535752

research-article2014
ISP0010.1177/0020764014535752International Journal of Social PsychiatrySlobodin and de Jong

E CAMDEN SCHIZOPH

Article

International Journal of

Mental health interventions for Social Psychiatry

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What do we know about their efficacy? DOI: 10.1177/0020764014535752

isp.sagepub.com

Ortal Slobodin1 and Joop TVM de Jong2,3

Abstract
Background: The prevalence of trauma-related problems among refugees and asylum seekers is extremely high due
to adverse experiences associated with forced migration. Although the literature presents a considerable number of
guidelines and theoretical frameworks for working with traumatized refugees and asylum seekers, the efficacy, feasibility
and applicability of these interventions have little empirical evidence.
Aims: The purpose of this article is to critically review the literature to provide a rationale for developing culturally
sensitive, evidence-based interventions for refugees and asylum seekers.
Methods: A literature review integrating research findings on interventions designed especially for traumatized asylum
seekers and refugees was conducted. Retained studies had to use some quantitative measurements of post-traumatic
stress and to have pre- and post-measurements to evaluate the efficacy of the intervention. Studies included in this
review cover a wide variety of interventions, including trauma-focused interventions, group therapy, multidisciplinary
interventions and pharmacological treatments.
Results: The majority of studies with traumatized refugees and asylum seekers reported positive outcomes of the
intervention in reducing trauma-related symptoms. There is evidence to support the suitability of cognitive-behavioral
therapy (CBT) and narrative exposure therapy (NET) in certain populations of refugees. Other intervention studies are
limited by methodological considerations, such as lack of randomization, absence of control group and small samples.
Conclusions: This review has again highlighted the shortage of guiding frameworks available to investigators and
clinicians who are interested in tailoring interventions to work with refugees and asylum seekers. Theoretical, ethical
and methodological considerations for future research are discussed.

Keywords
Refugees, asylum seekers, intervention, trauma, symptoms, review

Introduction
Refugees and asylum seekers are forced migrants. The
United Nations High Commissioner for Refugees
(UNHCR) estimated that there were 43.3 million forcibly
displaced people worldwide at the end of 2009. Of these,
15.2 million were refugees and 983,000 asylum seekers
(The United Nations Refugee Agency, 2009). Generally,
refugees have a lawful right to enter a country for the pur-
poses of seeking asylum, regardless of how they arrive or
whether they hold valid travel or identity documents.
Asylum seekers are individuals whose application for asy-
lum or refugee status is pending in the administrative or
legal processes (Harris & Zwar, 2005).
The process of migration has been described as occur-
ring in broadly three stages, each of them involves the
potential for traumatogenic experiences: (a) pre-migration;
(b) migration – the physical relocation to the new place
and (c) post-migration – the assimilation within the cul-
tural framework of the new society, through learning its
cultural rules (Bhugra, 2001). Prior to migration and dur-
ing this process, refugees are exposed to exceptionally
high rates of traumatic events such as war, violence, tor-
ture and persecution (Gerritsen et al., 2006; Steel et al.,
2004). Some refugees become subjects of human
1i-psy
(intercultural psychiatry), Amsterdam, The Netherlands
2Amsterdam Institute of Social Science Research, University of
Amsterdam, Amsterdam, The Netherlands
3School of Medicine, Boston University, Boston, MA, USA
Corresponding author:
Ortal Slobodin, i-psy (intercultural psychiatry), George
Westinghousestraat 2, 1097 BA Amsterdam, The Netherlands.
Email: ortal_saroff@yahoo.com

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2 International Journal of Social Psychiatry
trafficking who may be held for ransom or trafficked for
the purpose of forced marriage, sexual exploitation or
labor exploitation through the use of force, fraud or coer-
cion (United States Committee for Refugees and
Immigrants, 2011). Nevertheless, post-migration adverse
experiences, such as lack of social support, acculturation
difficulties, poverty, discrimination and changes in iden-
tity and concept of self, further complicate the mental
problems in those who have been previously traumatized
(Bhugra & Becker, 2005; Laban, Gernaat, Komproe,
Schreuders, & De Jong, 2004; Silove, Sinnerbrink, Field,
Manicavasagar, & Steel, 1997; Walsh, 2007). Many asy-
lum seekers who live in detention camps are exposed to
threatening conditions (e.g. sexual harassments, denial of
adequate food, inadequate health care, isolation etc.), as
well as to continuous uncertainty about their own future
and the future prospects of those who were left behind
(Carta et al., 2013; Laban et al., 2004).
