An Integrative Adapt Therapy for common mental health symptoms and adaptive stress amongst Rohingya, Chin, and Kachin refugees living in Malaysia: A randomized controlled trial

Abstract

Background

This randomised controlled trial (RCT) aims to compare 6-week posttreatment outcomes of an Integrative Adapt Therapy (IAT) to a Cognitive Behavioural Therapy (CBT) on common mental health symptoms and adaptive capacity amongst refugees from Myanmar. IAT is grounded on psychotherapeutic elements specific to the refugee experience.

Methods and findings

We conducted a single-blind RCT (October 2017 –May 2019) with Chin (39.3%), Kachin (15.7%), and Rohingya (45%) refugees living in Kuala Lumpur, Malaysia. The trial included 170 participants receiving six 45-minute weekly sessions of IAT (97.6% retention, 4 lost to follow-up) and 161 receiving a multicomponent CBT also involving six 45-minute weekly sessions (96.8% retention, 5 lost to follow-up). Participants (mean age: 30.8 years, SD = 9.6) had experienced and/or witnessed an average 10.1 types (SD = 5.9, range = 1–27) of traumatic events. We applied a single-blind design in which independent assessors of pre- and posttreatment indices were masked in relation to participants’ treatment allocation status. Primary outcomes were symptom scores of Post Traumatic Stress Disorder (PTSD), Complex PTSD (CPTSD), Major Depressive Disorder (MDD), the 5 scales of the Adaptive Stress Index (ASI), and a measure of resilience (the Connor–Davidson Resilience Scale [CDRS]). Compared to CBT, an intention-to-treat analysis ( n = 331) at 6-week posttreatment follow-up demonstrated greater reductions in the IAT arm for all common mental disorder (CMD) symptoms and ASI domains except for ASI-3 (injustice), as well as increases in the resilience scores. Adjusted average treatment effects assessing the differences in posttreatment scores between IAT and CBT (with baseline scores as covariates) were −0.08 (95% CI: −0.14 to −0.02, p = 0.012) for PTSD, −0.07 (95% CI: −0.14 to −0.01) for CPTSD, −0.07 for MDD (95% CI: −0.13 to −0.01, p = 0.025), 0.16 for CDRS (95% CI: 0.06–0.026, p ≤ 0.001), −0.12 (95% CI: −0.20 to −0.03, p ≤ 0.001) for ASI-1 (safety/security), −0.10 for ASI-2 (traumatic losses; 95% CI: −0.18 to −0.02, p = 0.02), −0.03 for ASI-3 (injustice; (95% CI: −0.11 to 0.06, p = 0.513), −0.12 for ASI-4 (role/identity disruptions; 95% CI: −0.21 to −0.04, p ≤ 0.001), and −0.18 for ASI-5 (existential meaning; 95% CI: −0.19 to −0.05, p ≤ 0.001). Compared to CBT, the IAT group had larger effect sizes for all indices (except for resilience) including PTSD (IAT, d = 0.93 versus CBT, d = 0.87), CPTSD (d = 1.27 versus d = 1.02), MDD (d = 1.4 versus d = 1.11), ASI-1 (d = 1.1 versus d = 0.85), ASI-2 (d = 0.81 versus d = 0.66), ASI-3 (d = 0.49 versus d = 0.42), ASI-4 (d = 0.86 versus d = 0.67), and ASI-5 (d = 0.72 versus d = 0.53). No adverse events were recorded for either therapy. Limitations include a possible allegiance effect (the authors inadvertently conveying disproportionate enthusiasm for IAT in training and supervision), cross-over effects (counsellors applying elements of one therapy in delivering the other), and the brief period of follow-up.

Conclusions

Compared to CBT, IAT showed superiority in improving mental health symptoms and adaptative stress from baseline to 6-week posttreatment. The differences in scores between IAT and CBT were modest and future studies conducted by independent research teams need to confirm the findings.

Trial registration

The study is registered under Australian New Zealand Clinical Trials Registry (ANZCTR) ( http://www.anzctr.org.au/). The trial registration number is: ACTRN12617001452381

Author summary

Why was this study done?

• Integrative Adapt Therapy (IAT) is a theoretically guided approach based on the Adaptation and Development After Persecution and Trauma (ADAPT) model, specific to the refugee experience.

• The 5 pillars identified in the ADAPT model—(1) safety/security, (2) attachments, (3) justice, (4) role/identity disruptions, (5) existential meaning—may have universal resonance with refugees and displaced persons.

• This is the first randomised controlled trial (RCT) in which IAT is compared with a brief, culturally adapted 6 weekly 45-minute Cognitive Behavioural Therapy (CBT).

What did the researchers do and find?

• Chin, Kachin, and Rohingya persons displaced to Malaysia were randomly assigned by an independent researcher to either the IAT or CBT control arm of the trial.

• Lay counsellors who received training in both IAT and CBT treated the participants according to their allocation status.

• Compared to CBT, IAT participants reported greater reductions in mental health symptoms, in all 5 adaptive stress areas (except the injustice domain), and a greater increase in resilience.

What do the results mean?

• The findings suggest that IAT, delivered by lay counsellors, was an effective treatment for improving mental health, adaptive stress, and resilience amongst refugees.

• The difference in treatment effect between the 2 treatments on resilience is small.

• We note that our findings are limited to only 6-week follow-up and may not be generalisable to refugees in other settings.