Mental health professionals' perspective on a brief transdiagnostic psychological intervention for Afghan asylum seekers and refugees.

Background: While many elaborated treatment protocols focus on post-traumatic stress symptoms, a large number of refugees suffer from a range of mental health problems. Thus, brief and transdiagnostic psychological interventions may be helpful first interventions for help-seeking refugees and asylum seekers in a stepped-care approach. Critically, there is limited research on how transdiagnostic interventions are received in general practice in non-specialized mental healthcare settings in high-income countries, where often only mental health professionals (MHPs) are legally allowed to treat people with mental disorders. MHPs may thus deliver such interventions, but their perspective towards them has not yet been investigated. Objective: We aimed to investigate MHPs' perception of the usability of adapted Problem Management Plus (aPM+), a brief transdiagnostic psychological intervention for refugees, which we adapted to address distress caused by post-migration living difficulties (PMLDs). Method: Employing an e-learning tool, we introduced the aPM+ intervention to 59 MHPs and assessed their perspective towards the intervention. We then used an inductive approach to analyse their perspective towards the intervention with open-ended questions.
Results: Altogether, 59 MHPs enrolled in the webinar and 29 provided feedback on the intervention. MHPs had a positive view on the intervention but emphasized the importance of situation-specific adaptations to the structure of the manual. The most favoured specific strategies were 'managing stress/slow-breathing', the 'tree of capabilities', and the 'riding the anger' exercise. The last two were additionally developed to reduce distress caused by PMLDs by either enhancing self-efficacy or reducing anger regulation difficulties. Conclusions: An adaptation to aPM+ regarding more flexibility of the manual may enhance the likelihood of MHPs implementing the intervention in their daily practice. Strategies addressing coping with PMLDs could be particularly helpful.Trial registration: German Clinical Trials Register identifier: DRKS00016538. HIGHLIGHTS: Mental health professionals had a positive view on a brief transdiagnostic psychological intervention for refugees but emphasized the importance of situation-specific adaptations to the structure of the manual.Low -intensity interventions may be useful not only in low- and middle-income countries but also in high-income countries as part of a stepped-care approach, even if distributed by MHPs instead of trained laypersons.

Introduction

Refugees and asylum seekers often suffer from a wide range of mental disorders, including post-traumatic stress disorder (PTSD), depression, and anxiety disorders (Turrini et al., 2017). Traumatic events and hardship experienced in the country of origin, during flight, and in the host country [post-migration living difficulties (PMLDs)] all predict poor mental health and greater difficulties in adapting to the host country (Alemi, James, Cruz, Zepeda, & Racadio, 2014). While there is growing evidence for the efficacy of treatments for PTSD, there is only emerging evidence for the efficacy of so-called low-intensity and transdiagnostic interventions (Koesters, Barbui, & Purgato, 2018). These latter interventions were mostly developed to address a lack of mental health professionals (MHPs) in low- and middle-income countries. Nevertheless, in high-income countries, these interventions could improve mental healthcare for asylum seekers and refugees within a stepped or collaborative care system (Sijbrandij, 2018). In general practice, the large number of people seeking help exceeds the capacity of specialized therapy facilities, resulting in long waiting lists. Not receiving psychological support at critical time-points could be associated with a higher risk of mental health deterioration and chronification (Giacco, 2020). A stepped-care model has been recommended as one of the possible cost-effective solutions to reduce the existing health burden (Trilesnik et al., 2019). Within stepped care, evidence-based psychological treatments are distributed across different levels of increasing therapy intensity, and individuals are assigned according to their individual needs. Low-intensity therapy may be considered as a stand-alone treatment or as preparation for more specialized treatment services (Härter et al., 2018). Furthermore, barriers to treatment acceptance may be reduced by low-intensity treatments that do not focus on traumatic experiences, facilitating motivation for more intense trauma-focused therapy, if needed (Giacco & Priebe, 2018). In recent years, a few transdiagnostic treatment programmes aiming to reduce distress in refugees have been evaluated (Bolton et al., 2014; Dawson et al., 2015; Koch, Ehring, & Liedl, 2020; Tay et al., 2020; Van Heemstra, Scholte, Haagen, & Boelen, 2019). In a stepped-care approach, MHPs working in primary care who are not specialized in refugee care can deliver such interventions. MHPs’ acceptance and perception of the usability of these interventions is thus crucial for their potential implementation in care systems. However, MHPs’ perspective towards the feasibility and acceptability of such an intervention has not been investigated yet. A brief webinar may provide a similar experience to a first session of a full intervention training, and participants in such a webinar could provide important information regarding their perception of the content and identify potential early barriers to implementation. In the present study, we aimed to survey MHPs’ opinions about a brief, transdiagnostic psychological intervention that was adapted for the context of Afghan refugees living in Austria, called adapted Problem Management Plus (aPM+).