These adverse experiences often lead to extremely high
prevalence of psychiatric disorders among refugees and
asylum seekers, including depression, post-traumatic
stress disorder (PTSD), anxiety, psychosomatic disorders,
grief related disorders and crises of existential meaning
(Gerritsen, et al., 2006; Laban et al., 2004; Steel et al.,
2004). It is estimated that PTSD prevalence among refu-
gees ranges between 20% and 74%, and depression ranges
between 39% and 64% (Gerritsen et al., 2006; Laban et al.,
2004; Mares & Jureidini, 2004; McColl & Johnson, 2006;
Sieberer, Ziegenbein, Eckhardt, Machleidt, & Calliess,
2011). The level of distress depends on many variables,
such as duration of the relocation, the similarity between
the culture of origin and the culture of settlement, language
and social support systems, acceptance by the new nation
and employment and education opportunities (Bhugra &
Becker, 2005; Cebulla, Daniel, & Zurawan, 2010; Shah,
2004; Walsh, 2007).
The refugee patient’s complex problems represent a
challenge for all care levels. Language barriers, cultural
differences in symptom presentation and clinical severity
cause difficulties in understanding symptoms and ail-
ments. General practitioners, who are the main responsi-
bility for treating these patients, often experience that the
general treatment conditions are insufficient and that men-
tal health services do not offer adequate help, especially
regarding traumatization (Varvin & Aasland, 2009).
Furthermore, mental health professionals working with
refugees and asylum seekers are facing multiple difficul-
ties in providing adequate care. Interventions with refu-
gees and especially with asylum seekers are threatened by
the instability and uncertainty of treatment. Asylum seek-
ers are often relocated to another center or just ‘disap-
pear’ to unknown destination and cannot be followed. If
the appeal for asylum is refused, the group health insur-
ance is shortly terminated, thus resulting in a pre-mature
termination of therapy. Refugees and asylum seekers are
also at high risk of drop out of treatment due to different
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expectations of treatment, language problems, interpreta-
tion of symptoms and difficulties in communicating with
the therapist (Bhatia & Wallace, 2007; Van Loon, van
Schaik, Dekker, & Beekman, 2011). Finally, since mental
health problems are one of the reasons that could grant
asylum, therapists are often asked to indicate their patients’
illness. Some asylum seekers start to believe that the
improvement of their stress symptoms may decrease their
chance of getting a positive asylum decision (Renner,
Bänninger-Huber, & Pelzer, 2011), and may even exagger-
ate experiences of trauma in order to strengthen their
claims (Keller et al., 2003; Laban et al., 2004). These com-
plicated considerations undoubtedly effect the therapeutic
alliance, the outcome of treatment and the therapist’s atti-
tudes toward the patient, and pose a serious challenge to
mental health professionals.
For many years, most psychological treatments used in
rehabilitation programs appear to be a mixture of various
psychotherapeutic elements, not based on a consistent the-
ory, and lack evidence on their effectiveness (Başoğlu,
2006). Because most efficacy studies do not include
minorities in their sample, the literature in the field has
long debated whether the standard PTSD interventions,
such as cognitive-behavioral therapy (CBT) or eye move-
ment desensitization and reprocessing (EMDR), are appli-
cable to the refugee population or whether a phased model
starting with stabilization is preferable. While some clini-
cians (e.g. Başoğlu, 2006) argue that traumatized refugees
should be treated according to the standardized protocols
of CBT and EMDR, others (Laban, Hurulean, & Attia,
2009; National Institute for Clinical Excellence (NICE),
2005) argue that treatment should initially focus on daily
living problems and a restoration of coping skills.
According to the NICE (2005), trauma-focused therapy as
the initial stage of therapy should be considered as inap-
propriate and ineffective. Nevertheless, refugee and asy-
lum seeker patients tend to feel ambivalent about engaging
in trauma-focused CBT, mainly for the fear of repatriation
(Vincent, Jenkins, Larkin, & Clohessy, 2012).
