An online intervention by UNSW Sydney scientists, in partnership with Settlement Services International (SSI), has successfully helped traumatised refugee men overcome the stigma associated with post-traumatic stress disorder (PTSD), a randomised control trial has shown. Men who participated in the trial went on to seek more help than those in the control group, and they experienced less self-stigma compared to the control group.

The trial’s results were recently published online in Psychological Medicine, an international, peer-reviewed journal.

“Over 70 million people are currently forcibly displaced as a result of war and persecution – their rates of psychological disorders are elevated,” says study and trial lead Associate Professor Angela Nickerson from the Refugee Trauma and Recovery Program at UNSW Science’s School of Psychology.

“The prevalence of PTSD in people from a refugee background is five times higher than in Australia’s general population, so PTSD is a devastating burden on refugees’ mental health.

“But even though the group’s mental health needs are high, their treatment uptake is low. That’s a big concern – those who don’t access treatment may have an increased risk of ongoing distress and impairment.

“One key barrier to seeking help is self-stigma, or negative beliefs about the psychological symptoms commonly experienced following exposure to trauma and help-seeking.”

Greg Benson, General Manager of Client Services and Operations at study partner SSI noted the reality of mental health stigma in recent refugee arrivals.

“SSI is a major provider of on-arrival support to refugees in NSW, and we observe first hand the psychological symptoms and the barriers to seeking help in our frontline work with refugees.”

That’s the problem the researchers wanted to address with this intervention – aiming to reducing stigma and improving help-seeking behaviour. 

A/Prof Nickerson says the intervention is the first of its kind.

“Before our project, there was no intervention to specifically reduce mental health stigma in refugees – ‘Tell Your Story’ (TYS) is the first program of its kind, and it’s so exciting to see the results of it after years of work.”

TYS consists of 11 short, interactive web-based modules that contain information, short videos, and activities. Participants completed up to 3 modules per week over a 4-week period.

“The focal point of the intervention was videos featuring Arabic, Farsi and Tamil-speaking men sharing their personal experiences overcoming stigma, and describing how they successfully sought support for PTSD,” A/Prof Nickerson says.

“Other interactive activities educated users about PTSD and supported them to develop personalised plans for seeking help. There was no therapeutic assistance, but a computer algorithm was used to feed back responses to various activities to assist men in generating a help-seeking plan.”

“SSI has seen the real world benefits in partnering in trials like this, where an online intervention is available to refugees in community languages,” said Mr. Benson.

Encouraging results: more men seeking help

103 refugee men with PTSD symptoms from Arabic, Farsi or Tamil-speaking background were randomly assigned to either receive the TYS intervention, or to participate in a control group of men who were put on a wait list.

The TYS participants completed an online assessment of their PTSD symptoms and help-seeking behaviour before the intervention, straight after the intervention, and 1 month after completion.

“One key finding was that men who participated in the intervention sought more help from new sources than those in the control group,” A/Prof Nickerson says.

Dr Yulisha Byrow, a Postdoctoral Research Fellow at the Refugee Trauma and Recovery Program, and the Project Manager believes the positive impact of this intervention relates to the nature of the content.

“We think the reason it worked so well could be because the videos gave participants concrete examples of the potential benefits of help seeking.

“For example, some study participants told us that realistic stories and information helped them understand the psychological state they are experiencing, and that psychological treatment can help them overcome these symptoms.

“The study participants often expressed their appreciation for a culturally sensitive resource that has been developed with their unique experiences, culture, and language in mind.”

The findings suggest that evidence-based stigma reduction strategies are beneficial in targeting self-stigma related to help-seeking and increasing help-seeking among refugees.

“Online interventions focusing on social contact may be a promising avenue for removing barriers to accessing help for mental health symptoms in traumatised refugees – that’s consistent with previous research,” A/Prof Nickerson says.

“What’s very encouraging is that participants had accessed more sources of support between post-intervention and follow-up than the control group.

“That’s important because previous studies showed that behaviour change is especially difficult to get from self-stigma interventions.”

Extending research to larger trials – and women

The authors now want to conduct larger randomised control trials to test some of these hypotheses and disentangle their findings’ exact mechanisms.

“We  also plan to extend the program to women – we focused on refugee men in this study because they are less likely to access psychological treatment than refugee women, but we’d love to extend this to women, too,” A/Prof Nickerson says.

“We also have already made stigma reduction guidelines available to case workers as a result of this research.”

“These guidelines have been helpful for SSI’s frontline staff working with refugees, to deepen their understanding of ways to reduce stigma,” noted Mr. Benson.

Director and Chief Scientist of the Black Dog Institute and contributor to the research, Scientia Professor Helen Christensen, highlights the importance of building on this evidence base.

“Refugees come to our shores often experiencing significant trauma and in desperate need of culturally sensitive mental health resources and services; therefore, it is imperative we understand the barriers that might prevent our refugees from seeking this much-needed help. This research is one pivotal step in the right direction” said Christensen.“Our next step is to broaden this evidence-base to address stigma preventing all refugees from seeking help, regardless of age, gender or religion.”

The initiative is a partnership between the Refugee Trauma and Recovery Program (RTRP) led by A/Prof Nickerson at UNSW's School of Psychology, Settlement Services International (SSI) and the Black Dog Institute. It was funded by beyond blue with donations from the Movember Foundation.