Challenges and facilitators in treating unaccompanied young refugees with posttraumatic stress disorder in a dissemination trial: a qualitative study with psychotherapists

Unaccompanied young refugees (UYRs) experience multiple stressors before, during, and after their flight [1, 2] and report high rates of post-traumatic stress disorder (PTSD; 4.6–43.0%), depression (2.9–61.6%), and anxiety (32.6–38.2%) [3]. Therefore, it is important that they receive appropriate interventions, as untreated posttraumatic stress symptoms (PTSS) can increase the risk of a wide range of physical and mental health conditions and chronic posttraumatic stress disorder [4, 5]. In light of the high needs, it is essential that evidence-based mental health care is available for this vulnerable group [6]. Trauma-focused cognitive-behavioral therapy (TF-CBT), developed by Cohen et al. [7], is recognized as an established treatment for PTSD in children and adolescents. The efficacy of TF-CBT has been demonstrated in meta-analyses and is recommended in international guidelines [8‐10]. Studies have also demonstrated feasibility and efficacy in refugee and UYR populations [11, 12].

Despite the availability of treatment options, the use of mental health services among asylum seekers is low [3, 13‐16]. Furthermore, studies on psychotherapy retention rates among UYRs are lacking, but a meta-analysis of adult refugees suggests a dropout rate of about 20%, which is comparable to non-refugee populations [17]. The difficulties of access and early dropout observed in this population can be attributed to several barriers. On the one hand, UYRs have complex needs, lack of trust in institutions and professionals, lack of awareness of mental health issues, lack of knowledge about the health care system, perceived discrimination, fear of stigma, and language barriers [16, 18‐24]. On the other hand, they face additional structural barriers such as a lack of resources, legal restrictions/asylum status, and accessibility issues in terms of reaching psychotherapists and getting appointments [20, 22, 24, 25].

Additional barriers exist on the part of psychotherapists. Some psychotherapists are perceived as reluctant, lacking awareness, cultural competence and capacity, and have negative attitudes towards refugees, as reported by experts and refugees [16, 19, 22]. Previous research on psychotherapists’ experiences of working with refugees identified a mixed response to the use of interpreters [26]. The efficacy of interpreter assisted treatment has been demonstrated to yield outcomes that are comparable to those achieved in the absence of interpreters [26‐28]. Psychotherapists themselves have reported several challenges during the psychotherapeutic process with refugees, including high bureaucratic and organizational effort, cultural challenges (different explanatory models of illness), different expectations of therapy, funding difficulties (intervention and interpreter), and communication and trust issues [29‐32].

Given the existence of numerous qualitative studies examining psychotherapists' experiences in treating migrants or refugees (e.g. [29, 31, 32]) and the lack of studies on facilitators of psychotherapy with UYRs, this study is unique as it was part of a stepped care approach called ‘BETTER CARE’ [33]. This project is a multicenter dissemination and implementation trial that aims to improve the mental health of UYRs, to implement TF-CBT and to reduce barriers to psychotherapy utilization. Consequently, this study may provide new insights into additional relevant factors. Therefore, we sought to assess whether the concerns reported by psychotherapists prior to their participation in the ‘BETTER CARE’ project were consistent with barriers documented in the literature. We also examined reported facilitators and challenges after the primary barriers were removed by the project design, and whether these differed between psychotherapists whose patients completed the TF-CBT and those who terminated prematurely.

Psychotherapists who had experience in working with UYRs mentioned the following experiences: referral through the CYWS institution/school context, challenging life circumstances (such as traumatic experiences in the host country that prompted them to seek treatment), and uncertainty in treatment and dealing with cultural differences. The worries psychotherapists expressed prior to their involvement in the project were mainly related to structural barriers, such as organizational difficulties and uncertain residency status; personal concerns such as high emotional strain and cultural competence; and patient-related issues, such as poor language skills, unreliable attendance, and severity of psychopathology, as seen in Additional file 2.

The study revealed that participants identified various factors, including project-related, structural, personal, patient-, and interpreter-related aspects, as either facilitating or challenging the implementation of psychotherapy with UYRs. Table 2 provides an overview of the categories and subcategories identified in the interviews regarding the facilitators and challenges that emerged. In the following text, all categories that were identified during the analysis are presented in italic font. In Additional file 3, Add3-Table 1–Table 5 present all results with codes, frequencies, and examples.

This study contributes to the current literature by exploring the experiences of psychotherapists working with UYRs in a dissemination and implementation trial. It further provides new insights into the facilitators of trauma treatment in a refugee population, after efforts have been made to address several care-related barriers as part of the ‘BETTER CARE’ project.