Several authors (Bekker &Van Mens-Verhulst, 2008;
Bernal & Sáez-Santiago, 2006) have argued that the lack
of evidence-based treatments makes therapists in the field
confused and uncertain about the appropriate intervention.
In particular, training was needed regarding assessment
and therapeutic issues, involving culturally appropriate
interventions, cultural awareness, working with interpret-
ers, legal and social issues and trauma work (Maslin &
Shaw, 2003). The aim of the current article is to review the
evidence-based data regarding mental health interventions
designed especially for traumatized asylum seekers and
refugees.
Method
To locate studies for this review, we searched PsycINFO,
Entrez-PubMed and PsycARTICLES. Keywords ‘trauma’,
Slobodin and de Jong 3
‘asylum seekers’, ‘refugees’, ‘treatment’ and ‘interven-
tion’ were selected. These search terms narrowed the list of
articles to those of interest (studies of intervention used to
treat conditions of trauma among asylum seekers and refu-
gees and those that have already been screened for quality
by the peer review process).
In addition, we consulted previous review articles
(Crumlish & O’Rourke, 2010; McFarlane & Kaplan, 2012;
Murray, Davidson, & Schweitzer, 2010; Palic & Elklit,
2011) and contacted researchers who are known to be
engaged in treatment research with these populations.
The studies we retained had to meet two criteria. They
had to use some quantitative measurements of post-
traumatic stress and to have pre- and post-measurements
to evaluate the efficacy of the intervention. The studies
included in this review cover a wide variety of interven-
tions, including trauma-focused interventions, multidisci-
plinary interventions and pharmacological treatments.
Findings from the studies: mental
health interventions for refugees and
asylum seekers
While not claiming to be exhaustive, this review seeks to
describe the current, pivotal, findings with treating trauma-
related problems among refugees and asylum seekers.
Many treatment strategies and techniques have been devel-
oped and used worldwide to help asylum seekers and refu-
gees. However, only a minority of them used a known
research methodology which allows generalization. A sys-
tematic review (Crumlish & O’Rourke, 2010), including a
total of 10 randomized-controlled intervention studies
among refugees and asylum seekers with PTSD, revealed
that no PTSD treatment has been firmly supported by
research. There was evidence for the efficacy of narrative
exposure therapy (NET) and CBT. Nevertheless, a later
systematic review by Palic and Elklit (2011), which
included a wider spectrum of prospective designs (not only
randomized-controlled trials (RCTs)), concluded that CBT
and NET are two well-studied and effective interventions
among refugees. In a recent work, McFarlane and Kaplan
(2012) reviewed research evidence on psychosocial inter-
ventions for adult survivors of torture and trauma (reset-
tled refugees, asylum seekers, displaced persons and
persons resident in their country of origin). They identified
a total of 40 studies from 1980 to 2010 that investigated
interventions for adult survivors of torture, including RCTs
(11/40), non-RCTs (8/40) and single cohort studies (21/40).
While single cohort studies were the most common
approach in the field, RCTs examining the efficacy of
applied treatments with asylum seekers and refugees were
very few and included small samples. RCTs mainly exam-
ined individual psychotherapies that targeted PTSD
symptoms.
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NET
NET incorporates CBT and testimony therapy. It is specifi-
cally targeted at the refugee populations by acknowledging
the narrative tradition common to many cultures. Neuner
et al. (2010) carried out an RCT with 32 asylum seekers in
Germany. Participants with PTSD received treatment as
usual (public mental health care) or 5–17 sessions of NET.
The amount of ‘treatment as usual’ was not known. After
treatment, NET participants had significantly improved
PTSD and pain symptoms compared to treatment as usual.
There were no improvements in depression. However, at 6
months, all participants except one still had PTSD.
In a RCT, Hensel-Dittmann et al. (2011) compared the
outcome of NET and stress inoculation training (SIT)
among refugees and asylum seekers in Germany. This
study revealed that a significant reduction in PTSD symp-
toms was found for NET, but not for SIT. Major depression
and other comorbid disorders did not decrease in both
groups. In another NET trial, PTSD caseness at follow-up
was significantly lower among NET participants than
among supportive counseling or psychoeducation partici-
pants (Neuner, Schauer, Klaschik, Karunakara, & Elbert,
2004). The advantage of NET over supportive counseling
was not consistent across studies (Neuner et al., 2008),
although both interventions were superior to the no-
treatment condition (Neuner et al., 2008; Ruf et al., 2010).
