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Individuals seeking asylum (asylees) typically experience several traumatic stressors before and during their asylum journey, as well as an extended period of uncertain living status following their arrival (Steel et al., 2006). As a result, they have significantly higher rates of posttraumatic stress than the general population (McColl & Johnson, 2006) and critically need effective trauma interventions. While research on effective treatments is only beginning to emerge, Culturally Adapted Cognitive-Behavioral Therapy (CA-CBT), Eye Movement Desensitization and Reprocessing therapy (EMDR), and Narrative Exposure Therapy (NET), have the most evidence of success among asylees with posttraumatic stress disorder (PTSD; e.g., Tribe et al., 2019; Turrini et al., 2021).
However, one concern when employing CA-CBT, EMDR, and NET is that the exposure therapy component of these interventions may reduce treatment engagement or increase dropout. Though exposure-based psychotherapies significantly outperform psychotherapies without an exposure component (Lee et al., 2016), higher dropout rates from these interventions have been observed (Swift & Greenberg, 2014). A preference for psychotherapies without an exposure component has been shown in the general population (Markowitz et al., 2016) but not among asylees. 
As the proportion of asylees receiving mental health care is significantly lower than the general population (Maier et al., 2010), understanding asylee perceptions of leading psychotherapies would provide valuable information for clinicians and researchers seeking to increase the treatment engagement of this population. To begin this work, we conducted virtual interviews with 40 US asylees from diverse countries living with symptoms of PTSD. In addition to questions about prior treatment engagement and barriers to treatment, we gathered participant perceptions of the effectiveness and difficulty of engaging in CA-CBT, EMDR, NET, and Interpersonal Therapy (IPT) for PTSD based on descriptions of each treatment. IPT is a non-exposure-based treatment with the most research support among asylees and refugees (Meffert et al., 2014).
All of our participants had directly experienced a traumatic event. 26 met the full criteria for PTSD or CPTSD (complex posttraumatic stress disorder), and 11 met all but one criterion. While there were no significant differences between asylees' perceptions of the effectiveness of each treatment, IPT was perceived to be less difficult than all other treatments. Most of our participants' qualitative comments about the perceived difficulty of each treatment also focused on exposure components or lack thereof. For example:
“I believe in the future, and I do not like to think about past experiences because they just make me scared. I want hope for the future, and to not think about the past.” - M, 39, Nigeria
This study gives voice to asylee perspectives on leading psychotherapies for trauma and illuminates asylees’ perceived barriers to receiving treatment. While the exposure element of some treatments may make it difficult to engage and retain some repeatedly traumatized individuals, it is important to note that these results do not mean that exposure-based interventions cannot be used with asylees. Rather, there is simply no one-size-fits-all approach for this population, and thoughtful consideration of asylees’ treatment goals will facilitate the best matching of treatment modality to each client. Further, there is a need for future research to examine factors that influence participant comfort with exposure work and how much differences in perceived difficulty of treatment impact potential therapeutic engagement and subsequent completion.
The primary limitation of this research is that reading an intervention description can never fully represent actual engagement in that therapy. However, our findings highlight that participants thought critically about the value of specific components of psychotherapy and shared rich perspectives about their therapy goals. Our most definitive conclusion is the necessity of including the voices of asylees in therapy research and in providing them greater agency in shaping their mental health care.

Implications for Clinicians

  • Exposure-based interventions are still the gold standard for PTSD treatment, but clinicians working with asylees should take extra care to address exposure-related concerns and should consider offering alternative interventions to asylee clients who are particularly averse to exposure.
  • For clinicians with little in common culturally with their asylee clients, following current best practices (e.g., APA, 1990; Asnaani and Hofmann, 2012) in discussing cultural barriers is especially important.
  • Working collaboratively with asylee clients to establish goals, expectancies, and timelines that are realistic to the therapeutic process and reflect the client's needs and strengths is critical. Clinicians should dedicate substantial time to explaining the intervention's goals, process, and rationale and frequently ask clients how they feel about the content of sessions.

Target Article

Cassidy, G. P., McQuaid, J., Heatherington, L., & Su, C. J. (2023). Asylee perspectives on psychotherapies for posttraumatic stressJournal of Traumatic Stress.

Discussion Questions

  1. What are some possible factors that might predict which potential clients are ready for, or willing to engage in, exposure-based treatments for trauma? 
  2. What are some ways in which clinicians can engage with clients early in treatment to assess the potential benefits of using one or another of these four treatment approaches?
  3. How might you describe the pros and cons of engaging in exposure-based treatments vs. non-exposure-based treatments to a potential patient who has never engaged in psychotherapy? 
  4. In thinking about the challenges of providing treatment to asylum seekers, what are some of the larger issues facing us as clinicians that cut across diagnoses and theoretical modalities? 

