WACIT; Refugee Mental Health and the Impact of Trauma

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For this podcast, for Refugee Week, we are joined by Professor Panos Vostanis, professor of Child Mental Health at the University of Leicester, and founder of the organisation World Awareness for Children in Trauma (WACIT).

As an expert in the impact of trauma on child and adolescent mental health, Panos sets the scene by talking to us about trauma as it relates to child refugees and other young people in conflict.
Panos then turns to his work at WACIT and details what WACIT is and the goals of the organisation, before detailing some of the training services for CAMH professionals who work with refugees, asylum-seekers, and other vulnerable groups.

With WACIT also running interventions for children and young people themselves, Panos further discusses the work they have done with children and young people who are refugees or living in conflict zones, and shares what the outcomes were like.

As one of the aims of WACIT is to develop evidence based psychosocial interventions and capacity building for children living in conflict and disadvantage, Panos comments on what the evidence shows to be the best approach to take when it comes to working with children and adolescent refugees who’ve experienced significant trauma.

Furthermore, Panos talks us through two new projects aimed at improving services for refugee children internationally and shares his message to policymakers.

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Professor Panos Vostanis
Professor Panos Vostanis

Professor Vostanis has published extensively on the impact of trauma on child mental health, evaluation of interventions and services for traumatized children, including those living in conflict settings. Other research includes school mental health and service evaluation. He founded the World Awareness for Children in Trauma programme (www.wacit.org) to develop evidence-based psychosocial interventions and capacity building for vulnerable children and young people. To this effect, he is involved in several projects with NGOs and academic centres in Asia, Africa and Latin America, especially on service improvement. Professor Vostanis has longstanding clinical experience as a child psychiatrist with vulnerable children, young people and families, i.e. in care, homeless, adopted, refugees, young offenders, or living in disadvantage. (Bio from University of Chester)


[00:00:31.899] 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. To tie in with Refugee Week June 2022. I’m interviewing Panos Vostanis, professor of child mental health at the University of Leicester and founder of the organization World Awareness for Children in Trauma.

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. Panos, thank you for joining me. Can you start with a brief introduction about who you are and what you do?

[00:01:14.843] Professor Panos Vostanis: Thank you for the invitation, really important week and your initiative and your ongoing series. I’ve had long-standing association with the journal, with the association over the years. So, my background is child psychiatry. I’ve worked clinically for many years with vulnerable groups, such as children in care and refugee children. And academically, I developed different levels of training programs and research in parallel for these groups, both in the UK, but in recent years, more internationally.

[00:01:47.070] Jo Carlowe: Great. Thank you. And you’re an expert in the impact of trauma on child and adolescent mental health. What can you tell us about trauma as it relates to child refugees and other young people living in conflict?

[00:02:01.155] Professor Panos Vostanis: Well, there has been a lot of interest and really good practice in recent years, so I would not claim that I have sort of expert knowledge more than others. There’s a lot of excellent work going on. I think the issues about refugee children and other vulnerable groups is more about focusing these days about the different types of impact of trauma, which I would refer to as complex recurrent trauma. That is traumatic events that happen over a long period and are associated with many other stressors like poverty, displacement, discrimination. And I think that’s the difference from other types of traumatic situations that we have been focusing on. And they are more challenging as well, of course.

[00:02:49.893] Jo Carlowe: Panos, as we stated in the intro, you founded the organization World Awareness for Children in Trauma, WACIT. What is WACIT and its goals?

[00:03:00.000] Professor Panos Vostanis: I’ve worked for many years for the National Health Service with vulnerable groups. I still work with different academic institutions. And in parallel to the research and training programs, I realized there was a need for a more flexible approach to work with different NGOs partners we have all over the world to help them build capacity to respond to needs in low-resource settings, resource constrained settings in areas of disadvantage or with refugee children.

So the reason that we established in parallel this social enterprise, essentially it is a partnership between many good colleagues around the world that work under very difficult circumstances. And it’s providing some help, some space, some frameworks, different levels of training to enhance the capacity and to make impact on the ground, which I can discuss in more detail, but also to establish evidence.

[00:04:01.320] Jo Carlowe: OK. Well, let’s go into some of the detail. Can you start by telling us about some of the training services for CAMH professionals who work with refugees, asylum seekers, and other vulnerable groups?

[00:04:14.370] Professor Panos Vostanis: I would probably define them at three levels. The first level is how to enhance skills, enhance their practice in working individually with children and young people, families. The second level is how to make some more systemic impact, bring systemic changes working with other ranges in the communities. And the third level, which is the more recent and links the other two for more sustainability, is what I would describe as train the trainer program or cascade program where we incorporate the previous two levels but through colleagues that we help and we support, we train in the local context and then train others to develop the skills.

[00:05:02.580] Jo Carlowe: Is that all delivered in person or is that online?