Finally, Halvorsen and Stenmark (2010) reported moder-
ate therapeutic gains in 16 torture survivor refugees on
PTSD and depression measures. Taken together, NET
appears as an effective intervention in reducing PTSD
symptoms in traumatized refugees. However, it does not
have any advantage over treatment as usual when it comes
to anxiety and depression (Palic & Elklit, 2011).
CBT
CBT interventions for traumatized refugees are relatively
well researched and support the use of trauma-focused
CBT among refugees. The majority of firm evidence is
centered in special variants of CBT, which incorporates
cultural knowledge into standard CBT methods for
Southeast Asians. By using cultural study of symptoms
and their meaning, Hinton and his colleagues (Hinton
et al., 2005; Hinton, Hofmann, Pitman, Pollack, & Barlow,
2008) tested the applicability of a somatic-focused CBT to
traumatized Cambodian refugees. The treatment which is
called ‘Flexibility and Sensation-Reprocessing Therapy’
was based on a careful analysis of symptom presentation
among Cambodian refugees. This cultural phenomenology
of illness experience included a study of sensation-related
catastrophic cognitions, trauma associations, metaphors
and cultural expectations for treatment. In a RCT, Hinton
et al. (2005) reported that 12 patients (60%) in the immedi-
ate treatment group were in remission from PTSD after
4 International Journal of Social Psychiatry
their course of CBT, while none were in remission in the
control group. However, most of CBT trials were per-
formed among Cambodian refugees and half of them (2 of
4) were pilot studies with a moderate to high risk of bias
(Hinton et al., 2004; Otto et al., 2003). Integrating CBT
with other types of interventions has also revealed positive
results. Snodgrass et al. (1993) studied the effects of a
3-month CBT treatment that included coping skills group
with 11 Vietnamese refugees with PTSD symptoms.
Treatment consisted of six 3-hour weekly sessions (includ-
ing relaxation, CBT, psychoeducation, self-talk and role
modeling of stressful scenarios). Significant reductions in
PTSD symptoms and improved ability to relate to others
were found in treatment group but not in the control group
(no-treatment).
EMDR
In a pilot RCT comparing EMDR and stabilization in 20
traumatized refugees and asylum seekers, it was found that
EMDR and stabilization were equally accepted by patients,
with a high drop-out for both conditions. No participant
dropped out of the EMDR condition because of unman-
ageable distress. While improvement for EMDR partici-
pants was small, EMDR was found to be no less efficacious
than stabilization. The authors concluded that because
EMDR showed some improvement and stabilization
showing some deterioration between pre-treatment and
post-treatment, there is a rationale to integrate the two
approaches (Ter Heide, Mooren, Kleijn, de Jongh, &
Kleber, 2011).
Family interventions
Given the importance of the family in the aftermath of
trauma and the theoretical ease of including the social and
cultural context in systemic approaches to therapy
(Mendenhall & Berge, 2010; Shamai, 1999; Woodcock,
2001), family interventions are argued to be a suitable
approach for refugees (Allen & Bloom, 1994; Figley &
Figley, 2009; Ter Heide et al., 2011; Weine et al., 2003,
2004, 2005; Zagelbaum & Carlson, 2011). Although some
authors have described their experience with traumatized
refugee families, there is a dearth of evidence-based data
that would confirm the applicability of systemic family
intervention to these groups (Coulter, 2010; Weine et al.,
2008). In one of the few RCTs, Weine et al. (2008) showed
that multi-family group intervention increased the number
of mental health visits of Bosnian refugees compared to
no-treatment control group. This difference was constant
over time (6, 12 and 18 months following intervention),
and was observed in both primary participants and their
family members. However, this study did not evaluate the
efficacy of the intervention in reducing depression or
PTSD symptoms. In another study of Kataoka et al. (2003),
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CBT therapy with 2-hour optional multi-family group ses-
sions were assigned to Latino immigrant children in the
United States and their families (37% of parents attended
at least one session). Results showed that PTSD and
depressive symptoms significantly decreased in the inter-
vention group, but not in the control group. There was no
report whether engaging in the multi-family group ses-
sions had any advantage over CBT-only. In this study, only
a portion of the participants were randomized.
