An Integrative Adapt Therapy (IAT) for Common Mental Health Symptoms and Resilience amongst Chin, Kachin, Rohingya Refugees living in Malaysia

INTERVENTION: The proposed project will involve a two‐armed, randomized, double‐blind RCT with a 2 (treatment conditions) x 4 (assessment points) factorial design, conducted amongst Chin, Kachin, and Rohingyas in Malaysia. Persons of refugee background agreeing to participate will be recruited from the epidemiological study (PUIRBHC0130) at that site and randomly allocated to either Integrated ADAPT Therapy (IAT) or Problem Management Plus (PM+). Novel studies published by Alvin Tay based on these inquiries (Tay, Rees, Chan, Kareth, & Silove, 2015; Tay, Rees, Chen, Kareth, Lahe, et al., 2015) show that the disruptions of the psychosocial systems underpinning the ADAPT model play an important role in shaping mental health and adaptation outcomes and contribute (in concert with past trauma and adversity) not only to a wide array of comorbid mental disorders (CMDs) but also to difficulties in functioning and capacity to adapt to the new environment. Drawing on established Cognitive Behavioural Therapy (CBT) and problem‐solving principles and techniques, IAT is based on the psychosocial domains of the ADAPT model (safety/security, bonds/networks, access to justice, roles/identities, and existential meaning) and designed to be grounded in the culture and context of displacement of individual refugee groups given their appropriateness, ease‐of‐delivery, flexibility, and effectiveness. A manualized protocol of IAT developed by Dr Tay will be adapted to the history, culture, language, terminology, context of each refugee group. The manual describes in detail the rationale underlying IAT, the steps involved in applying IAT, the use of psychotherapeutic approaches in addressing adaptive issues faced by refugees, clinical vignettes and scenarios, sample exercises and homework. Procedure: Training in delivery of intervention: The therapy will be administered individually by trained counsellors trained and supervised by psychologists. Pre‐treatment assessments: will be conducted by an assessment team blind to the treatment condition. Research team will apply a stringent procedure to ensure that participants and counsellors are concealed from the study objectives. Treatment: IAT: individuals assigned to IAT will receive 6x1 hour sessions provided on a weekly basis. The sessions involve: (1) overview of the ADAPT model and refugee adaptation; (2) safety and security; (3) disrupted bond CONDITION: Adaptive distress Anxiety Complicated Grief Depression Explosive anger Post Traumatic Stress Disorder PRIMARY OUTCOME: Interpersonal functioning: will be assessed using the Inventory of Interpersonal Problems Short Form, a brief index of individuals’ self‐reported difficulties in interpersonal relationships (Barkham, Hardy, & Startup, 1996). ; Mental disorders will be assessed using the Revised Harvard Trauma Questionnaire and the Refugee Mental Health Assessment Package (R‐MHAP). ; ; The mental disorder categories/reactions assessed include: post‐traumatic stress disorder (PTSD)/Complex‐PTSD, depression, generalized anxiety disorder, panic disorder, complicated grief, and intermittent explosive disorder. mental disorder categories/reactions assessed include: post‐traumatic stress disorder (PTSD), depression, generalized anxiety disorder, complicated grief, psychotic symptoms, adult separation anxiety disorder, and intermittent explosive disorder. ; Sense of injustice will be assessed using a brief index of moral injury (Nash et al., 2013). INCLUSION CRITERIA: The sample will comprise adults (18 years of age or older) who are members of the Chin, Kachin, and Rohingya communities. (c) at least one symptom of adaptive distress associated with each of the five psychosocial domains indexed using the ADAPT measure. Recruitment: Dr Tay has conducted extensive consultations with academic partners, community leaders and members of the Chin, Kachin, and Rohingya communities to assess the feasibility and acceptability of the proposed project since 2013. Based on consensus from refugee communities, we intend to use a systematic informant‐driven sampling method applying the following sequence: 1. community personnel who have received training will provide specific information about the nature of the project at weekly community meetings at community centers (attended by a large portion of refugees). Individual attendees who seek out additional information about voluntarily at the end of the meeting will be provided with as much detail as possible. 2. In addition, in their routine visits to all households (based on the comprehensive record of all residents), community leaders will include information about the project in discussions with residents, answering all questions and queries. 3. Those who consent to further contact will be phoned or visited by team workers who will explain the details of the study further and seek consent for potential participants to complete the tablet‐based screening measures. Persons who wish further time to consider consent, will be given ample opportunity to do so. 4. Those who meet criteria for the intervention will be followed up by phone or home visits (depending on participant preference) to clarify further questions, concerns and expectations, and to consent if they so wish. If participants appeared ambivalent, they will be given sufficient time to consider their participation and our workers will follow up and re‐approach if necessary. Our workers are trained specifically to ensure that there is no perceived duress in relation to participation at each step of the process, the emphasis being on respect for privacy and autonomy. At all times, participants will be assured by the community worker that their their decision and right to withdraw at any time will not have any adverse impact on their status, their asylum application, or the services to which they are entitled as refugees. In addition, participants are granted the full right to withdraw from the study at any point over the course of the intervention without any adverse consequence. 5. As indicated, one randomized, participants will attend the interventions at established NGO community centres where they are used to attending, places of safety given the provision of Malaysian law affording designated NGOs legal immunity against government interference. ; Resilience: will be assessed using an inventory of locally identified indicators of resilience including those identified from the literature (e.g., personal competence, tolerance of negative affect, acceptance of change, sense of control) ‐ Composite outcome SECONDARY OUTCOME: Anticipatory traumatic stress will be assessed using a brief index drawing on our previous research in Timor‐Leste. (Tay, Rees, Chen, Kareth, Silove, 2015) Attachment styles will be assessed using Close Relationship Scale (Wei, Russell, Mallinckrodt, & Vogel, 2007). Functionality: will be assessed using the abbreviated version of the World Health Organization Disability Assessment Schedule (WHO‐DAS) (Ustun et al.,2010) Inclusion criteria are (a) witnessed or experienced a traumatic event; (b) met criteria of at least one current mental disorder assessed (post‐traumatic stress disorder (PTSD)/Complex‐PTSD, major depressive disorder and generalized anxiety disorder; Algorithms based on DSM‐5 and ICD‐11 criteria will be used to generate symptom based case assignments following the international diagnostic systems.