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September, 10th, 2007Hans Rohlof, M.D.
Group Treatment with Multiethnic Groups
September, 10th, 2007 Hans Rohlof, M.D.2 GROUP TREATMENT WITH MULTIETHNIC GROUPS
Content lecture
• Literature about group therapy with multiethnic groups
• Our experience with multiethnic group therapy• Outcome of group therapy
September, 10th, 2007 Hans Rohlof, M.D.3 GROUP TREATMENT WITH MULTIETHNIC GROUPS
Literature Group Therapy with Multiethnic Groups(1)
• Rather scarse• Davis (1984): Mixed groups with African
Americans: attention for as well sociocultural position as personal issues.
• Tsui and Schultz (1988): Asian clients in Caucasian groups: different perceptions of power, authority, interpersonal boundaries and family process.
September, 10th, 2007 Hans Rohlof, M.D.4 GROUP TREATMENT WITH MULTIETHNIC GROUPS
Literature Group Therapy with Multiethnic Groups (2)
• Vasquez & Han (1995): divers ethnic minorities: therapeutic factors of validation, empowerment, mutuality and self-empathy.
• Warriner (1978): warnings about dangers of thinking as race as the most distinguishing characteristic of individuals in multiethnic groups.
September, 10th, 2007 Hans Rohlof, M.D.5 GROUP TREATMENT WITH MULTIETHNIC GROUPS
Literature Group Therapy with Multiethnic Groups (3)
• Matsukawa (2001): • Exploration of ethically derived values• Observe and understand nonverbal and symbolic
forms of communication• Explore cultural transferences and counter-
transferences• Help examine ethnic or racial prejudices
September, 10th, 2007 Hans Rohlof, M.D.6 GROUP TREATMENT WITH MULTIETHNIC GROUPS
Literature Group Therapy with diverse groups of Refugees: Dutch literature
• Santini et al (1999): integrative multidimensional group therapy
• van Emmerik et al (1999): psychoeducation, existential problems. Three themes: coping with trauma symptoms, acculturation, self care.
• Tonk (2004): thematic, flexible, non-verbal.
September, 10th, 2007 Hans Rohlof, M.D.7 GROUP TREATMENT WITH MULTIETHNIC GROUPS
Literature Group Therapy with diverse groups of Refugees: international literature
• Entholt et al (2005): two groups of children, n=15 and n=11. First group CBT-group (6 weeks), second waiting list. PTSD symptoms significantly decreased. Follow-up after 2 months: no change.
• Otto et al (2003): Cambodian patients refractory to medication (n=5/5). Sertraline alone or combination with 10 sessions of CBT-group (psychoeducation and relaxation): significant difference in outcome (effect size 0,82).
September, 10th, 2007 Hans Rohlof, M.D.8 GROUP TREATMENT WITH MULTIETHNIC GROUPS
Refugees as patients
• Traumatisation: PTSS about 40 % (NL), (normal population: 1-2 %)
• Losses and forced migration. Depression about 50 % (NL), (normal population: 7,6 % year, 19 % life prevalence)
• Acculturation. 'Liminal' vulnerability in people in change: culture, language.
• Social marginalization and isolation. Living in asylum centers, juridical procedures, unemployment in refugees with status (50 %), lack of social support.