About the Authors 

Galen P. Cassidy, BA (they/he) graduated from Williams College in 2022 and is a Clinical Psychology Doctoral Student in the Laboratory for the Study of Anxiety Disorders at The University of Texas at Austin. Their research interests focus on the mechanisms of efficacy of psychotherapies for PTSD and other anxiety disorders and on improving and adapting these interventions for groups who have been historically underrepresented in the clinical psychology literature. Galen is the corresponding author for this study and can be reached at gcassidy@utexas.edu.

Jennifer McQuaid, PhD (she/her) is a Visiting Lecturer in the Department of Psychology at Williams College and an Assistant Clinical Professor at the Yale Center for Asylum Medicine. Her research, teaching, and clinical work focus on capacity-building in the network of legal-psychological-medical partnerships that addresses the needs of asylum seekers. She frequently serves as an expert witness providing forensic mental health evaluations to survivors seeking humanitarian relief on the grounds of gender-based violence and other forms of persecution. Jennifer can be reached at jmcquaidphd@gmail.com

Laurie Heatherington, PhD is Edward Dorr Griffin Professor of Psychology, emerita, at Williams College, Williamstown, MA, USA. She has published widely in journals and books on her research about processes of interpersonal and cognitive change in family therapy and therapeutic interventions in community and global mental health settings. She is Past-President of the North American Chapter of the Society for Psychotherapy Research and was the 2010 co-recipient of the Distinguished Contribution to Family Systems Research award by the American Family Therapy Academy.

Chi Jiun Su (she/her) will graduate from Williams College in June 2023 and will pursue a post-baccalaureate research position and Clinical Psychology Ph.D. following her BA degree. Her research interests include mechanisms of change in psychotherapy, emotion regulation strategies across development, and the neurobiological mechanisms underlying psychopathology.    

References Cited

APA. (1990). Guidelines for providers of psychological services to ethnic, linguistic, and culturally diverse populations. https://www.apa.org/pi/oema/resources/policy/provider-guidelines

Asnaani, A., & Hofmann, S.G. (2012). Collaboration in multicultural therapy: Establishing a strong therapeutic alliance across cultural lines. Journal of Clinical Psychology, 68(2), 187-197. https://doi.org/10.1002/jclp.21829

Lee, D.J., Schnitzlein, C.W., Wolf, J.P., Vythilingam, M., Rasmusson, A.M. & Hoge, C.W. (2016). Psychotherapy versus pharmacotherapy for posttraumatic stress disorder: Systemic review and meta-analyses to determine first-line treatments. Depression and Anxiety, 33(9), 792-806. https://doi.org/10.1002/da.22511

Maier, T., Schmidt, M., & Mueller, J. (2010). Mental health and healthcare utilization in adult asylum seekers. Swiss Medical Weekly, 140, w13110. https://doi.org/10.4414/smw.2010.13110

Markowitz, J.C., Meehan, K.B., Petkova, E., Zhao, Y., Van Meter, P.E., Neria, Y., Pessin, H., & Nazia, Y. (2016). Treatment preferences of psychotherapy patients with chronic PTSD. The Journal of Clinical Psychiatry, 77(3), 363-370. https://doi.org/10.4088/jcp.14m09640

McColl, H., & Johnson, S. (2006). Characteristics and needs of asylum seekers and refugees in contact with London community mental health teams. Social Psychiatry and Psychiatric Epidemiology, 41(10), 789-795. https://doi.org/10.1007/s00127-006-0102-y

Meffert, S.M., Abdo, A.O., Alla, O.A.A., Elmakki, Y.O.M., Omer, A.A., Yousif, S., Metzler, T.J., & Marmar, C.R. (2014). A Pilot Randomized Controlled Trial of Interpersonal Psychotherapy for Sudanese Refugees in Cairo, Egypt. Psychological Trauma, 6(3), 240-249. https://doi.org/10.1037/a0023540

Steel, Z., Silove, D., Brooks, R., Momartin, S., Alzuhairi, B., & Susljik, I. (2006). Impact of immigration detention and temporary protection on the mental health of refugees. British Journal of Psychiatry, 188(1), 58-64. https://doi.org/10.1192/bjp.bp.104.007864

Swift, J.K., & Greenberg, R.P. (2014). A treatment by disorder meta-analysis of dropout from psychotherapy. Journal of Psychotherapy Integration, 24(3), 193. https://doi.org/10.1037/a0037512

Tribe, R.H., Sendt, K.V., & Tracy, D.K. (2019). A systematic review of psychosocial interventions for adult refugees and asylum seekers. Journal of Mental Health, 28(6), 662-676. https://doi.org/10.1080/09638237.2017.1322182

Turrini, G., Tedeschi, F., Cuijpers, P., Del Giovane, C., Kip, A., Morina, N., Nosè, M., Ostuzzi, G., Purgato, M., Ricciardi, C., Sijbrandij, M., Tol, W., & Barbui, C. (2021). A network meta-analysis of psychosocial interventions for refugees and asylum seekers with PTSD. BMJ global health, 6(6), e005029. https://doi.org/10.1136/bmjgh-2021-005029