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 for the specialism in psychology. I’m interviewing clinical psychologist Gwladys Demazure who is the first author of the CAMH Review article, “Unaccompanied Refugee Minors’ Perception of Mental Health Services and Professionals– A Systematic Review of Qualitative Studies.” This paper 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 do with a rating or review, and do share with friends and colleagues. Gwladys, thank you for joining me. Can you start with a brief introduction about who you are and what you do? Dr. Gwladys Demazure Hello, Jo, and thank you for your invitation to this interview. Well, I am a French clinical psychologist, as you said, and a PhD candidate hoping to graduate on the 10th of November. My PhD thesis is about psychotherapeutic care for unaccompanied refugee minors. And they are girls and boys under the age of 18 who arrived in a country without any responsible adults with them. Jo Carlowe For your paper, “Unaccompanied Refugee Minors’ Perception of Mental Health Services and Professionals– A Systematic Review of Qualitative Studies” recently published in CAMH, can you start with a brief overview of the paper? What did you look at? Dr. Gwladys Demazure So, as you may know, unaccompanying refugee minors went through many traumatic situations, like physical violence, loss of close family members, or life-threatening events. And they are a population at risk for developing mental health problems, like post-traumatic stress disorder, or PTSD, anxiety, and/or depression. In fact, 42% of unaccompanied refugee minors could meet the DSM-5 criteria for a mental disorder. So, you’ll agree that this population is in need for mental health care. However, we know that they make less use of psychiatric care than born peers even though half of them report that their need for mental health care is unmet. Because we were interested in implementing an adapted psychotherapeutic intervention for them, we wanted to explore the barriers to its implementation. We know that therapeutic alliance quality can impact the therapeutic results and the effectiveness of psychotherapeutic interventions. That’s why we wanted to explore an unaccompanied refugee minor’s perception of mental health and mental health professionals in the host country through a systematic review to get a better understanding of their expectations and the potential barriers to their mental health care. Jo Carlowe Is it an area that’s been looked at before? I’m trying to understand why it’s just so important to explore their experience. Dr. Gwladys Demazure It’s not something that has been really studied before. The literature is more about their mental health and a little bit of the psychotherapeutic interventions to help them to get better, but not really on this topic. Jo Carlowe So really important. Before we look at the findings, can you tell us a little bit about the methodology used for the review? Dr. Gwladys Demazure Yeah. So we explored seven different databases using both English and French search terms, like “unaccompanied minor,” “youth,” “adolescence,” and “interview.” We identified 527 records, and ultimately included only nine studies in the review. We included all studies with URMs interviews about psychotherapy intervention, mental health services, or professionals. We decided to exclude the qualitative studies, as only one study was available at this time, in order to maintain a methodological consistency. And we also decided to explore the quality of included studies by using the standards for reporting qualitative research. Jo Carlowe And what were the main findings? Dr. Gwladys Demazure So, after the analysis of the studies included in the review, three major themes emerged from unaccompanied refugee minor experiences with therapeutic care, mental health services and mental health professionals. The first theme concerns unaccompanied refugee minors’ negative perceptions about mental health and mental health professionals. Having mental health problem is often considered as being crazy to them, which can lead to isolation and rejection in their home country. They experience a form of distrust towards mental health professionals and therapeutic care offered in Western countries. They can feel significant pressure to talk, with the feeling that the questions of the professionals were a way to make them talk about things they did not really want to talk about, such as their past. When questions were asked by professionals, this can create a sense of being interrogated, and indirectly hinder the building of the therapeutic alliance with the professional. On the other hand, they have the feeling that the professionals are not really addressing their day-to-day concerns, and may impose their vision of what might be good for them. Talking can be perceived as ineffective, too slow, or may even worsen their condition by bringing back traumatic memories. In fact, they seem to appreciate activity-based intervention rather. The second point concerns barriers to therapeutic process. Unaccompanied refugee minors, they do not prioritize their mental health, which comes second to basic needs, such as education and material possessions. They do not like the formal and impersonal environment of a clinic, and prefer more comfortable, familiar, non-intimidating place. Language barrier is also a barrier for them. But some of the young people interviewed were quite dissatisfied with the presence so of an interpreter. And finally, the last theme concerns positive views of psychologists. Some unaccompanied refugee minors were able to express satisfaction that they were able to ask questions, receive answers, and get encouragement from mental health professionals. Jo Carlowe Very significant. Just to touch on something that you said there, you implied that there’s a stigmatization, basically, to having mental health issues. Dr. Gwladys Demazure Yeah. Jo Carlowe So, I’m just wondering about how you work with that in– so it’s not just the perception of how the professionals are behaving, it’s actually the acknowledgment of mental illness being accepted in some way. Dr. Gwladys Demazure Exactly. Actually, our results indicate that we need to adapt our practice to unaccompanied refugee minor needs who come from different countries with different cultures, different values, and habits. First, I think we need to give them access to information about the role of mental health professionals and the purpose of a therapy. And for that, we can focus maybe on specific goals that seem relevant to them. That’s how I think we can try to change this stigmatized perception of mental health and maybe mental health professionals. Jo Carlowe I mean, you’ve actually described earlier there’s ample evidence to show that the more positive the therapeutic alliance, the higher the efficacy of therapy. So– Dr. Gwladys Demazure Yeah. Jo Carlowe Your review has revealed that unaccompanied refugee minors often don’t trust mental health professionals, they don’t value their work, nor do they have a clear perception of what they actually do. So, it’s got huge implications. What