September, 10th, 2007 Hans Rohlof, M.D.9 GROUP TREATMENT WITH MULTIETHNIC GROUPS
Arbeidsparticipatie
• Werkloosheid (1.1.2004):
0
5
10
15
20
25
30
35
40
autocht Turken ex-Joegsl I ran Somaliërs
werkloosheid
September, 10th, 2007 Hans Rohlof, M.D.10 GROUP TREATMENT WITH MULTIETHNIC GROUPS
Book: 'Group therapy with refugees''
• two theoretical and reviewing chapters• nine chapters with descriptions of specific groups:
one psychoeducation, three day clinical, one clinical, two ambulant, two adolescent groups
• one concluding chapter
September, 10th, 2007 Hans Rohlof, M.D.11 GROUP TREATMENT WITH MULTIETHNIC GROUPS
September, 10th, 2007 Hans Rohlof, M.D.12 GROUP TREATMENT WITH MULTIETHNIC GROUPS
Description of possible effective items of group therapy with refugees(1)
• Mutual support• Mutual respect • Mutual identification• Group psycho-education• Group exercises
September, 10th, 2007 Hans Rohlof, M.D.13 GROUP TREATMENT WITH MULTIETHNIC GROUPS
Group exercises
September, 10th, 2007 Hans Rohlof, M.D.14 GROUP TREATMENT WITH MULTIETHNIC GROUPS
Description of possible effective items of group therapy with refugees(2)
• Most groups very heterogeneous• Focus needed for identification• Most used focus: acculturation: probably more
positive and less harmful • Focus on traumatization probably too harmful, too
insecure, too complicated (different political/ethnic groups)
September, 10th, 2007 Hans Rohlof, M.D.15 GROUP TREATMENT WITH MULTIETHNIC GROUPS
Description of possible effective items of group therapy with refugees(3)
• no protoprofessionalisation: psychoeducation needed
• information about symptoms, about mental health care, about treatment
• informed consent
September, 10th, 2007 Hans Rohlof, M.D.16 GROUP TREATMENT WITH MULTIETHNIC GROUPS
Description of possible effective items of group therapy with refugees(4)
• group rules and confidentiality: complicated by:• paranoid symptoms from traumatization• fear of gossip (small ethnic groups)• fear of stigmatization• much attention to confidentiality!
September, 10th, 2007 Hans Rohlof, M.D.17 GROUP TREATMENT WITH MULTIETHNIC GROUPS
Description of possible effective items of group therapy with refugees(5)
• Somatization and psychologization• Next to verbal group therapy: relaxation exercises,
psychomotor therapy, other nonverbal techniques. • Turning passive into active
September, 10th, 2007 Hans Rohlof, M.D.18 GROUP TREATMENT WITH MULTIETHNIC GROUPS
Description of possible effective items of group therapy with refugees(6)
• Influence of social/juridical problems:
• good cooperation with social workers, lawyers, wellfare institutes etcetera.
• look out for negative attitude against group therapists, wrongly seen as representatives of other institutions (ministry of justice, vocational and wellfare services)
• education about racism, discrimination,
• education about building relationships with native people.
September, 10th, 2007 Hans Rohlof, M.D.19 GROUP TREATMENT WITH MULTIETHNIC GROUPS
Description of possible effective items of group therapy with refugees(7)
• Working with interpreters:• Complicated in group therapy: without is better• Two (maybe three) interpreters is maximum a
group can handle• Translating interpreters, not interpreters who are
treating or consulting
September, 10th, 2007 Hans Rohlof, M.D.20 GROUP TREATMENT WITH MULTIETHNIC GROUPS
Description of possible effective items of group therapy with refugees(8)
• Gender specific or gender mixed?• In cultures of origin less confidentiality in mixed
gender groups• Taboo items better expressed in gender specific
groups• Male behavior and female behavior reinforced in
specific groups• Training in inter gender relation building possible
in mixed gender groups
September, 10th, 2007 Hans Rohlof, M.D.21 GROUP TREATMENT WITH MULTIETHNIC GROUPS
Description of possible effective items of group therapy with refugees(9)
• multi-ethnic or mono-ethnic groups:• mono-ethnic much identification• multi-ethnic groups many opportunities, but
problems according to Matsukawa (2001) :• 1. need to clarify different norms and values• 2. help in understanding nonverbal and symbolic
ways of communication• 3. need to clarify cultural (counter) transference• 4. investigate and control of racial prejudices
September, 10th, 2007 Hans Rohlof, M.D.22 GROUP TREATMENT WITH MULTIETHNIC GROUPS
Description of possible effective items of group therapy with refugees(10)
• Exposure in groups:• No evidence for effectiveness of group exposure• Common avoidance probably also not good• Talking about horrible details produces many
uncontrolled emotions in different group members• Talking about experiences together with reactive
coping behavior better than stories alone
September, 10th, 2007 Hans Rohlof, M.D.23 GROUP TREATMENT WITH MULTIETHNIC GROUPS
Conclusions
• Many effective items in group therapy with refugees
• Precautions important• Making choices important• More research needed about the overall effect of
group therapy with refugees. • Group therapy with PTSD patients has low
evidence of effectiveness (Foy, in Foa et al, 2000), but refugees seem to profit more.
Consult our website www.centrum45.nl for further information.