[00:05:07.010] Professor Panos Vostanis: I mean, the pandemic has changed a lot of how we work. And although we had plans we can start these programs intensively and face to face, I’m not sure they were sustainable at that level. In a positive way, I think the pandemic has brought sort of new– has demonstrated new ways of working with large networks globally. So the current model is that we work remotely with the networks, the groups I will talk about. Having said that, there is no substitute for face-to-face intermittent visits which we also started doing at critical points of the different training programs that I can also refer to. So it’s a combination ideally.

[00:05:52.040] Jo Carlowe: OK. Thank you. You also run interventions for children and young people themselves. Can you talk through some of the work that you’ve done with children and young people who are refugees or living in conflict zones?

[00:06:05.360] Professor Panos Vostanis: Again, there is increasing knowledge. There are different levels of interventions, some are to enhance resilience to strengthen their coping strategies during transition but also after they move to a host country and the more popular, the better known group of interventions which the association has so much expertise in on reprocessing trauma. And we have been involved in both. It depends on the timing at which stage children are at and which context.

We have worked with both. So, for example, one intervention with refugee children in Turkey in Istanbul was to both help them regulate their emotions, whether becoming angry because of experiences and so on, but also strengthen their relationship with their parents, which had suffered in the middle of all the paralysis, the distress, and the movement through a type of intervention, which is increasingly, again, popular called theraplay. But it was the first time we adopted it to this difficult group. And the circumstances were pretty challenging, particularly in engaging parents.

[00:07:19.310] Jo Carlowe: What were the outcomes like?

[00:07:22.210] Professor Panos Vostanis: The outcomes were the children engaged better. We worked through local schools and community centres. It was more difficult to engage with parents for practical reasons, for stigma, mental health, quite common challenges. We did towards the end. And they did report some benefits. But the main benefits were actually from the children. They found that their sense of attachment to their parents, their sense of security and dealing with difficult emotions had improved. So it was promising but also an important lesson that you have to work harder and understand this context and work with other agencies rather than in isolation with families. I think other colleagues have found the same.

[00:08:05.570] Jo Carlowe: One of the aims of WACIT is to develop evidence-based psychosocial interventions and capacity building for children living in conflict and disadvantage. What does the evidence show to be the best approach to take when it comes to working with children and adolescent refugees who have experienced significant trauma?

[00:08:23.885] Professor Panos Vostanis: These children in a crude sense have complex needs. OK. It is pretty obvious there is strong evidence about the high levels of unmet mental health needs. But the issue here, the distinct feature is that the complexity means that the mental health needs come together with basic needs. We work in very disadvantaged areas like in South Africa, in Pakistan, in Brazil in favelas where they come with extreme poverty, with exposure to violence, and a number of adversities that are very strongly linked.

And even if you wanted to do the difficult to disentangle. But also they have very limited resources. And we know that. So whichever way one looks at it from sort of needs point of view or from services point of view from evidence on different approaches, all the evidence indicates that a multimodal approach that is integrating psychosocial support within the context of these communities, whatever is available, I would not say is the only options. But it is the only option that is likely to succeed and to have some sustainable impact that is working with schools, with community agencies, with social care supports, whatever this might be, but also with informal systems. So this is the consensus and indication of evidence. OK. How you do it in practice is not usually easy. But that’s the model.

[00:09:57.770] Jo Carlowe: OK, yeah. And I guess you talked about limited resources, so I suppose it’s not always possible. I understand that WACIT it is launching two new projects aimed at improving services for refugee children internationally. Panos, what can you tell us about these?

[00:10:14.284] Professor Panos Vostanis: These have actually recently started. They have become active. I’m very excited about both. They share similarities, but there are some differences.

The first one in Turkey working through a large refugee association called Mülteciler, they cover a very large part of Istanbul with a high concentration of refugee children. And they do provide, as I mentioned, psychosocial services already. They endorse a holistic approach. I visited two weeks ago. We had started before the pandemic, continued. And now we’re picking it up again. So following some training of their staff on trauma-informed practice using different tools and linking theory with evidence but relate to their practice only, not just theoretical, then we moved to our sort of second level of training, which is about improving services in the broad sense according to a multilevel framework.

It’s a psychosocial framework like Maslow’s hierarchy of needs. It’s not sort of exactly the same but in relation to different supports that refugee children might need in a community. And now we’re working with them to improve all these levels, which is safety, support for parents, resilience through school and communities, enhancing the skills of other agencies, improving counselling, and even access to mental health services, which is problematic but aligned to what is already happening on the ground. And we’re working with the staff now for that next level of the service plans.

[00:11:54.330] Jo Carlowe: Was there a second intervention as well, a second service that you were going to mention as well?