Methods

Intervention

The intervention presented to MHPs was an adapted version of Problem Management Plus (aPM+) (World Health Organization, 2016), which is a transdiagnostic, low-intensity psychological treatment. The original PM+ manual was developed for adults suffering from symptoms of common mental health problems (including depression, anxiety, stress, or grief), as well as self-identified practical problems (including unemployment and interpersonal conflicts) (Dawson et al., 2015). It is not a specific trauma-therapy method, but can be considered as a trauma-informed approach as it was developed to provide help for adults impaired by distress in communities exposed to adversity. In the initial phase of our study, we developed an additional sixth session for the intervention that aimed to reduce the burden caused by PMLDs, and thus termed the intervention ‘adapted PM+’ (aPM+). We evaluated the effectiveness of the intervention in a randomized controlled trial study (Knefel et al., 2022). The aPM+ manual comprises of six weekly, individual face-to-face sessions based on six cross-cutting core therapeutic strategies: ‘Managing Stress’, ‘Managing Problems’, ‘Get Going, Keep Doing’, ‘Strengthening Social Support’, ‘Anger Regulation’, and ‘Increasing Self-efficacy’. The first four strategies are part of the original PM+ manual (World Health Organization, 2016) and the last two were developed as part of a pilot study interviewing experts in the field (Knefel et al., 2020). ‘Managing Stress’ aims to optimize the initial mastery of stress and other symptoms, as well as to enhance relaxation with a slow-breathing exercise. ‘Managing Problems’ aims to support individuals to take control of their problems with basic problem-solving skills. ‘Get Going, Keep Doing’ aims to increase the opportunity for positive reinforcement from the environment by behavioural activation, addressing inertia. ‘Strengthening Social Support’ aims to optimize a person’s capacity to re-engage with their peer group and elicit support from others. The additional session, developed by the research team, focuses on either one of the two therapeutic strategies ‘Anger Regulation’ or ‘Increasing Self-efficacy’ in relation to PMLDs. These strategies were developed to improve psychological coping with PMLDs. To foster participants’ self-empowerment, they can decide during treatment whether they prefer a session on improving anger regulation or one on increasing self-efficacy, depending on their subjective needs and preferences. ‘Anger Regulation’ aims to develop skills for the management of intense anger and aggression. It combines strategies from existing treatment manuals [Skills Training in Dialectical Behavior Therapy (Linehan, 2015); STARK manual (Koch et al., 2020)] and includes psychoeducational aspects on emotion regulation as well as a regulation strategy, ‘riding the anger’, which follows the principles of radical acceptance of emotions and responding with opposite actions. ‘Self-efficacy’ follows an empowerment principle and is rooted in a systemic psychotherapy approach (Röhrbein, 2019). It comprises an exercise, the ‘tree of capabilities’, helping participants to reidentify with their competences and strengths. The last session also includes relapse prevention by identifying individual early warning signals and recapitulating the strategies from the previous sessions (Dawson et al., 2015). In total, the aPM+ intervention comprises six weekly 90 min face-to-face sessions.

Webinar and procedure

To investigate MHPs’ perspective on aPM+, we developed a 90 min e-learning session (webinar). The session included general information about aPM+, and six learning packages for each aPM+ session, with several questions to self-test one’s learning progress. To host the webinar we used moodle, a free and open-source learning management system that is widely used in academic institutions. We provided written information material, audio records, and videos explaining the core components of the intervention, and exemplified them with role-play. Participation was rewarded with credit points for mandatory continuing training and education. We utilized a judgement sampling approach and invited MHPs (clinical psychologists, psychotherapists, and psychiatrists) via different communication paths, including sending e-mail invitations to specialized care facilities and promoting the webinar in online lectures. We aimed to reach participants with and without experience in refugee care. MHPs with experience in refugee care may be able to provide critical feedback on the intervention, while those with little to no experience can provide important information on the potential of the intervention to empower less experienced MHPs. After finishing the webinar, participants could evaluate the presented intervention. We used open-ended questions to assess MHPs’ opinions regarding helpful and problematic aspects of aPM+, which sessions they would use in their clinical work, and any improvements to aPM+ that they would suggest. We assessed the overall evaluation of aPM+ through a five-point scaled question and, finally, personal characteristics and professional background.

