Cultural Adaptations to Psychosocial Interventions for Refugee Families

In this podcast, we are joined by Dr. Alice Taylor, a clinical psychologist for CAMHS in Scotland, to discuss her co-authored CAMH review paper “Cultural adaptations to psychosocial interventions for families with refugee/asylum-seeker status in the United Kingdom – a systematic review” (doi.org/10.1111/camh.12547).

Alice begins by giving us with a brief overview of the paper and sharing insight into what they looked at in this review.

Alice provides some examples of cultural adaptations and explains how these differ from nonculturally adapted interventions, which are also known as treatment as usual.

Alice then explores this further by discussing the ways in which treatment as usual can act as a barrier to accessing quality mental health care for families with refugee and/or asylum-seeking status, before turning to explain how cultural adaptions could improve the situation.

Furthermore, Alice shares additional key takeaways from her review, comments on what the implications of her findings are for CAMH professionals, plus shares her message to policymakers based on her research.

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Dr. Alice Taylor is a clinical psychologist working with children and young people in the NHS. She has a particular interest in increasing accessibility to effective mental health support to young people who may face extra barriers, e.g., complex trauma or cultural differences. She volunteers with various charities to provide both practical and socio-emotional support to families with refugee / asylum seeking status. Alice is also involved in a current project with NHS Lothian, Social Services and multiple charities to develop and facilitate groups for unaccompanied minors, and provide training for staff working within the refugee/ asylum seeking community. She hopes to continue this work, and share learning with others’ interested in this field.

Transcript

[00:08] Jo Carlowe: Hello. Welcome to the In Conversation podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Jo Carlowe, a freelance journalist with a specialism in psychology. I’m interviewing clinical psychologist Alice Taylor, who works for CAMHS in Scotland. Alice also develops and implements well-being groups for refugee and asylum-seeking adolescents and runs trauma-informed training for staff working with this population. Alice is a co-author of the review “Cultural adaptations to psychosocial interventions for families with refugee/asylum-seeker status in the United Kingdom – a systematic review“, recently published in the journal CAMH.

This review will be the focus of today’s podcast. The CAMH is one of the three journals produced by the Association for Child and Adolescent Mental Health. ACAMH also produces the Journal of Child Psychology and Psychiatry and JCPP Advances. If you’re a fan of our In Conversation series, please subscribe on your preferred streaming platform. Let us know how we did with a rating or review. And do share with friends and colleagues.

Alice, welcome. Thank you for joining me. Can you start with a brief introduction about who you are and what you do?

[01:39] Dr. Alice Taylor: Hi, Jo. Thanks for having me. As you said, I’m Alice Taylor. I’m a clinical psychologist working in CAMHS in NHS Lothian. So, I’ve been working there for a couple of years now, after finishing my clinical doctorate. And my interests would be ensuring equal access to mental health support for all young people and their families, especially those that might face extra barriers in reaching public services. So that might include neurodiverse young people, people with complex trauma experiences, and, of course, people from different cultural backgrounds as well. And I also volunteer with some charities across Scotland who do lots of amazing work with refugee and asylum-seeking communities.

[02:14] Jo Carlowe: As stated in the introduction, you co-authored the review “Cultural adaptations to psychosocial interventions for families with refugee/asylum-seeker status in the United Kingdom – a systematic review”, recently published in CAMH. Alice, can you give us a brief overview of the paper? What did you look at?

[02:32] Dr. Alice Taylor: So, we’ve all seen the increased need for support for young people and their families coming from areas of conflict and persecution. So, to meet those needs, we have to think a little bit about how mental health might be presented, how coping strategies might be culturally developed, and how we can support young people in the most effective way whilst also taking into account their socioeconomic and their cultural background. So, we looked at different studies across the UK who had implemented cultural strategies to mental health interventions. This included any intervention that supported mental health for young people and families, especially those that didn’t meet the traditional evidence-based criteria. And the reason for that is because often, the criteria is based on Western views and Western cultural ideas and criteria. So, we also felt it was quite important to think about the UK specifically and how we might be able to use some of the adaptations within NHS services, given the current climate and the resources available to the NHS at the minute.

