Trauma Systems Therapy for Refugees (TST-R) in a multi-ethnic refugee population in Maine, USA: early findings from a programme evaluation project with children and adolescents
Authors: Emma Cardeli, Seethalakshmi Davis, Osob Issa, B Heidi Ellis
Journal: The Lancet Global Health (2020)

BackgroundTrauma Systems Therapy for Refugees (TST-R) is a multi-tiered, behavioural health intervention that directly targets barriers to care for refugee children and families. Informed by a population-based approach, TST-R encompasses three levels of practice (individual/family, community, and systems), aiming to address not only individual behaviour, but also social or structural factors, or both, that contribute to distress. Services are delivered by a clinician and a cultural broker (a community member who shares the client's ethnic background) who work in partnership to provide psychoeducation on mental health, reduce acculturative stress, enhance the safety and stability of the child's social environment, and improve the child's regulatory capacities. Here, we describe components of TST-R and report early findings from an ongoing, multi-site programme evaluation.MethodsTST-R services began in Lewiston, ME, USA, in September, 2016; since then, two additional TST-R programmes have started in neighbouring communities (Biddeford in September, 2017, and Portland in September, 2018). These three communities have high proportions of refugees from various countries of origin. Each TST-R programme is comprised of clinicians, cultural brokers, and site supervisors; these teams received an initial TST-R training followed by subsequent consultation to ensure model fidelity. We used the strengths and difficulties questionnaire (SDQ) to measure the effect of clinical services on clients' emotional and behavioural symptoms and functioning over time (the parent-report version of the SDQ was used if the child was aged 10 years or younger). This measure was administered at intake and repeated at 6-month intervals until discharge. The impact of cultural brokering on treatment outcomes was also assessed, as cultural brokers were not available on the TST-R team for every ethnic group served by TST-R programming.FindingsBetween April 1, 2017, and April 1, 2020, 103 clients, or parents of clients, completed the SDQ at intake; 44 clients, 20 clients, 10 clients, and 5 clients completed the measure at the 6-month, 12-month, 18-month, and 24-month timepoints, respectively. Clients were aged 3–19 years (median 11 years), mostly male (n=63, 64%), and from 17 different countries, with most refugee clients born in the Democratic Republic of Congo (n=20, 20%) or Somalia (n=10, 10%). When cultural brokers were included in treatment, there was a marked decrease in clients' self-reported emotional and behavioural problems 6 months into service delivery (intake M=0·56; 6 months M=0·46); this decrease was not evident for refugee clients whose mental health services were supported instead through the use of the language line, an interpreter, or clinician intervention alone. Mixed design ANOVA showed a significant interaction effect between timepoint (intake and 6-months) and the inclusion of cultural brokering services in treatment: F(1,42)=7·42, p=0·009, r=0·39.InterpretationOur findings underscore TST-R's potential as a promising intervention for refugee children and adolescents experiencing both acculturative hassles and traumatic stress. In addition, results support the inclusion of cultural brokers into outpatient treatment teams as a strategy for providing linguistically appropriate, culturally responsive mental health services to multi-ethnic, refugee populations.FundingSubstance Abuse & Mental Health Services Administration, US Department of Health & Human Services