Dohrmann, Katalin
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“It is worth hanging in there” – Psychotherapeutic experiences shaping future motivation for outpatient psychotherapy with refugee clients in Germany
Background: A high prevalence of mental disorders in refugees contrasts with a low rate of treatment and limited access to health care services. In addition to pre-, peri- and post-migration stress, language, cultural barriers together with lack of information about cost reimbursement, and access to German (mental) health care institutions are discussed as barriers to use of available services. Such barriers together with insufficient experience of treating traumatized refugee clients may lower therapists’ motivation and facilities to accept refugee clients. A model project called “Fearless” trained, and supervised therapists, translators, and peer counsellors to reduce these barriers and increase therapists’ motivation and engagement in future treatment of refugees. Methods: From a total 14 therapists participating in the project N = 13 were available for semi-structured interviews. The interviews were scheduled during or after their outpatient psychotherapy of refugee clients and lasted one hour on average. Based on qualitative assessment strategies, open questions addressed the therapists’ experience of challenges, enrichments, and motivation throughout the therapy. Therapists’ responses were analyzed using content structuring qualitative content analysis. Results: Three major challenges modulated therapists’ future motivation for treating refugee clients: specific bureaucratic efforts (e.g., therapy application), organizational difficulties (e.g., scheduling appointments), and clients’ motivation (e.g., adherence, reliability). Still, most interviewed therapists ( n = 12) evaluated the therapy as enriching and expressed their motivation to accept refugee clients in the future ( n = 10). Conclusion: Results recommend the reduction of bureaucratic effort (e.g., regular health insurance cover for all refugees) and implementation of organizational support (e.g., peer counsellors) in support of therapists’ motivation for future treatment of refugee clients. Further structural support e.g., with organizing and financing professional translators and referring refugee clients to psychotherapists should be deployed nationwide. We recommend the training in, and supervision of, the treatment of refugee clients as helpful additional modules in psychotherapy training curricula to raise therapists’ motivation to work with refugee clients.
Gewalterfahrungen und psychische Gesundheit im Verlauf bei unbegleiteten minderjährigen Flüchtlingen in Deutschland
Hintergrund: Über die seelische Gesundheit von minderjährigen Flüchtlingen, die ohne sorgeberechtigte Person nach Deutschland gereist sind, liegen bisher kaum Daten und keinerlei längsschnittliche Untersuchungen vor. Fragestellung: Ziel ist es daher, die psychische Gesundheit im Zusammenhang mit stressvollen Erfahrungen (insbesondere familiäre und organisierte Gewalterfahrungen) sowie deren Entwicklung nach etwa zwei Jahren bei unbegleiteten minderjährig Geflüchteten in Deutschland zu untersuchen. Methode: In einer Querschnittsstudie wurden belastende Erlebnisse sowie posttraumatische, depressive und psychosomatische Symptome bei 57 unbegleiteten und 22 begleiteten minderjährig eingereisten Flüchtlingen mittels strukturierter klinischer Interviews untersucht. Nach durchschnittlich 20 Monaten wurde eine Subgruppe der unbegleiteten Minderjährigen erneut untersucht. Ergebnisse: Ein Drittel der Teilnehmer erfüllte die Kriterien einer PTBS-Diagnose (Posttraumatische Belastungsstörung) nach DSM-IV. Nach Einbezug einer Gruppe begleiteter minderjähriger Flüchtlinge zeigte sich, dass vor allem organisierte und familiäre Gewalterfahrungen sowie die Dauer der Flucht bedeutsame Prädiktoren hinsichtlich der PTBS-Symptomschwere waren. Für das psychische Wohlbefinden insgesamt waren die erfahrene Gewalt in der Herkunftsfamilie, bestehende Freundschaften und das Vorhandensein von Privatsphäre relevant. Ergebnisse einer Folgeuntersuchung mit einer Teilgruppe der UMF etwa 20 Monate später zeigten, dass die psychische Beeinträchtigung im Durchschnitt unverändert hoch geblieben war. Fazit: Die Möglichkeit einer frühzeitigen psychologischen Untersuchung mit Erfassung kindlicher Gewalterlebnisse sowie ein verbesserter Zugang zu einer traumafokussierten Behandlung mit Sprachmittlern sind wichtig, um Leid zu reduzieren und Integration zu ermöglichen.
Are experiences of family and of organized violence predictors of aggression and violent behavior? : A study with unaccompanied refugee minors
Background: There is strong support for familial abuse as a risk factor for later delinquency and violent offending, whereas empirical evidence about the contribution of experienced organized violence to the cycle of violence is less clear. Nevertheless not all abused children do become violent offenders. This raises the question of which factors influence these children’s risk of future aggressive behavior. Recent evidence suggests that the trait of appetitive aggression plays an important role in the prediction of aggressive behavior.