[00:11:59.700] Professor Panos Vostanis: The second one that I was going to mention is an interesting, quite unprecedented project in Greece. Again, it’s on the other side of– the Aegean have similar challenges with Turkey about large numbers of refugees in recent years. And we’re working– this is quite a systematic approach. We’re working with all the agencies that provide shelters, care homes for unaccompanied minors. That is for refugee children or asylum-seeking children without parents.

And there are 29 organizations providing 69 shelters. So quite a large group across Greece. There are different strands to this program. Our work involves the training of the trainers. I met a few of them yesterday and were due to start shortly. So again, we’re providing the same framework, the two levels of training practice and service-related training but also training on trainer’s skills. And they’re going to cascade to all the staff across all their organizations. So pretty ambitious and challenging. But I’m very excited by it.

[00:13:10.320] Jo Carlowe: WACIT takes the stance that there is always hope. And Refugee Week 2022 had the theme of healing, which was defined as recovering from a painful experience or situation. Given the number of displaced children in the world and the levels of suffering, how and why should we retain hope?

[00:13:30.380] Professor Panos Vostanis: Of course, we have to address the question, the issues, the challenges in the context of what these children are faced with. So we can’t ignore that. However, there is pretty strong evidence that it’s not all or nothing. It’s not either completely healing. It’s about steps. This is a word that one of our Turkish psychologist Sinema mentioned last week in Istanbul.

She said, we work on small steps. But the steps are foundations. Colleagues in Greece mentioned the same, saying words even working in very tough reception centres that they use the word starting by making them feel human, respected, think about their dignity, and then moving on up the hierarchy. So, there is hope at different levels. So, at the psychosocial level, it is depending when they’re out, of course. And it may not take the traditional form, which is highly desirable. People think of therapies. And the association has done an awful lot of work over the years. So that’s still the case. However, it is making contribution at all levels of their lives. So, the examples I gave that you work with all the settings, with transition centres, with communities building layers of support and protection, all the way to providing or improving mental health interventions and services at the other end of that hierarchy. The hope is I would say is contextualize, is not all or nothing, is building them towards the next step, whatever that might be of their journey.

[00:15:01.640] Jo Carlowe: Panos, from your experience of working with refugee children, families, and other stakeholders, what’s your message to policymakers?

[00:15:10.670] Professor Panos Vostanis: Well, the first message is what you just mentioned that hope, it’s not a vague rhetoric. There is evidence. But it has to be broken down, has to be contextualized and really focused. The less focused it is, the more difficult it is to relay that to people and can be overwhelming. The second message is about integrated joined-up working. It’s about joining up policy. So, I had a very pleasant surprise to see all the shelters in Greece. I did not expect that after a few years to see that the policies bring psychosocial support and mental health into the guidelines of setting up NGOs. It was something I did not expect. Mental health usually comes quite late. So, these are positive messages. And the third one is not reinventing the wheel, not only focusing on specialist interventions that is looking at ways of supporting children wherever they live with whoever the carers are and the settings and the supports.

So psychosocial support mental health should go there rather than only be seen as external only for those who’d go to specialist services, which is highly desirable if needed, but take a comprehensive approach, take mental health into the community and to the post conflict zones.

[00:16:33.350] Jo Carlowe: Panos, is there anything else in the pipeline that you would like to tell us about?

[00:16:37.460] Professor Panos Vostanis: Again, it’s– I mean, vulnerable children living in disadvantage, unfortunately, not just refugee children. So we’re working in other areas. Two of our projects, very similar philosophy and the majority, I would say are in disadvantaged areas in South Africa and Pakistan at the moment. Again, low-resource settings but really positive messages, working, understanding local strengths, local resources, informal supports, and developing networks and strengthening supports and layers around children at a much larger scale than with refugee children.

Obviously, their needs are slightly different, but the principles are the same. So I would take the same principles wherever disadvantage conflict is that it’s possible and there is emerging good practice.

[00:17:30.350] Jo Carlowe: And finally, what is your takeaway message for those listening to our conversation?

[00:17:36.085] Professor Panos Vostanis: I think the takeaway is that one needs all sectors, all actors. The media are so important. I think processing the messages is as important as providing therapy and how you relate to that. And I think there has been a lot of improvement. However, the take-home message is about that integrated, joined-up working, taking mental health to where people needed rather than the inevitable fragmentation that we all know is out there. And I think the media policy, there are many actors, community religious groups have very strong part to play. Otherwise, it’s impossible to get to the ground, to engage, to break stigma. So, it’s a multilevel approach. It’s not just multimodal interventions. But there are good examples. More and more international organizations are adopting similar frameworks.

[00:18:35.080] Jo Carlowe: Thank you so much and very informative and hopeful actually. For more details on Professor Panos Vostanis, 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 share with friends and colleagues.


ACAMH response to the conflict in the Middle East

The Association for Child and Adolescent Mental Health (ACAMH) is deeply concerned about the escalating conflict in the Middle East, particularly those who have lost loved ones or been displaced.

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