TRAINING FOR NHS TALKING THERAPIES HIGH INTENSITY CBT THERAPISTS TO MEET THE NEEDS OF REFUGEES AND ASYLUM SEEKERS

Outline structure of the training

There are four sections to the training:

1. A directed self-study module in which the therapists will study some background information about refugees and asylum seekers (RAS) and various aspects of the diagnosis of PTSD, including Complex PTSD. They will be required to undertake this module first, taking approximately one day.

2. DAY 1 Basics of adapting CT-PTSD for RAS (online workshop).

This will include working with interpreters; cultural competence; models of mental health across cultures; working with trust; rebuilding life; working in unstable circumstances; the importance of being memory focused; and the outcome research for this client group.

3. DAY 2 Adapting CT-PTSD for multiple traumatic events (online workshop)

This will include how to select treatment targets in long trauma histories; practise in the use of lifelines (including NET-informed approaches); and how to understand and manage dissociation.

4. DAY 3 Using imagery to update trauma memories with RAS (online workshop)

RAS typically experience horrific traumatic events, including a great deal of sexual violence and torture, in childhood and adulthood. Imagery re-scripting is often the best way to update hotspots in such events. The workshop will include: the neuroscientific background to imagery re-scripting; how to update hotspots in childhood using imagery; how to update hotspots in adulthood using imagery; common difficulties; coached small group role plays practising the techniques.

5. DAY 4 Focusing on the cognitive themes typical in RAS suffering from PTSD (online workshop)

This will include working with shame in torture/sexual violence; working with guilt and responsibility; working with cultural blame; working with moral injury; working with mental defeat; working with contamination; working with traumatic grief.

6. Once the rest of the training has been completed, the therapists will be offered eight, monthly, 2-hour video group supervision sessions with the trainers, covering how to deliver CT-PTSD with RAS.

Entry requirements

Therapists will have completed NHS Talking Therapies High Intensity CBT Training or be BABCP Accredited CBT therapists working in NHS Talking Therapies services. In addition, each therapist will need to have had experience of at least three supervised cases treating PTSD using the Ehlers and Clark model.

Accreditation

This training will be recognised by BABCP as suitable CPD for ongoing accreditation.

1. Directed self-study module (approximately one day)

PTSD is the most common diagnosis in treatment seeking RAS. Because RAS tend to have experienced multiple traumatic events in their country of origin and en route to the UK, they present to services with a complex PTSD presentation. This is characterised by high levels of dissociation, nightmares and flashbacks to many different events and by some ‘psychotic-like’ symptoms e.g., hearing the voice of a torturer commenting on events in the here and now. NHS Talking Therapies CBT Therapists working with PTSD in RAS need be confident in assessing and treating ‘simpler’ PTSD presentations before they can adapt this knowledge for the more complex RAS client group.

How to treat ‘simple’ forms of PTSD is a core part of the NHS Talking Therapies High Intensity CBT curriculum. Once qualified, it is often the case that a few interested/experienced clinicians in each service tend to undertake most of the PTSD treatments. Thus, to target this training most effectively, it is these therapists (with some existing experience of treating PTSD) who should attend this training on working with refugees and asylum seekers.

To reduce training costs, background, theoretical and diagnostic issues can easily be covered via directed self-study. Conversely, practical treatment techniques need to be taught interactively with live feedback.

The same distinction also applies to the general training on RAS issues - background information about why people become refugees, rates of asylum seeking in the UK, the asylum process and the prevalence of common mental health problems in refugees can all be covered in a remote self-study training, whereas RAS assessment and treatment techniques are taught in a live interactive workshop.

2. Four days of live interactive online workshops on how to adapt CT-PTSD for RAS

These 4 days of live interactive online workshops will be delivered via Zoom. To aid concentration and attendance for part-time workers, we will teach for two days one week and two the following week.

At the end of the workshops, therapists will:
xiii. Have practised the use of lifelines (including NET-informed approaches) to select targets in long trauma histories

1. Have knowledge of how to undertake the fundamental techniques involved in the application of CT-PTSD (reliving, hotspot identification and updating, stimulus discrimination and grounding)
2. Have knowledge of how undertake CBT through interpreters and best practice guidance for doing CT-PTSD with an interpreter.
3. Have competence in how to approach making culturally sensitive modifications to CT-PTSD
4. Have knowledge of what to consider when assessing RAS with reference to the most common diagnoses – PTSD, Complex PTSD and Depression
5. Have competence in how to adapt the Ehlers and Clark model to conceptualise PTSD in multiply traumatised people, including RAS
6. Have competence in how to plan CBT for PTSD and Depression in RAS
7. Have competence in how to maintain the focus in therapy on mental health difficulties and not on practical/medical/financial/social/legal problems.
8. Have competence in how to understand and manage the common problem of dissociation in traumatised RAS
9. Have competence in how to work with trust issues in RAS
10. Have competence in how to teach emotion regulation strategies when needed
11. Have knowledge of how to conceptualise and work with the ‘psychotic-like’ symptoms which are prevalent in RAS with PTSD
12. Have competence in how to do reliving with RAS who have experienced more than one traumatic event – including how to select treatment targets in long trauma histories

xiv. Have competence in delivering imagery-based updates to trauma memories in RAS. This will include how to update hotspots in childhood and adulthood

1. Have undertaken small-group coached role plays in the use of imagery-based updates in CT-PTSD
2. Have knowledge about how to work with reclaiming life in this client group
3. Have competence in working with stimulus generalization and ‘now versus then thinking’ in RAS
4. Have knowledge of the outcome research in this area and its limitations
5. Have competence in how to address some of the cognitive themes common in this client group. This will include working with shame in torture/sexual violence/human trafficking; working with guilt and responsibility; working with cultural blame; working with moral injury; working with mental defeat; working with contamination; working with traumatic grief.

Assessment of competence in adapting CT-PTSD for RAS cannot be made at the end of the four-day training. Therapists’ competence will be evaluated in the supervision phase (Section 4 below).

3. Eight, monthly group supervision sessions

On completion of the training, the participants will be offered eight, monthly group supervision sessions (each lasting 120 minutes) to help consolidate the learning. The supervision sessions will be facilitated by the members of the original training team.

The supervision groups will contain no more than four therapists and will be carried out over a video conference call.

The evaluation of the therapists’ competence in using CT-PTSD will be made during this phase of the training as follows:

Competence in CT-PTSD with RAS:

- each therapist must submit a full therapy recording to their supervisor. This recording must be of a session in which they undertook memory-focused work (reliving, updating of hotspots or ‘now versus then’ interventions.)

- we will encourage therapists to submit their tape roughly half-way through supervision, to make good use of the feedback by building on their learning during the latter stages of supervision.

- both the therapist and supervisor will rate the session using the PTSD specific version of the Cognitive Therapy Rating Scale Revised.

- if this recording is not deemed adequate by the supervisor, the therapist must submit another.