Group interventions
Research on group interventions among asylum seekers is
even rarer than individual approaches. Drozdek (1997)
recruited 120 Bosnian concentration camp survivors in the
Netherlands who were asylum seekers at the time. Most
were diagnosed with PTSD and were offered psychody-
namic group therapy, psychodynamic group therapy plus
medication or medication only. Control group was com-
posed of participants with PTSD who refused treatment.
No significant differences between the active interventions
were found for PTSD diagnosis. Recently, Drozdek,
Kamperman, Bolwerk, Tol, and Kleber (2012) evaluated
the effectiveness of three different trauma-focused day-
treatment group programs for treatment of PTSD in male
asylum seekers and refugees from Iran and Afghanistan.
The results of this study indicated that group psychother-
apy combined with nonverbal treatments significantly
improved the mental health of asylum seekers and refu-
gees with PTSD, as compared to a waiting list group.
Similarly, Renner et al. (2011) examined the efficacy of
group intervention in reducing post-traumatic symptoms,
anxiety, and depression symptoms among Chechen refu-
gees in Austria. Results indicated that the group interven-
tion was significantly superior to no-treatment condition,
but was equally effective as CBT. Individual EMDR
yielded negative results.
Multidisciplinary interventions
In addition to standard trauma-focused methods, several
studies employed a more integrative approach in working
with refugees and asylum seekers. Two studies evaluated
the efficacy of multidisciplinary treatment (psychotherapy,
family therapy and/or medication) in reducing psychiat-
ric symptoms in Hmong refugees (Westermeyer, 1988;
Westermeyer, Vang, & Neider, 1984) compared to a
control group of non-help-seeking participants. Both
studies suggested that depression and psychopathology
among Hmong refugees improved with multidiscipli-
nary outpatient treatment, and the gains were main-
tained after 2 years. However, the fact that the
intervention and control groups differed on relevant
variables at baseline limits their conclusions. In the last
decade, several non-experimental studies (without a
Slobodin and de Jong 5
control group) using multidisciplinary treatment were
published. All of them used psychotherapy, psychophar-
macological treatment and usually physiotherapy (Arcel
et al., 2003; Brune et al., 2002; Carlsson, Mortensen, &
Kastrup, 2005; Palic & Elklit, 2009). Except for Carlsson
et al. (2005), moderate to large effect sizes were found for
PTSD, anxiety, depression and global function. Given that
the majority of these studies are non-experimental, future
controlled studies of multidisciplinary treatments are war-
ranted (Palic & Elklit, 2011).
Naturalistic interventions
One of the prominent issues in the research of ethnic
minorities is the preference for naturalistic designs
(McFarlane & Kaplan, 2012), which is based on both theo-
retical and ethical/practical rationales (Silove,
Manicavasagar, Coello, & Aroche, 2005; Van Wyk &
Schweitzer, 2013). In a systematic literature review, Van
Wyk and Schweitzer (2013) examined the outcomes of
naturalistic interventions (provided within treatment set-
ting) to people from refugee background. They identified
only 7 eligible studies and pointed out a significant varia-
tion in the outcomes of naturalistic intervention studies,
with a trend toward showing decreased symptomatology at
post-intervention. However, conclusions were limited by
methodological problems of the studies reviewed, particu-
larly poor documentation of intervention methods and lack
of control group.
Pharmacological interventions
The pharmacological treatments of choice today for PTSD
are antidepressants from the subgroup selective serotonin
reuptake inhibitors, especially sertraline (Sonne, Carlsson,
Elklit, Mortensen, & Ekstrøm, 2013). There may be an
assumption that evidence from drug trials in the general
population applies to the refugee population in a way that
psychological interventions do not (Stein, Ipser, & Seedat,
2006). However, sufficient evidence is lacking to draw
conclusions on the efficiency of psychopharmacological
treatments of traumatized refugees with PTSD (Crumlish
& O’Rourke, 2010; Rohlof, 1995; Sonne et al., 2013).