Objective: The focus of the study is to investigate whether exposures to 1) organized; and 2) family violence equally contribute to aggressive behavior and how this is related to a trait of appetitive aggression. Furthermore it is of interest to uncover how the severity of posttraumatic stress disorder (PTSD) symptoms modulates associations between violent experiences and aggression.
Method: To answer these questions, we investigated unaccompanied refugee minors who had been exposed to varying levels of both violence types. Using structured interviews, experiences of organized and familial violence, self-committed aggressive acts, the trait of appetitive aggression, and PTSD symptoms were assessed in 49 volunteers.
Results: A sequential regression analysis revealed that the trait of appetitive aggression and experienced family violence were independent and significant predictors of self-committed aggressive acts, altogether accounting for 70% of the variance. Exposure to organized violence, however, was not significantly associated with aggressive acts or appetitive aggression. PTSD symptom severity was not correlated with measures of aggression but with the exposure to familial and organized violence.
Conclusions: Results suggest that in addition to the impact of family violence, an elevated trait of appetitive aggression plays a crucial role in aggressive behavior and should be considered in psychotherapeutic treatment.
Tuning the tinnitus percept by modification of synchronous brain activity
Purpose: Tinnitus, the perception of sound without the presence of a physical stimulus, provides the opportunity to study neural codes of percepts without simultaneous processing of stimuli. Previously, we have found that tinnitus is associated with enhanced delta- and reduced tau-power in temporal brain regions. By operantly modifying corresponding aspects of spontaneous EEG activity, the aim of the present study was to corroborate the assumption that tinnitus should be reduced if patterns of ongoing synchronous brain activity are normalised.
Methods: In response to different variants of neurofeedback, a total of twenty-one patients produced significant changes in EEG frequency bands.
Results: Simultaneous alteration of both frequency bands was strongly related to changes in tinnitus intensity matched before and after the intervention (r = −0.74). In those two patients with the greatest modulatory success, the tinnitus sensation resided completely in response to the treatment. Comparing the neurofeedback-treated patients with a group of patients trained with a frequency discrimination task (n = 27), the tinnitus relief in the neurofeedback group was significantly stronger.
Conclusions: This study supports the notion that altered patterns of intrinsic ongoing brain activity lead to phantom percepts and offer new routes to the treatment of tinnitus.
The impact of experiencing severe physical abuse in childhood on adolescent refugees' emotional distress and integration during the COVID-19 pandemic
Background: Accumulating evidence highlights the importance of pre- and post- migration stressors on refugees’ mental health and integration. In addition to migration-associated stressors, experiences earlier in life such as physical abuse in childhood as well as current life stress as produced by the COVID-19-pandemic may impair mental health and successful integration – yet evidence on these further risks is still limited. The present study explicitly focused on the impact of severe physical abuse in childhood during the COVID-19 pandemic and evaluated the impact of these additional stressors on emotional distress and integration of refugees in Germany.
Methods: The sample included 80 refugees, 88.8% male, mean age 19.7 years. In a semi-structured interview, trained psychologists screened for emotional distress, using the Refugee Health Screener, and integration status, using the Integration Index. The experience of severe physical abuse in childhood was quantified as a yes/no response to the question: “Have you been hit so badly before the age of 15 that you had to go to hospital or needed medical attention?” Multiple hierarchical regression analyses further included gender, age, residence status, months since the start of the COVID-19 pandemic and length of stay in Germany to predict emotional distress and integration.
Results: Two regression analyses determined significant predictors of (1) emotional distress (adjusted R2 = 0.23): duration of being in the pandemic (ß = 0.38, p < 0.001) and severe physical abuse in childhood (ß = 0.31, p = 0.005), and significant predictors of (2) integration (adjusted R2 = 0.53): length of stay in Germany (ß = 0.62, p < 0.001), severe physical abuse in childhood (ß = 0.21, p = 0.019) and emotional distress (ß = −0.28, p = 0.002).
Conclusion: In addition to migration-associated stressors, severe physical abuse in childhood constitutes a pre-migration risk, which crucially affects the well-being, emotional distress and integration of refugees in Germany.
Versorgungsmodelle für traumatisierte Flüchtlinge in Deutschland
People with a migration background are a risk group for psychiatric disorders. Innovative, transnational and sustainable projects are necessary to ensure adequate care for refugees and asylum seekers. Selected projects of the University of Munich, the Charité Berlin and the University of Konstanz show promising approaches in addition to other initiatives.