We aimed to examine whether psychotherapists reported the same worries before participating in the project as reported in the literature. We found partial evidence, especially for structural and psychotherapist-related worries, such as organizational and residency issues [22], the involvement of interpreters [24], cultural competence [19, 25], and emotional burden for the psychotherapist [38]. Patient-related worries were also reported, such as language barriers [16, 22, 30] and unreliable attendance, which may be due to different cultural concepts of time [24]. However, a quarter reported no worries, indicating openness and low prejudice towards psychotherapy with UYRs in our sample.

Because the project attempted to address primary structural barriers, the study found that initial worries largely did not re-emerge as challenges, with psychotherapists facing mainly coordination issues, but not the anticipated emotional distress or problems related to interpreters and cultural competences. Patient-related worries, particularly language skills, persisted, while issues such as attendance and severe psychopathology were less prominent. Thus, it appears that the inclusion of resources such as the German TF-CBT Web, workshops, and case consultations significantly facilitated the delivery of psychotherapy to UYRs. Therefore, we can conclude that psychotherapists who were interested in learning evidence-based treatment methods and treating UYRs responded positively to the combination of an online learning platform and a workshop, although a potential bias in the interpretation of the results should be considered, as those who were not interested in online training and (UYR) trauma treatment did not participate in the project. The results align with research highlighting the value of formal training for positive treatment outcomes [29, 39] and the combination of a variety of strategies [40]. In addition, psychotherapists highlighted the benefits of preparing and organizing psychotherapy through the project, in addition to support by the project staff. This included initiatives such as: a brief training for a mental health coordinator to act as a contact person within the CYWS facility, making phone calls to determine whether UYRs recommended for treatment were interested in psychotherapy, and if so, making further phone calls to verify if these adolescents received a psychotherapy slot. The project is considered a successful approach, as evidenced by the fact that eight out of 18 participants reported no challenges associated with the project. The primary challenge identified, documentation, is likely due to the extensive project-specific paperwork required for a detailed evaluation and thorough understanding of the treatment process. Challenges related to the TF-CBT treatment approach could be addressed by providing organizational information about common issues related to psychotherapy funding and interpreters within the learning platform, and by providing separate materials for younger children and adolescents.

From a structural perspective, psychotherapists emphasized the importance of caregivers supporting and/or accompanying psychotherapy, which is also an integral part of the TF-CBT manual [41]. This is particularly important because, in addition to providing emotional and practical support, they are relevant as models of resilient coping mechanisms and protection against future harm [41]. The psychotherapists in our study agreed on this part with the manual that points out the immense impact of caregiver inclusion during the psychotherapeutic process. In addition, a supportive infrastructure within the facility, which includes not only facilitating transportation to psychotherapists, but also caregiver compliance and knowledge about PTSS and psychotherapy, was seen as critical to UYRs' treatment attendance and compliance. McGuire et al. [42] identified several potential reasons for the lack of caregiver support and involvement, including limited staff availability for one-on-one support, placement nature that occasionally prevents caregiver presence, instability within the support network, and scenarios where the youth preferred to exclude their caregivers. Compounding these challenges, the location of the psychotherapeutic practice, and the distance between it and the facility, along with unreliable public transportation, were also highlighted as significant challenges in our study, suggesting remote or outreach psychotherapy as an alternative. Remote psychotherapy received mixed reviews in our study; some psychotherapists highlighted problems stemming from the lack of personal contact and a secure space, which are vital for effective treatment. This issue was particularly pronounced when psychotherapy was conducted solely via online platforms during the Covid-19 pandemic, while the patients were often located in shared rooms. This created situations in which they might avoid sharing traumatic events, especially since many of these experiences are associated with feelings of guilt and shame. Therefore, an outreach approach, in which psychotherapists meet patients at home or at a location of the patient's choice, may reduce barriers and facilitate caregiver involvement [43]. Additionally, under such circumstances, psychotherapists could ensure that psychotherapy takes place in a safe space for the patient. If this is done by psychotherapists who are interested and trained in working with UYRs, it could also help facilitating the process of bringing them into psychotherapy, especially as the willingness of outpatient psychotherapists in Germany to treat refugees is lower than that of non-refugee patients [44].

The psychotherapists interviewed were less likely to mention personal factors. The most important factor was the ability to build a strong relationship with patients. This finding is consistent with studies indicating that a strong therapeutic relationship is an important component of TF-CBT, leading to reduced PTSS [45], with the alliance being particularly important at mid-treatment. Ormhaug et al. [45] also found that a positive alliance also led to more efficient treatment, with fewer sessions. In addition to facilitating psychotherapy, a positive alliance may also reduce dropout rates among refugees, as shown in a recent review with refugees [17]. To strengthen the alliance, studies by Colucci et al. [24] and Mirdal et al. [36] further emphasize the need for mental health professionals to use presence-focused, adolescent-friendly approaches and to provide psychoeducation. Psychoeducation plays an important role in the process of establishing a strong alliance with refugee patients, as they often come from a different cultural background, have a different explanatory model and different expectations of psychotherapy [29]. Promoting psychoeducation can help to build trust and safety by providing clear information.