Moreover, the NICE (2010) asserted that drug treatments
for PTSD should not be used as a routine first-line treat-
ment for adults (in general use or by specialist mental
health professionals) in preference to a trauma-focused
psychological therapy. Prescribing pharmacological treat-
ment to individuals coming from another culture requires a
careful consideration of issues such as variability of medi-
cation effects in different ethnic groups, compliance rates
and sensibility to side effects (Kroll et al., 1990; Lin,
Poland, & Lesser, 1986; Lin & Shen, 1991). High-quality
drug trials should be conducted in refugee populations, to
guide treatment when psychological interventions are
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unavailable or poorly tolerated (Crumlish & O’Rourke,
2010). Of note, a large Danish RCT (n = 150) of antide-
pressant treatment (sertraline or venlafaxine) and/or CBT
with traumatized refugees was assigned for 2013
(Sonne et al., 2013).
Discussion
The treatment of refugee populations is only recently con-
sidered as a distinct area in the field of mental health (De
Jong & Van Ommeren, 2002; Miller & Rasco, 2004). This
review points out the heterogeneous types and qualities of
interventions assigned for traumatized refugees and asy-
lum seekers and the shortage of evidence-based treatments
for these populations.
Currently, two directions of intervention are well-
researched and revealed promising results: the cultural
sensitive CBT and the NET; both incorporated culturally
sensitive attitude and techniques into the standard proto-
cols. Both strategies were studied with RCTs and yielded
large effect sizes. Other intervention studies are limited not
only by methodological problems (e.g. lack of RCTs, little
samples, etc.) but also by trying to use standardized
approaches to PTSD instead of basing them on a local
understanding of trauma and psychological distress in this
population (Crumlish & O’Rourke, 2010).
Contrary to some professionals’ view (Laban et al.,
2009; NICE, 2005) that stabilization should be preferred
over trauma-focused therapy when working with refugee
population, findings suggest that when culturally adapted,
standardized protocols of trauma-focused interventions,
such as CBT, could be suitable for traumatized refugees.
To our knowledge, there is no firm evidence that exposure
to traumatic contents in the therapeutic setting causes repa-
triation, fragmentation or worsening of symptoms.
However, further research is needed in order to identify
potential barriers to treatment.
Several theoretical and methodological considerations
in refugee trauma research arise from this review. First,
attention should be given to the complexity of employing
RCTs in refugee populations (Goodkind, LaNoue, Lee,
Freeland, & Freund, 2012; Kataoka et al., 2003; Silove
et al., 2005). It has been argued that RCTs are of use only
when studying narrowly defined groups of people under
artificial laboratory conditions, and thus their external
validity is questionable (Fuller, 1999). Goodkind et al.
(2012), who studied the efficacy of community interven-
tion for trauma in American Indian and Alaska Native
youth, indicated that a control group is not an appropriate
design when working with small communities, because the
interconnectedness of families increases the risk for con-
tamination across groups. Moreover, studies of immigrants
and refugees are often conducted within regular assistance
programs that do not allow for randomization due to prac-
tical and ethical considerations (i.e. it is unfair to prevent
6 International Journal of Social Psychiatry
treatment from some people while providing it to others)
(McDonald, 2009; Rimpela, 2000; Silove et al., 2005).
Some non-randomized studies used a control group of
individuals who did not seek mental help (Westermeyer
et al., 1984; Westermeyer, 1988) or refused it (Drozdek,
1997). These methods involve major methodological limi-
tations, such as differences in baseline condition and other
clinical and personality characteristics that may affect
treatment outcomes. These complexities should not auto-
matically lead health researchers to avoid RCT, but rather
call for the development of more sophisticated methods of
randomization, for example, those that involve dialogue
with patients and take patients’ needs and preferences into
account (Jadad, 1998).
Another important issue arising from this review is the
assessment of treatment efficacy. The majority of the stud-
ies reviewed here used the improvement of PTSD symp-
toms as an indicator to intervention efficacy. However, it
may be instructive to include other dimensions of person-
ality such as improvements in relationships, identity and
meaning (Victorian Foundation for Survivors of Torture,
1998). In addition, because refugees often present more
complex traumatic reactions to trauma reactions than those
strictly specified in the diagnostic category of PTSD,
effectiveness of PTSD treatments should address a boarder
range of trauma-related symptoms (Palic & Elklit, 2011).