Analysis

MHPs’ answers to the open-ended questions (data set) were transferred to MAXQDA software (VERBI Software, 2019). For the purpose of data organization, we divided the data set into three topics: positive feedback, critical comments, and suggestions for improvement. We used an inductive approach of thematic analysis to analyse the MHPs’ responses. First, two researchers coded all answers independently, compared the results, and agreed on a final set of codes. Secondly, they analysed all codes thematically, reviewed the resulting themes in relation to the codes and underlying quotes, and agreed on final key themes (Braun & Clarke, 2006). They solved disagreement by discussion and by consulting a third researcher. All relevant quotes (Q) are presented in Table S1 in the supplementary material. To depict the overall evaluation of aPM+, we tabulated participants’ responses to the quantitative question. We used non-parametric Spearman’s correlations to explore the association of years of work experience with refugees with the two quantitative questions.

Results

Overall, 59 MHPs enrolled in the webinar, 29 answered the quantitative single-choice questions (Table 2), and 25 provided written feedback to the open-ended questions (Table S1, supplementary material). Sample characteristics are provided in Table 1.

Table 2.

Mental health professionals’ quantitative feedback on aPM+ (single choice).

Statements	Strongly agree	Agree	Undecided	Disagree	Strongly disagree	ρa
I find the webinars’ contents interesting	21 (72.4)	7 (24.1)	1 (3.5)	0	0	−.120
I would utilize aPM+ in my practical work	12 (41.4)	12 (41.4)	4 (13.8)	1 (3.5)	0	−.381

Note: N = 29. Data are shown as n (%). aSpearman’s rho, correlation with years of work experience with refugees; both values were not significant (p > .05).

Table 1.

Participants’ characteristics.

Gender (female), n (%)a	24 (88.8)
Age (years), M (SD)b	35.9 (14.4)
Mental health profession, n (%)b
Clinical and health psychologist	21 (75.0)
Clinical and health psychologist, in training	1 (3.7)
Psychotherapist	6 (21.4)
Psychotherapist, in training	6 (21.4)
Psychiatrist	2 (7.1)
Psychiatrist, in training	1 (3.7)
Others	2 (7.1)
Years of professional experience, M (SD), rangec	10.4 (6.8),2–29
Percentage of current work with refugees/asylum seekers, M (SD), ranged	24.4 (31.6),1–100
Percentage of current work with people with migration background, M (SD), rangee	41.3 (24.5),6–91

Note: Total N = 29; an = 27; bn = 28; cn = 26; dn = 22; en = 23.

The MHPs’ quantitative and qualitative feedback on aPM+ was generally positive. The majority found the content of the webinar interesting and more than 82% would utilize aPM+ in their practice (Table 2). MHPs with more work experience with refugees were less likely to report that they would use the intervention in their practical work. They particularly favoured its clear structure and short duration, as well as the compact and easily comprehensible content (Q1.1a–d): ‘The clear and easy structure is very helpful (e.g. Managing problems in small steps: Choosing a problem, brainstorming possible solutions, choosing helpful strategies, developing [sic] action plan, etc.)’ [Q1.1a; male (M), 39 years, clinical and health psychologist, in psychotherapy training]. The flexible use and low-threshold access were also described as beneficial (Q1.2). When asked about their preferred strategies, most of the MHPs mentioned managing stress/slow-breathing (Q1.3): ‘The stress management strategy/breathing exercise is useful for all my clients’ [Q1.3a; female (F), 44 years, psychiatrist]. Some perceived all strategies as useful (Q1.3b). Additional strategies that were favoured included improving self-efficacy or managing feelings of aggression (both from the additional sixth session), problem management, and reactivating pleasant and task-oriented activities (Q1.3c–f): ‘I liked especially the session to improve feelings of self-efficacy and to regulate feelings of anger’ (Q1.3c and d; F, 55 years, psychotherapist).

