Psychological Treatment of Posttraumatic Stress Disorder and Moral Injury in Refugees

The intervention used in this study will be the Moral Injury Treatment for Refugees (MIT-R). The aim of this clinical study is to assess if MIT-R is effective in reducing post-traumatic stress disorder symptoms, reducing negative moral emotions (i.e., anger, shame, and guilt) and increasing social functioning in a group of Arabic, Dari, Farsi and English-speaking refugees. MIT-R was developed in consultation with refugee community leaders and service providers. We drew on evidence-based strategies from existing interventions focused on moral injury, anger, guilt and shame, as well as interventions adapted to the refugee context. This study will utilise a randomised multiple baseline case series design, where participants will be randomised to a baseline length of 4, 6, or 8 weeks before receiving the intervention. MIT-R comprises 12 weekly sessions (1.5 hours each session) for individuals and will be delivered online via Zoom. This intervention comprises four phases: Psychoeducation- in this phase, participants’ symptoms are normalised and participants learn about the psychological effects of traumatic events and morally injurious events for refugees; Narrative Exposure Therapy: in this phase, participants’ autobiographical narrative is constructed, key morally injurious/traumatic events are identified and processed. Narrative Exposure Therapy is the leading evidence-based trauma-focused intervention for PTSD in refugees and has been evaluated in more than 20 studies; Culturally-Informed Cognitive Therapy: In this phase, moral injury appraisals are situated within participants’ personal and cultural moral frameworks and addressed using evidence-based cognitive techniques for reducing negative emotions; Reconnecting with Community: In this phase, functional implications of moral injury appraisals are identified; participants re-connect with important relationships and cultural values; an action plan is developed to facilitate increased future engagement in life and with community, consistent with existing treatments of moral injury in non-refugee populations. The treatment manual for MIT-R has been adapted to suit Arabic, Dari, Farsi and English-speaking refugees. Psychologists trained in the delivery of MIT-R and Narrative Exposure Therapy will facilitate the interventions. Trial therapists will undergo specific training in delivering all treatment sessions including the use of a protocol-based treatment manual. The following protocols will be followed to ensure close therapeutic compliance with the treatment manual: (i) therapists will receive regular clinical supervision; (ii) participant attendance will be recorded by the clinician as part of routine care; (iii) the treatment manual will be used in all treatment sessions; (iv) with participant consent all treatment sessions will be video recorded and 15% will be randomly selected and rated for therapist adherence to the manual.