[03:31] Jo Carlowe: Can you give some examples of cultural adaptations and explain how these differ from nonculturally adapted interventions, which are also known as treatment as usual?

[03:42] Dr. Alice Taylor: Firstly, treatment as usual. I suppose it’s good to explain that that would refer to– in our paper, refers to interventions that we would generally provide across services with the general population. So of course, there’s unique strengths and difficulties for any young person and their family. And we use a formulation-based approach to make sure that that is person centred. The difference between person-centred and then culturally adapted is recognizing that there’s very unique barriers that people from different cultures will face that might not be applicable to young people within their native country. So that is treatment as usual. And several researchers before us had identified several ways of categorizing the cultural adaptations that we can provide to those interventions. So, the adaptations can be split into surface-level adaptations– so that’s making sure that the intervention is available in their language, using pictures, music, things that are familiar to and representative of the culture.

I’m sure some of us are already aware that there’s interpreters available for many of the NHS services. And there’s also been increased awareness of including pictures of various ethnicities in leaflets and things like that. And I think that shows us the surface-level adaptations. On the other hand, deep-level adaptations are the other category that we used within the paper. And it requires more profound adaptations to treatment as usual. So that would require more understanding and more knowledge about the culture and open communication with the population as well. So that might be explaining difficulties using a familiar context, so using food, religion, stories from native countries, all those kinds of things. And I think one of the biggest ones is making sure that there’s a cultural representative within the decision-making, development, and implementation of the interventions as well.

[05:32] Jo Carlowe: In what way does treatment as usual act as a barrier to accessing quality mental health care for families and refugee and/or asylum-seeking status?

[05:42] Dr. Alice Taylor: If we think about the steps to accessing CAMHS, for example, that’s where I work. So first off, the difficulty has to be recognized. You then have to go to the GP or school or social work, who first has to then believe us and then write the referral. And then that referral goes to a triage at CAMHS level. And then you have to be accepted for an assessment. And then if you get accepted for the assessment and on to the treatment waiting list, then there’s quite a long wait, as everyone knows at the minute for CAMHS. So, there’s multiple barriers across each step of the access and the engagement with CAMHS services. Initially, the mental health difficulties might present very differently across different cultures. So, what we might see as mental health in the UK might be acceptable in other cultures and vice versa. And one thing that we’ve seen quite regularly within refugee and asylum-seeking communities is complaints about physical pain. Those complaints about physical pain might turn out to be stress related, whereas within the UK, we very much separate our mental health and our physical health. And that can be quite difficult to then determine what is causing the difficulty for the young person. Then, on top of that, if we think about stigma within communities, building up the courage to speak to someone when you’re struggling, which is difficult, even when we don’t have language barriers or possible fears about deportation. You don’t have to always think about looking grateful and happy to be here, all those kinds of things.

And then, I suppose– I could talk about this for a long time– but I’m thinking if you get through those barriers, you then have to wait for treatment. And by that time, you might be relocated. You might be dealing with Home Office. You might be losing courage in talking about these things that are really difficult for anyone to talk about.

And finally, all of our interventions, our outcome measures, our diagnosis criteria are all based on white Western populations and their research, so therefore might not even be effective for these different cultures. So, I think, although there’s many, many other barriers, those are just a few of them. I think it really highlights that actually, there’s so many things that refugee and asylum-seeking communities and people from other cultures will have to go through before they even get to the point of meeting mental health services.

[07:51] Jo Carlowe: You’ve really conveyed it. I mean, it sounds immense, the barriers. In what ways, then, do cultural adaptations improve the situation?

[08:00] Dr. Alice Taylor: That’s a really good question. Well, I suppose the hope would be that we could be more open and understanding to the barriers that I’ve just talked about and make changes to allow young people and their families to feel more included and less stigmatized. Even as simple as seeing yourself represented can make a huge difference towards feeling included and foster that sense of belonging. And I think if any of us feel unwelcome or not understood, it can hugely impact our well-being.