Some perceived the structure as too rigid (Q2.3) or had concerns about the limited number of sessions (Q2.1): ‘In general, I think it is important to have enough time to develop a therapeutic relationship and to invest more time to establish rapport. I think due to the shortness of the programme there is not much time scheduled for that’ (Q2.1b; M, 37 years, clinical and health psychologist, in psychotherapy training). Others noted that some strategies (e.g. managing problems) require internal (e.g. cognitive skills, self-reflection) or external (e.g. solvable problems) prerequisites (Q2.2).

Suggestions for improvement were heterogeneous and included ideas for additional strategies for managing traumatic stress and stress-related symptoms (Q3.1), structural adaptations and additional content (Q3.2), dealing with challenges of migration (Q3.3), and facilitating long-term effects (Q3.4): ‘After completing the training, follow-up or refresher sessions (a couple of weeks or months later) might be helpful in order to see if clients use the strategies in their daily life, to repeat single strategies, or just to motivate them’ (Q3.4a; F, 37 years, psychiatrist). All resulting themes, subordinated codes, and representative quotes are provided in Table S1 (supplementary material).

Discussion

Overall, MHPs rated the aPM+ intervention positive, and favoured its clear structure, short duration, and compact and easily comprehensible content. Together with diverse recommendations for adaptation, favoured strategies, and concerns, our study suggests that MHPs may use the intervention in a more flexible manner compared to the strongly structured manual.

MHPs positively valued the collection of simple but useful psychosocial interventions and material supporting facilitation of these interventions. They often directly or indirectly emphasized the importance of situation-specific adaptations to the structure of the intervention, depending on their clients’ living situations and needs. Adapting manualized clinical interventions to specific needs in routine mental healthcare settings may be necessary to sustain evidence-based practice (Swain, Whitley, McHugo, & Drake, 2010). The most favoured specific strategies were managing stress/slow-breathing, the tree of capabilities, and the riding the anger exercise. The last two were from the additionally developed session aiming to reduce distress caused by PMLDs by either enhancing self-efficacy or reducing anger regulation difficulties, supporting this adaptation. The favoured strategies all follow a non-cognitive approach, either by using body-oriented strategies such as controlling one’s breath or responding to anger with opposite actions, or by using a graphically supported intervention. These strategies may allow for a type of therapy that is less cognitive- and language-based, which could be particularly fruitful in settings where language barriers restrict therapeutic interventions.

The MHPs did not report any fundamental resistance to using aPM+. MHPs with more work experience with refugees were less likely to use the interventions than those with less experience. Given that the legal situation in Austria prohibits lay therapists from treating people with mental disorders, MHPs with less experience in refugee care, in particular, may be able to offer evidence-based short-term psychological support to refugees if they receive brief training. Thus, they might provide important primary mental healthcare for refugees even if they are not specifically trained in trauma-specific or trans-cultural treatments. An e-learning session to train MHPs could pave the way for future implementation as part of a stepped-care approach, where many help-seeking refugees may find help soon. Consequently, such an approach may contribute towards relieving pressure on the healthcare system, because only those with resistant or reoccurring problems may need to seek help from the next step, such as specialized treatment facilities (Härter et al., 2018). Low-intensity interventions may be useful not only in low- and middle-income countries (Koesters et al., 2018) but also in high-income countries (Sijbrandij, 2018), even if distributed by MHPs instead of by trained laypersons.

The specific legal regulations, which differ from country to country, limit the generalizability of our study. Lay-therapist-delivered interventions for people with mental disorders may or may not be prohibited depending on national regulations. Furthermore, even if MHPs were trained to use aPM+, rolling out such an intervention depends on language skills and interpreters may often be needed. However, access to interpreters may rarely be easy. Finally, we only assessed MHPs’ opinion and views on the intervention following a webinar and cannot conclude what their real actions would be if they were to use the intervention. Future research should include MHPs who have experience in using the intervention. Furthermore, it is important to remember that refugees and asylum seekers face different obstacles compared to people with a migration background, and interventions should differentially be adapted to their needs. Clinical trials should investigate the effectiveness of aPM+ in different populations.

Ethics

The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Declaration of Helsinki of 1975, as revised in 2013.

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