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Adapting Interventions for
Refugee Youth:
Trauma Systems Therapy for
Somali Adolescent Refugees
B. Heidi Ellis
Alisa Miller
Saida Abdi
And the Project SHIFA team: Naima Agalab, Abdi Yusuf, Colleen Hayden, Molly
Benson, Lee Staples, Ellen Devoe, Deb Socia, Hassan Warfa, Yolanda Coentro,
Imani Seularine, Amy Spindel, Glenn Saxe, Lisa Baron, Bob Kilkenny
Children’s Hospital Center for
Refugee Trauma
A project under the Robert Wood Johnson Foundation’s
Caring Across Communities program
Overview
• Need
• Overview of Trauma Systems Therapy
• Process and principles of adapting treatment
for refugees
• Questions for the field
Local Data:
Somali
Youth
Mental
Health
Needs
Trauma exposure
Trauma exposed
Not exposed
94%
•Youth reported
having experienced
on average 7
traumatic events
(range 0-22)*
* Ellis, et al. (2008). Mental health of Somali adolescent refugees: The role of trauma, stress, and
perceived discrimination. Journal of Consulting and Clinical Psychology, 76, 184-193.
PTSD
33%
38%
Full PTSD
Partial PTSD
No PTSD
•Nearly 2/3 of youth
reported significant
PTSD symptoms,
and 1/3 screened
positive for Full
PTSD*
29%
* Ellis, et al. (2008). Mental health of Somali adolescent refugees: The role of trauma, stress, and
perceived discrimination. Journal of Consulting and Clinical Psychology, 76, 184-193.
Service utilization
Of those with full PTSD, how many sought
services of any type?
8%
No Services
Sought services
92%
* Ellis, et al. (2008). Mental health of Somali adolescent refugees: The role of trauma, stress, and
perceived discrimination. Journal of Consulting and Clinical Psychology, 76, 184-193.
Goal
• Provide trauma informed care to Somali
youth that is
A) accessed
B) effective
Challenge
• Few models of care for refugees
• Fewer with empirical support
• Fewer still adapted for Somali
community/culture
Revised Goal
• Adapt and evaluate a trauma intervention
model for Somali adolescent refugees
Trauma Systems Therapy for
Refugees
Social-Ecological Model
Culture
Neighborhood
Peer Group
School
Family
Individual
Trauma Systems Therapy (TST)
. . . Is about a traumatized child who
has trouble regulating emotions, a
social environment that cannot help
contain or even triggers this
dysregulation, and the interface
between emotion regulation and the
social environment.
Service Elements
Cultural
Psychiatry
leaders/ MAAs
Skill-based
Psychotherapy
Home-Based
Legal
advocacy
TST: Fit with refugees
• Emphasis on social environment and
acknowledging core role of environmental
stress in child’s symptoms
• Inclusion of advocacy
• Integration of systems
• Strong community-based components
• Fidelity is measured flexibly, via principles
Adaptation #1:
Continuum of care
Prevention
Community education/
anti stigma
School/teacher trainings
School-based
youth groups
Early
identification
and
intervention
TST
Intensive
intervention
Adaptation #2: Continuum of
cultural competence
Service system
Somali community
Teachers and
school staff
educated in
culture and
trauma
Raised awareness
of School-based
clinicians
Clinicians on
SHIFA team gain
expertise in Somali
culture
Religious and
Parent leaders
educated about
mental health,
support youth
access to care
Somali MAA staff
gain knowledge
of MH
Somali BUSSW
graduates join
MH profession
Process of
Adapting
Interventions
for Refugees
Principles of Adaptation
1. True partnership with the community
– Community Based Participatory Research
Religious leaders
Family Advisory Board
Leadership Team
Clinical
team
Principles of Adaptation
2. Flexible approach, learn as we go
Process of Adaptation:
Comprehensive Dynamic Trials- Continuous Quality Improvement
(CDT-QI; Rapkin & Trickett, 2005)
Intervention
implemented and
evaluated
TST
identified for
adaptation with
Somali refugee
group
Program Advisory
Committee
identified measures
of fit and outcomes
that are important
to the community
“Lessons
Learned”
incorporated
into intervention,
adapted
intervention
Program Advisory
implemented
Committee reviews
and recommends
adaptations as needed
Principles of Adaptation
3. Evaluate in stages
– Accessed?
– Accepted?
– Effective?
Access
• 100% of those referred for services enrolled in
treatment (n=40)
– 100% of those who have enrolled in treatment have
remained in treatment (duration of treatment range 0-7
months)
– 80% of those in individual treatment were referred from
group
– 8 parents have contacted program asking for additional
services for sibling
– 4 parents approached independently asking for services
for their children
Adapting interventions for Refugees:
Questions for the field
• What constitutes an adaptation?
– Change in language or content of the intervention?
– The infrastructure you build around the core
intervention that allows access?
– The process of community outreach that accompanies
the successful implementation of an intervention with a
new group?
• Is the goal to be culture-specific, or to find
adaptations that generalize among refugees?
Evaluating interventions for
Refugees:
Questions for the field
• What constitutes a successful intervention
for refugees?
– Is a change in symptoms among treated
individuals meaningful if most refugees are not
engaging in services?
– Do we document, manualize, and ‘count’
collateral work outside the core intervention?
Is this work actually an essential ingredient of
the intervention?
Do we need alternatives to the
RCT?
• Limitations to RCT in Community Based Research
(Rapkin & Trickett, 2005)
– Random assignment
• Ethics of other conditions: what if there are no viable alternatives for
this linguistic/cultural group? How does community perceive
‘denying’ a child a certain service?
– Independence
• community involvement leads to change across the whole group from
which participants are drawn
• Adjustment of one youth may affect adjustment of others
– Adherence to strict fidelity and no systematic way to capture
or further incorporate “lessons learned”
• Particularly important when working with groups for whom there is
little evidence base to draw from