I’m thinking, growing up in Northern Ireland, it was obvious what could happen when different communities weren’t so accepting of each other. So, if we can be more culturally sensitive towards others and make adaptations that help others feel more included and more supported, I think we would all benefit from hearing new ideas, alternative solutions, and work together to be a more inclusive society. And I think on top of that, if we can provide early intervention and effective support for these young people, then there’s a potential that families and those young people, when they grow up to be adults, will not need as much support in the long term.

[09:00] Jo Carlowe: What else were the key takeaways from your review? What can you share of the findings?

[09:05] Dr. Alice Taylor: I think the three main takeaways would be that there is some evidence to support culturally adapted interventions. The studies used various levels of cultural adaptation. All the studies showed clinical improvement in participant well-being. Qualitative data also showed that participants find it really helpful to have peer support and to use creative approaches to therapy, so art, music, those kinds of things. And those would both fall under cultural adaptations there.

Secondly, I think that the participants in these studies identified various barriers and challenges that they experienced when trying to engage in the supports available. So those were practical things, like language and the location of the service, but also uncertainty about their future, stigma, and not really knowing what mental health meant within the UK.

And then finally, I suppose there’s a bit of a caveat for what I’ve just said. Although there is support for cultural adaptations, it was pretty impossible. There’s no way to compare the cultural-adapted interventions to treatment as usual. There’s not enough of a literature base to show how these differences might impact on the effectiveness of support. So, there was none of that case control. And I think the takeaway from that is that we need more services open to providing those cultural adaptations, and noting them officially because I think sometimes services are doing things without even realizing, and that the more research within this area to ensure that these approaches are evidence-based, the better.

[10:31] Jo Carlowe: What are the implications of your findings, then, for CAMH professionals?

[10:35] Dr. Alice Taylor: Think there were a few things that might be helpful for clinicians moving forward. So some studies have suggested that practical barriers might be getting in the way. And those could be overcome quite easily by changing the location of the intervention, so going into schools. And the other thing that came up that would be helpful to think about in more of the community would be thinking about how professionals outside CAMHS could provide some of that support to reduce stigma of mental health services and also because they generally have more interaction with the young person. So, we would need to make sure that appropriate training and supervision for those staff was available and that they felt comfortable doing that.

Within the clinic more specifically, I think we need to be thinking a lot about how we use medical models, how we use diagnosis, and where those criteria are based specifically on Western cultures. So, we need to be really aware of not just culture but also the socioeconomic factors that might affect the refugee and asylum-seeking families more than the general population, so things like loss, trauma, uncertainty about the future. And racism is a big one. On the other hand, as I’ve just said that, young people who have experienced this hardship also show incredible resilience and unbelievable strength. And I think that always hits me when I’m working with these young people, is their ability to motivate themselves to seek opportunities for the future, educate themselves, build social connections with anyone around them, even when a lot of what they’ve experienced would make most people shut down. So, I think that’s a really, really big thing that us clinicians need to recognize.

Also need to be incredibly careful that we don’t generalize all refugee and asylum-seeking populations. So, if we think about our own communities in the UK, we’ve got unique cultures and beliefs between England, Scotland, Northern Ireland, Wales. And then if we break that down further, there’s big differences between, let’s say, the cultures at Edinburgh and Glasgow in Scotland. And if we break that down even further, there’s examples in Northern Ireland of people living in the same street that can have vastly different cultural beliefs. And I think this applies across the world. So, refugees from a certain country in Africa will not be the same as those from another country in Africa or in Asia or in the Middle East. And I think we need to make sure that we’re not falling into that mistake as well, that we’re generalizing and lumping people together just because they have a refugee or asylum-seeking status.

[12:57] Jo Carlowe: Do you think CAMH professionals can be guilty of that as much as anybody else?

