apr;144(4):497-500. try. Screening for PTSD et al. S, Forstbauer Miley K, - vali and depression in Bosnia and Herzegovina: Questionnaire and Trauma the Harvarddating Int J Culture the Hopkins Symptom Cheklist. 2008 Dec;1(2):105-116. Ment Health. assessments stress symptoms in refugees: matic Questionnaire and the Trauma with the Harvard - Hopkins symptom Checklist-25 in different lan Apr;88(2):527-32. 2001 Psychol Rep. guages. mastering depression in Info package; WHO. World primary care Frederiksborg, Denmark: Regional Office for Europe, Health Organisation, 1998]. 1998 [updated Psychiatric Research Unit; http://www.who-5.org. from: Available Assessing treatment Sheehan DV. Sheehan KH, effects in clinical trials the discan metric with of Clin Psychop- Int the Sheehan Disability Scale. 2008 Mar;23(2):70-83.harmacol. Assessment Swinson RP. Michalak EE, Lam RW, London: anxiety. mania and scales in depression, 152-3. p. 2005. & Francis; Taylor The Cognitive Dobson KS. BF, Shaw TM, Vallis J Con- psychometric properties. Therapy Scale: 1986 Jun;54(3):381-5. sult Clin Psychol. Lewis Montemarano J, CA, Padesky AD, Simons and Training et al. Lamb K, Murakami J, CC, therapy for behavior of cognitive dissemination a preliminary examination depression in adults: J of therapist competence and client outcomes. 2010 Oct;78(5):751-6. Consult Clin Psychol. - Val Olmsted M, J, Yamaguchi Elkin I, BF, Shaw Therapist competence et al. Dobson KS, TM, lis to clinical outcome in cognitive in relation ratings J Consult Clin Psychol. therapy of depression. 1999 Dec;67(6):837-46. Suitability for psychoanalytic psycho- K. Valbak 2004 Scand. Acta Psychiatr a review. therapy: Mar;109(3):164-78. Suitability Hougaard E. Rosenbaum B, K, Valbak of validation for psychoanalytic psychotherapy:

12. 12. Khuon de Marneffe D, G, Wyshak RF, Mollica 13. J, Lavelle Culhane M, A, Kapetanovic Oruc L, 14. - Posttrau JJ. Rodenburg JE, Hovens WC, Kleijn 15. 16. 17. 18. 19. 20. 21. 22. 23. - - Crumlish N, O'Rourke K. A systematic review A systematic O'Rourke K. Crumlish N, stress disorder post-traumatic for of treatments J Nerv Ment among refugees and asylum-seekers. 2010 Apr;198(4):237-51. Dis. Cognitive-behavior Ost LG. N, Paunovic in the treatment therapy vs exposure therapy 2001 Ther. Res Behav of PTSD in refugees. Oct;39(10):1183-97. Kalender M, Livanou Salcioglu E, Basoglu M, treatment behavioral Single-session Acar G. D, of earthquake-related- stress disor posttraumatic J list controlled trial. a randomized waiting der: 2005 Feb;18(1):1-11. Stress. Trauma Hof- Safren SA, V, Pich Chhean D, Hinton DE, A randomized controlled MH. Pollack mann SG, therapy for Cambo- trial of cognitive-behavior PTSD dian refugees with treatment-resistant Trauma J design. a cross-over and panic attacks: 2005 Dec;18(6):617-29. Stress. Otto Safren SA, M, Tran T, Pham Hinton DE, Vietnamese refu- CBT for MH. Pollack MW, PTSD and panic gees with treatment-resistant 2004 Stress. Trauma J a pilot study. attacks: Oct;17(5):429-33. Ba A, Chea Korbly NB, Hinton D, Otto MW, of pharmaco- Treatment et al. Gershuny BS, P, therapy-refractory stress disorder posttraumatic pilot study of a among Cambodian refugees: with cognitive-behavior treatment combination 2003 Ther. Res Behav therapy vs sertraline alone. Nov;41(11):1271-6. M, Odenwald Ruf M, Kurreck S, Neuner F, Can asylum-seekers with Schauer M. T, Elbert be successfully stress disorder posttraumatic controlled pilot study. A randomized treated? 2010;39(2):81-91. Ther. Cogn Behav M, Odenwald V, Ertl PL, Onyut Neuner F, of posttrau- Treatment T. Elbert Schauer E, counselors stress disorder by trained lay matic a randomized African refugee settlement: in an 2008 J Consult Clin Psychol. controlled trial. Aug;76(4):686-94. Neuner Schauer F, M, Klaschik C, Karuna kara Elbert U, A comparison T. of narrative exposure therapy, supportive counseling, and psychoeducation for treating posttraumatic stress disorder in an african refugee settle 2004;72(4):579- ClinPsychol. JConsult ment. 87. Psychological of treatment Andrew M. Bisson J, Cochrane stress disorder (PTSD). post-traumatic 2007 Jul 18;(3). Syst Rev. Database Nor- J, Ryberg EL, Mortensen, Buhmann CB, study of the Follow-up Ekstroem M. dentoft M,

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Acta Psychiatr Scand. 2011 Aug;124(2):102-19. tematic reviewofrandomizedcontrolledtrials. and mindfulness-basedcognitive therapy: asys- Walach H. Mindfulness-basedstressreduction Fjorback LO, Arendt M, E, Ornbøl FinkP, 2007 Apr;52(4):260-6. view ofthecontrolledresearch. CanJPsychiatry. tion improve anxietyandmoodsymptoms? A re- Toneatto T, Nguyen L. Doesmindfulnessmedita- 2010 Dec;16(4):117-27. refugees -theDenBoschModel. Traumatology. and therapy withtraumatized asylumseekers Drozdek B, Bolwek N. Evaluation ofgroup Jan;52(1):17-20. traumatic stressdisorder. JClinPsychiatry. 1991 SCIENTIFIC ARTICLE