In addition, the fact that many studies did not consider the
impact of participant characteristics (demographic varia-
bles, comorbidity, general functioning, etc.) on interven-
tion outcomes gives rise to questions about which factors
mediate the efficacy of intervention.
Future evaluation of intervention efficacy should take
into account the chronic, long-lasting consequences of
trauma among refugees and asylum seekers (Murray et al.,
2010). Although many treatments for traumatized refugees
revealed promising results, very few patients are actually
free from PTSD at the end of the intervention. Therefore,
Palic and Elklit (2011) asserted that focus on the long-term
treatment effects is needed before any conclusion about
treatment efficacy could be drawn.
While aiming to present an up-to-date review of the
central findings in the field, this review is obviously
limited by its non-exhaustive literature search. Due to the
limited number of evidence-based studies in the field, asy-
lum seekers were not distinguished from refugees,
although the two groups cope with different challenges. In
addition, the fact that articles in this review included dif-
ferent refugee populations limits their generalizability and
cannot supply conclusions toward the suitability of the
interventions for other refugee statuses or origins.
Nevertheless, this review has again highlighted the short-
age of guiding frameworks available to investigators and
clinicians who are interested in tailoring interventions to
work with refugees and asylum seekers. The challenge is to
develop evidence-based, culturally sensitive interventions
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that would reflect the different worldviews and cultural
backgrounds of clients (such as norms, customs, language,
lifestyle, etc.), incorporating clients’ ethnic, linguistic,
racial and cultural background into therapy (Zayas, Torres,
Malcolm, & DesRosiers, 1996). Additionally, it is impor-
tant to consider acculturation processes, such as accultura-
tive stress, phases of migration, developmental stages,
availability of social support and the one’s relationship to
his or her country or culture of origin (Bernal & Sáez-
Santiago, 2006).
Finally is the concern expressed by many professionals
(Harvey, 2007; Kramer & Bala, 2004; Papadopoulos,
2007; Tomasso, 2010) that existing research on refugee
mental health has overlooked the large majority of refu-
gees who display enormous capacities for resilience.
Although trauma and its sequel are targets for comprehen-
sive discussion, strength, growth and resilience have only
recently become the focus of attention (Murray & Zautra,
2012).
Because most resilience theories were developed within
Western populations, which mainly emphasizes individual
resilience, our understanding of resilience processes
among non-Western cultures is very limited (Ungar, 2008).
Many authors have underscored that individual models of
resilience are not sufficient and at times may even be
harmful (Bracken, 2002; Westoby, 2008). A community
resilience framework provides an important way of under-
standing human adaptation, in particular among cultures
with more collectivist values. Thus, there is a need for
additional research of the similarities and differences in
resilience processes across cultures (Ungar, 2008).
Conclusion
This article reviewed the current literature describing men-
tal health interventions for traumatized refugees and asy-
lum seekers. Up to date, CBT and NET arose as two
evidence-based and effective strategies for these popula-
tions. There is not enough data to confirm or refute alterna-
tive approaches, such as group intervention, family
intervention or multidisciplinary approach in working with
traumatized refugees and asylum seekers. In light of the
lack of methodologically rigorous trials in the field, it is
advisable that health promotion researchers should attempt
to develop randomized designs that are both appropriate
and feasible to refugee population rather than expending
research efforts on alternative methods. Future research
should go beyond the common, individualistic PTSD
approach to include the broad experience of forced migra-
tion, while incorporating in-depth knowledge of cultural
issues related to functioning and adaptation. A community
resilience framework can provide an important way of
understanding trauma and resettlement that is useful in
guiding research, intervention and advocacy. Systemic
interventions that recognize and foster communities’
Slobodin and de Jong 7
natural and adaptive ways of coping allow the community
to sustain its sense of agency and self-respect and enhance
positive adaptation in both individual and group levels.
In addition to the development of therapeutic interven-
tions for refugees, there is a need to consider the ethical
dilemmas that these services raise for professionals, such
as different expectation from interventions, mutual suspi-
cion and distrust, and therapist’s involvement in advocacy
aspects of the asylum procedure.
Acknowledgements
The authors gratefully thank Rob van Dijk for reviewing this arti-
cle and for his excellent comments.
Conflict of interest
The authors report no conflict of interests.
Funding
The review was made possible with the support of i-psy (intercul-
tural psychiatry).
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