Transgenerational impact of intimate partner violence on methylation in the promoter of the glucocorticoid receptor
Prenatal exposure to maternal stress can have lifelong implications for psychological function, such as behavioral problems and even the development of mental illness. Previous research suggests that this is due to transgenerational epigenetic programming of genes operating in the hypothalamic–pituitary–adrenal axis, such as the glucocorticoid receptor (GR). However, it is not known whether intrauterine exposure to maternal stress affects the epigenetic state of these genes beyond infancy. Here, we analyze the methylation status of the GR gene in mothers and their children, at 10–19 years after birth. We combine these data with a retrospective evaluation of maternal exposure to intimate partner violence (IPV). Methylation of the mother's GR gene was not affected by IPV. For the first time, we show that methylation status of the GR gene of adolescent children is influenced by their mother's experience of IPV during pregnancy. As these sustained epigenetic modifications are established in utero, we consider this to be a plausible mechanism by which prenatal stress may program adult psychosocial function.
Trajectories of posttraumatic stress symptoms during and after Narrative Exposure Therapy (NET) in refugees
Background
Trauma-focused therapy approaches are recommended as treatment for posttraumatic stress disorder (PTSD). This includes the treatment of trauma-related suffering in refugee populations. However, there is a lack of knowledge about symptom trajectories in refugees living in volatile conditions. This has led to fear of “retraumatisation” and general skepticism in clinicians concerning the use of exposure therapy.
Methods
To test the relevance of this concern, we investigated PTSD symptom trajectories and potentially influencing factors during the course of Narrative Exposure Therapy (NET) in a refugee sample living in Germany. Refugees filled out the PTSD Checklist prior to each treatment session and also during follow-up interviews. Therapists continuously documented positive and negative life events as well as the content of the treatment sessions. Additionally, structured clinical interviews were conducted pre-treatment and at follow-up time points.
Results
On average, clients presented with substantial decreases in PTSD symptoms already during and after NET. However, symptom trajectories differed and ranged from fast responders to slow responders to no immediate response during treatment. Importantly, a persistent worsening of symptoms was not observed, also not after exposure to the most distressing events. In contrast, stressful life experiences seemed to aggravate PTSD symptoms.
Conclusions
Consistent with earlier studies, NET leads to clinically and behaviorally relevant reductions in PTSD symptoms both throughout and following treatment in refugees living in volatile conditions. Concerns about imaginal exposure in refugees were not substantiated. While stressful life events contributed to transient symptom increases, they weren’t found to prevent the overall effectiveness of NET.
Relations between traumatic stress, dimensions of impulsivity, and reactive and appetitive aggression in individuals with refugee status
Objective:
Traumatic stressors and other forms of adversities, especially when experienced during childhood, shape aggressive behavior. Effects of differential dimensions of impulsivity on the relationship between psychological trauma, reactive aggression (defensive survival response to threat), and appetitive aggression (the pleasure of attacking and fighting) have not yet been assessed.
Method:
Using structural equation modeling, we sought to uncover precursors of reactive and appetitive aggression investigating a sample of 94 adult individuals with refugee status. We were interested in direct effects of childhood maltreatment and posttraumatic stress disorder (PTSD) and indirect effects via impulsivity dimensions.
Results:
For reactive aggression there was a direct link between childhood maltreatment and (a) PTSD symptoms and (b) marginal sensation seeking. Childhood maltreatment and sensation seeking best predicted appetitive aggression. There was no evidence for indirect effects of impulsivity.
Conclusions:
Fear-driven response to perceived threat based on inadequate cognitive appraisal is assumed to cause pathological reactive aggression, whereas excessive appetitive aggression can be explained by repeated experiences of thrill and excitement during violent acts. Prevention of early traumatic stress and adversities seems key to breaking the cycle of violence.
Assessment and Modification of the Tinnitus-Related Cortical Network
Tinnitus refers to the perception of a sound in the absence of any physical source, and it is widely believed that this phantom sound is generated in the central nervous system. Thus the activation of neuronal cell assemblies is chronically changed in patients with an ongoing tinnitus perception. We used magnetoencephalography to investigate these changes in a resting condition. There was an increase of synchronized activity in the gamma and delta frequency range together with a decrease in the Ci band. Manipulation of these cortical networks by means of neurofeedback therapy resulted in a reduction of tinnitus loudness and distress. In this article we review the basic research and the clinical studies conducted in our laboratory and propose a model that explains the results and helps guide future research and therapy.