should CAMH professionals be doing and thinking about these findings? Dr. Gwladys Demazure As I said, first, I think we need to take time to really explain to them our work and what we do and how we can be useful for them because they don’t know who we are. They don’t know what we do. Although we may be tempted to dive into the PTSD treatment and talk about their past and their traumatic experience to help them overcome their big PTSD symptoms, we must take our time and secure this therapeutic alliance, maybe on focusing on their day-to-day issues, like sleeping difficulties, administrative procedures, stress, relationships. All these topics can be a good way to gain their trust and then get them to work on their traumatic memories if it’s necessary. Working directly also in their residential homes or their schools can also help. I’ve worked myself several years as a clinical psychologist in an institution with many unaccompanied refugee minors, and I spent time with them at their school or directly in their homes. This helped me a lot to gain their trust, and they said that it was easier for them to approach me and ask for my help. Jo Carlowe Were there any types of interventions that were valued by unaccompanied refugee minors, and can you talk through some of those? Dr. Gwladys Demazure According to our results, unaccompanied refugee minors prefer activity-based group interventions rather than talked-based one. In the past few years, many psychotherapeutic interventions have been tested with unaccompanied refugee minors with different modules around psychoeducation, emotional regulation strategies, such as relaxation, meditation, or a cognitive restructuring. And at the end, if necessary, it’s possible to work on more trauma-focused sessions using, for example, exposure. Those sessions usually take place in a group setting, which allows URMs to form social bonds, which is really important for them. And I think this type of interventions are valued by unaccompanied refugee minors, and this can help them in their daily problems, reducing, in fact, the barriers that we discussed earlier. Jo Carlowe What’s your message then to mental health professionals about how they might adapt their practice to better meet the needs of unaccompanied refugee minors? You’ve certainly touched on some of it, but do you want to elaborate at all? Dr. Gwladys Demazure There is also my thesis show that mental health professionals need to adapt their practice, but not in a radical and extreme way. Of course, working with culturally diverse population requires extra time and effort. It seems important to be aware of our beliefs, values, attitudes, biases, towards our own culture and that of the patients’, but also to be aware of the barriers that they face. In this way, we can try to avoid making judgments about cultures that are different from ours. And addressing these issues with the patients can lead to a more common worldview, fostering the establishment of the therapeutic alliance. However, we believe that there are already many tools available to help unaccompanied refugee minors, but it is important not to be afraid to use them with them. We believe that defining goals for therapy with the youth can be useful for them. It helps identify how the professional will help and clarify the expectations. Psychoeducation is a great tool to speak the same language, which mean that the unaccompanied refugee minor can have access to a better understanding on how emotion works, how symptoms work, sleep, et cetera, and be able to understand the words that we use as mental health professionals. But the mental health professional can also learn for the terms that they use in their home country to express feelings or express mental disorders or whatever, and it can be used later in the therapy. Finally, as I said, they can use therapeutic tools, such as relaxation, meditation, cognitive restructuring, exposure. All those tools can be used with the general population, but we really believe that it can also be used with unaccompanied refugee minors. Jo Carlowe Excellent. Thank you. That’s very clear. Gwladys, is there anything else in the paper that you’d like to highlight? Dr. Gwladys Demazure Well, I think it’s important to address some limitations of our review because only a few studies, nine, were available on this topic, and studies had fairly small sample sizes. Sometimes the authors of the studies were sometimes unclear about the number of youth interviewed about specific situations. In addition, the quality of included studies varied greatly, with scores ranging from 0 to 19 out of a maximum of 21. This can have an impact on the results of the review, and I think it’s important to know it and take the results into this consideration. Jo Carlowe Are you planning some follow-up research? Dr. Gwladys Demazure Yeah. We did, actually. Because after the review, we conducted two quantitative studies on this topic. The first study is a questionnaire study on unaccompanied refugee minors’ mental health and their perceptions about psychologists and psychotherapeutic care in France. This study follows our systematic review, and the aim was to explore their mental health, emotional regulation, adaptive strategies, and their perception of psychologists, meetings, exercises that they did with the professionals. And the second study is also a quantitative study on the experiences and practices of the psychologists working with unaccompanied refugees in France. And we are currently in the process of submitting those two studies in peer-reviewed journals. Jo Carlowe Is there anything else in the pipeline that you would like to mention? Dr. Gwladys Demazure As I mentioned earlier, my thesis is about psychotherapeutic treatment for unaccompanied minors, and our results will therefore be presented during the oral exam on the 10th of November, and then hopefully published in the coming months in peer-reviewed journals. Jo Carlowe Very best of luck with that. Finally, Gwladys, what take-home message do you have for those listening to our conversation today? Dr. Gwladys Demazure I’d like to say that working with unaccompanied refugee minors might seem difficult at first, and professionals may feel reluctant or unsure on how to work with them due to biases, stereotypes, perceived barriers, and different concerns. However, evidence is now available to assist professionals and guide them in adapting their practice when working with this population. To me, professional practices need to be based on evidence, but we need to improve the dissemination of research findings by opening up the access to scientific data to professionals, like in this podcast, for example. And also, I think we need to improve translation tools for non-English speakers. But that’s my French part that speaks. But to reduce the gap between research and practice, we also need to be able to bring the research closer to the professionals’ practices with more practice-based research. Jo Carlowe Brilliant. Such important messages. Thank you ever so much. For more details on Dr. Gwladys Demazure, 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.