[13:02] Dr. Alice Taylor: I think we can. And I don’t think it comes from a place of maliciousness. I don’t think it comes from a place of ignorance. I think it comes from an uncertainty about what we should be doing and wanting to follow the evidence base and wanting to be able to provide the best care. We generalize because we are taught transferable skills. And I think one of the things that we often get caught up in, or some of the people that I work with have got caught up in, is the fact that refugees and asylum seekers have understandably faced traumas that half of us can’t even imagine. And I think we could get really, really caught up on the fact that there’s so much trauma. I think our generalization maybe comes a little bit from the trauma that some of these young people in asylum-seeking and refugee communities have experienced. And I think we get very caught up in that because it’s not something that we can imagine. It’s not something that we have ever experienced in the same way. And I think we focus on that a lot because we can’t possibly understand how other people could deal with that. And I think that’s where we have the danger of lumping people together, that everyone who is a refugee or everyone who is an asylum seeker will have trauma and will want trauma work extensively.

And actually, when you speak to young people, they all have huge differences in what they want. Some people want to go home. Some people want to stay. Some people want to make their lives here but visit, all those kinds of things. And I think what we forget often is the similarities between young people in our community and young people within the refugee and asylum-seeking community. And, I think, one of the things currently in a project I’m in at– and one of the things they all talk about is football and FIFA. And I think that’s something that we forget sometimes when we’re generalizing refugee and asylum seekers into traumatized young people.

[15:00] Jo Carlowe: I’ve got to ask you, Alice, what is your message to policymakers?

[15:04] Dr. Alice Taylor: That’s going to be a bit of a harder question. I think generally, my message would be that we need to be treating people the way we would want to be treated in the same situation. So, all of us have experiences, however minimal, of times where we felt alone, misunderstood, dismissed, and it really hurts. And I think no one chooses to be persecuted so much that they have to flee their own country. And we need to be compassionate to those people that have had really difficult experiences, who are coming here to make a new life. I think on the highest level, we need to fix our immigration system and how we practically support families with housing, with education, with social connection. And then I think within the mental health policies, we need to be thinking more collaboratively with these communities on how we can improve services. Our policies need to reflect what’s happening on the ground. And I think often policies can be a little bit behind if we’re not open to admitting our mistakes and actively collaborating with the people most affected by the policies.

[16:04] Jo Carlowe: And I know you spoke earlier about there being a lack of literature on cultural adaptations. And are you, yourself, planning some follow-up research that you can share with us?

[16:14] Dr. Alice Taylor: Currently, I’m trying to publish a paper looking at the mental health experiences of young people and their families integrating into Scotland, Scottish communities. So, within that study, we also looked at the experiences of mental health professionals working with these young people. And we compared the views and experiences of young people, then their families, and then the professionals. And we saw how these matched or they differed from each other’s groups. And we’ve based some recommendations on that, so that’s currently in the pipeline.

And secondly, I’m involved with a project with the NHS, with social work and a couple of charities, such as Mental Health Foundation and Cyrenians. And we’re running a photovoice group for unaccompanied asylum seekers in Edinburgh. And we’re also facilitating training for staff using a peer-group mentoring approach. So hopefully, there’ll be some research results being published from that soon, too.

[17:06] Jo Carlowe: Great what’s the timescale on those, then?

[17:09] Dr. Alice Taylor: Well, the first one, the paper, I just need to submit it. And the second one, the project, will be finishing in December. And hopefully, we’ll be getting some information out to policymakers and the community as soon as possible from that.

[17:27] Jo Carlowe: Great. Thank you. Finally, Alice, what take-home message do you have for those listening to our conversation?

[17:35] Dr. Alice Taylor: I think the take-home message is to be open to learning about different cultures and communities and how we can all learn from each other, so not being afraid to make mistakes as long as we’re willing to try and make it right afterwards. And I think the big thing I’m very aware of doing this podcast is that I am a white Western woman talking about a community that I’m not part of. And I can’t possibly understand or explain what it’s like to be a refugee or an asylum seeker. So, the most important thing for people listening, I think, would be to ask those who are actually experiencing this, what’s helpful, what’s not helpful, and what we can do better to meet the needs of the most vulnerable in our communities.

[18:15] Jo Carlowe: Alice, thank you so much. For more details on Alice Taylor, please visit the ACAMH website, www.acamh.org, and Twitter, @acamh. ACAMH is spelled A-C-A-M-H. And don’t forget to follow us on your preferred streaming platform. Let us know if you enjoyed the podcast with a rating or review. And do you share with friends and colleagues.