The most important patient-related factors influencing the psychotherapeutic process were readiness for psychotherapy and language skills. The significance of these factors has also been reported by previous research [16, 22, 30] and reflects prior worries articulated by psychotherapists in the current study. The findings indicate that the project team's involvement in the preparation and initiation of psychotherapy was perceived positively by psychotherapists, leading to patients who were better informed and had undergone a pre-selection process. In fact, each participant received a letter post-screening that included treatment recommendations based on their sum scores. Based on this, utilizing digital screening tools that offer automatic treatment recommendations and ideally, the contact details of trained psychotherapists nearby, is advisable. In addition, knowledge of psychotherapy and PTSS among CYWS staff was seen as beneficial. Therefore, it appears that staff training is important to enable them to provide psychoeducation to UYRs and to increase readiness for psychotherapy. Summarizing the results, the information and screening approach implemented in the ‘BETTER CARE’ project can be considered successful, especially as the commonly discussed mental health illiteracy among refugees [29] was not reported as a challenge in this study. Patient-related challenges included family concerns or daily challenges. These are known to be important factors that also influence well-being [46], underlining the need to address them and achieve early improvements in psychotherapy, as noted by Mirdal et al. [36] and Colucci et al. [24]. Although language proficiency is not mandatory, it greatly facilitates effective psychotherapy. However the lack of b language skills were experienced as challenging by psychotherapists in our study.

Given the importance of language proficiency, it’s not surprising that the provision of trained interpreters was mentioned several times as being helpful. A trusting, collaborative relationship between interpreter, patient and psychotherapist was reported not only by psychotherapists, but also in a study that included the views of all three parties [36]. For psychotherapists, accurate translation skills and transparency are important, but so are the interpreters’ soft skills such as building trust with the patient and showing empathy. It is noteworthy that psychotherapists in our study also indicated that an overly close bond could be problematic. This finding also aligns with Mirdal et al. and Vivino et al. [36, 47], both of whom reported interpreter involvements that exceeded western expectations regarding the professional distance. This highlights possible cultural differences and conflicting expectations regarding the role of the interpreter. As the majority of patients and their interpreters originate from collectivist societies where community involvement is more important, group identity may be incompatible with the “neutrality” required by individualistic psychotherapists [24, 48]. To reduce potential problems, it is suggested that a training program for interpreters be implemented, that focuses on translation in trauma-focused psychotherapy, particularly with regard to the rationale behind the trauma narrative. This knowledge could lead to more accurate translations and improve the quality of collaboration within the therapeutic triad [49]. Finally, the results of the interviews show that the inclusion of interpreters is advantageous because interpreters can foster a trusting relationship and are able to show empathy and provide a comfortable and safe environment for the patient, which is essential in the therapeutic context. In addition, they serve not only as language mediators, but also as cultural mediators, enhancing communication in ways that artificial intelligence translation applications cannot replicate. Moreover, the use of most AI translation tools is not advisable as they often process data externally and risk data breaches. Comparing answers from completers’ psychotherapists and non-completers’ psychotherapists regarding facilitators, revealed that completers’ psychotherapists benefited from resources such as case consultations, worksheets, videos, and interpreters funded and provided by the project. These psychotherapists also formed stronger alliances with patients and trusted long-term relationships with interpreters. This bond may also have served as a source of social support, a factor that facilitates psychological well-being [3]. Following the advice of Colucci et al. [24] to consider patient-preferred interpreters in psychotherapy may prove beneficial. In contrast, non-completers' psychotherapists benefited less from the projects' resources, mentioning the manual and evidence-based treatment and willingness to treat UYRs as facilitators, possibly reflecting socially desirable behavior. In addition, it is possible that the psychotherapists felt less secure and thus preferred more guidance, which could be provided by the manual, even though five out of seven had worked with UYRs before.

The challenges reported by completers’ psychotherapists and non-completers’ psychotherapists showed that the challenges faced by completers’ psychotherapists do not necessarily lead to premature termination, but become more apparent with longer treatment duration, such as more contact with the Youth Welfare Office and more complex study documentation. In addition, the lack of educational background may become more pronounced during the cognitive processing module, which appears later in TF-CBT. Non-completers' psychotherapists also mentioned more structural challenges, such as the absence of a primary responsible caregiver and distant locations, as well as an increased effort for psychotherapists. This highlights the role of caregivers in successful trauma treatment and is consistent with research with primarily biological parents showing that their presence at the first session and adolescents' assessment of parents' treatment approval predicted treatment dropout [50]. An additional challenge for non-completers’ psychotherapists was the presence of an ongoing grief process. Given the prevalence of comorbid grief disorder and PTSS among refugees [51, 52], the integration of grief-specific treatment components is essential. The use of grief specific components during the TF-CBT treatment is also incorporated into the manual [7]. Research on the treatment of trauma and grief among UYRs is limited; however, a recent meta-analysis for children and adolescents suggests that grief-focused cognitive-behavioral psychotherapies are effective in reducing grief and related posttraumatic stress symptoms [53].

In summarizing key findings and offering practical implications, we have chosen to integrate our findings into Michaels et al.’s [54] “Socio-Ecological Model of Mental Health & Well-Being” which allows us to identify individual, organizational, and policy dimensions essential for successful trauma treatment. At the core of this model is the individual, the UYR, where treatment readiness and language proficiency serve as key facilitators. Subsequently, interpersonal relationships are a relevant factor, including the social support network, which comprises, for example, the CYWS facility and its caregivers. In this context, the support and compliance of the aforementioned individuals were of particular significance, as was their collaboration with the psychotherapist and their knowledge. For practical implications both the individual and interpersonal levels should be considered. It becomes evident that trauma-informed care is a recommended approach, which should include education and training for caregivers about symptomatology and trauma treatment. This will increase mental health literacy among caregivers and UYRs, and may result in greater mental health service use, treatment readiness, and higher treatment compliance among caregivers. These topics were all mentioned as facilitators within this study. At the organizational level, it is recommended that local partnerships are established between psychotherapists and CYWS facilities to decrease some of the structural challenges such as logistical, distance and coordination issues, which were also suggested by Borbon et al. [55] as part of their lessons learned for trauma-informed care with UYRs. At the community level, the use of skilled interpreters was seen as a facilitator and is recommended. Ideally, they are already known to the patient and can facilitate understanding of cultural differences, while building a trusting relationship with the patient and providing social support. Lastly, the policy makers have a huge responsibility, and our recommendation is the provision of resources, training and standards for CYWS facilities, psychotherapists and interpreters. CYWS need to be provided with the personal resources and above-mentioned training in order to be able to accompany treatment sessions and facilitate transportation, this is of particular importance, as the German federal states have lowered the minimum standards within UYR facilities [56]. Furthermore, we propose that psychotherapists get the ability to implement an outreach approach in collaboration with local partners. Finally, our recommendation is to implement country-wide requirements for interpreters in psychotherapy, ensuring adherence to data protection and confidentiality standards.

This study has several strengths, such as conducting interviews with twenty psychotherapists representing a range of backgrounds, experiences with UYRs, and regions across Germany. However, several limitations warrant further attention. First, it is possible that the experiences of the thirteen psychotherapists who had previously treated traumatized UYRs may have influenced the responses given in the present interviews. Second, although all invited psychotherapists participated, the sample is not representative of all psychotherapists because it only included those interested in treating traumatized UYRs. Third, the project funded treatment provided by two psychotherapists, as the UYRs did not yet have health insurance to cover the costs due to the ongoing asylum process. All psychotherapists had free access to German TF-CBT web training and were paid for documentation and case consultations. This arrangement may have led to socially desirable responses in the interviews. Fourth, the mode of interpreting (face-to-face, video, or telephone) may have influenced the triangular relationship and the development of a trusting relationship and thus the responses regarding interpreter-related facilitators and challenges need to be interpreted with caution. Fifth, the analysis of whether the reported facilitators and challenges differed between completers' psychotherapists and non-completers' psychotherapists should be interpreted with caution, as we considered only the completion status of patients and not the extent of symptom reduction or adherence to the manual.

It is recommended that future research include the perspectives not only of patients, but also of their caregivers and interpreters. It would be beneficial to gain further insight into how they perceive the patient-interpreter relationship. This could include whether they perceive challenges in an overly close relationship, or whether such perceptions differ between collectivist and individualist cultures. The possibility of further integrating interpreters into the therapeutic process may also be explored. In addition, the role of comorbid prolonged grief disorder symptoms in trauma-focused treatment requires further attention, with a recommendation to explore how they affect the efficacy of trauma treatment. In this regard, we also recommend an analysis of the adaptations that psychotherapists have made to the TF-CBT manual when working with UYRs in CYWS settings.

In conclusion, there are numerous facilitating factors for the psychotherapy of UYRs that should be addressed at the individual, interpersonal, organizational, community, and especially at the policy level. In particular, specialized training should be provided to psychotherapists on evidence-based treatment, to caregivers on the process and content of trauma-focused therapy, and to interpreters on effective collaboration and translation within treatment. Additionally, the supervision of psychotherapists and the compliance of caregivers are of immense importance.