Fostering trust – a qualitative outcome study of psychodynamic group and individual psychotherapy for refugees with PTSD

ABSTRACT

Background: Refugees and asylum-seekers have an elevated risk of mental health issues, such as depression and posttraumatic stress. Qualitative outcome studies can contribute by offering insight into patients’ experiences of what they find beneficial and how they undergo the process of recovery. This study aligns with the small body of qualitative research focusing on refugees’ perspectives of psychotherapeutic treatment for PTSD.

Objective: This study investigates and compares the treatment experiences of refugees with posttraumatic stress disorder (PTSD) in psychoanalytic group therapy (PAGT) and individual psychodynamic therapy (PDT) within an outpatient context in Sweden.

Method: 10 former patients were interviewed using a semi-structured interview schedule. Data were analysed and interpreted according to the principles of grounded theory.

Results: The findings reveal distinct categories for each treatment modality, being reborn for PDT and building a home for PAGT. Being reborn involved persistent intrapersonal change and lasting improvement in posttraumatic symptoms. Building a home involved a sense of belonging, support and temporary relief from posttraumatic symptoms. Participants from both treatment modalities underscored the significance of cultivating trust in therapeutic relationships.

Conclusions: The study emphasises the necessity for tailored therapeutic approaches, contributing valuable insights to the limited research on effective mental health interventions for this population.

HIGHLIGHTS

• This study explored the experienced value of mental health interventions for refugees who have experienced traumatic events.

• Both individual and group psychotherapy were experienced as valuable, and at the core of this value was the social or relational experience with the therapist or the group.

• To experience this value, fostering a trusting relationship with either the therapist or the group was crucial.

1. Introduction

Refugees and asylum-seekers face an elevated risk of mental health issues (Yip et al., 2021). For instance, a comprehensive meta-analysis involving 80,000 war-affected refugees revealed that every third participant reported experiencing posttraumatic stress and depression (Steel et al., 2009). A more recent systematic review of 5000 refugees reported similar prevalence rates (Blackmore et al., 2020). Moreover, refugees are less likely than the general population in Europe to receive appropriate health care, and various structural challenges, such as post-migration stressors, systematic discrimination, and inadequate cultural sensitivity and competence among mental health workers, pose significant risks that can exacerbate their health conditions (Dalgard et al., 2007; Reko et al., 2015; Satinsky et al., 2019; Yip et al., 2021).

Bunn et al. (2016) argued in a literature review that group therapy may be particularly well-suited to address the unique vulnerabilities of refugees by effectively addressing post-trauma symptoms, fostering a sense of community, mitigating feelings of isolation, and facilitating the exchange of support among participants. Moreover, cross-sectional studies have observed that higher social support is associated with less likelihood for PTSD among refugees (Carlsson et al., 2006; Gottvall et al., 2019; Jolof et al., 2022), and naturalistic prospective cohort studies have observed social support to be preventive of a chronic, severe PTSD symptom trajectory (Denkinger et al., 2021; Steinert et al., 2015).

Correspondingly, group therapy has shown promise in recent studies and reviews. Two meta-analyses, one focusing on refugees (Turrini et al., 2019) and the other on the general population (Schwartze et al., 2019), found group therapy non-inferior to individual therapy. Across the studies, a recurrent pattern appears to be the establishment of a sense of trust and safety, alongside efforts to enhance social connectedness within the group while addressing posttraumatic symptoms. Certain studies, particularly those focused on refugees, also placed emphasis on exploring identity and everyday issues. Most interventions appear not to have involved the sharing of traumatic memories within the group, which holds particular interest in light of the prevalent reliance in evidence-based individual treatments for PTSD on the retelling or reprocessing of traumatic memories as a pivotal modality for alleviating posttraumatic symptoms (Bryant, 2021; Wright, 2020). Indeed, in a recent qualitative study with forced migrants who had concluded treatment at multidisciplinary trauma centres in Sweden, participants suggested that their treatment could have been improved by also adding group-based peer support (Jolof et al., 2024).

Qualitative outcome studies can contribute to inform policy and practice by offering insight into patients’ experiences of what they find beneficial and how they undergo the process of recovery (McLeod et al., 2021). Revealing and affirming the lived experience of diagnosis, therapeutic process, and recovery can enrich the understanding and appreciation of trauma treatment for the patient. However, such literature is very limited with regards to trauma treatment for refugees. A recent and important qualitative meta-synthesis of refugees’ and asylum seekers’ experiences of individual psychotherapy could only identify eight relevant studies (Khairat et al., 2023). These studies provide important insight around the five themes identified by the authors: (1) the importance of recognition and validation within therapy, (2) building a human connection within the therapeutic relationship and the importance of cultural competency, (3) revisiting trauma, managing difficult emotions from therapy and regaining hope, (4) the value of practical interventions, and (5) cultural stigma and accessing therapy (Khairat et al., 2023). The qualitative findings in these studies offer valuable insights into understanding recovery for refugees.

However, further research is necessary. And, as noted by Khairat et al. (2023), one particular area needing further research is the efficacy of group interventions for addressing the collective trauma and shared experiences of refugees. Thus, this study aligns with the emerging but still relatively small body of qualitative research focusing on patients’ perspectives of psychotherapeutic treatment for PTSD. In particular, it is the first study to our knowledge to explore and compare how refugees with PTSD experience psychodynamic group therapy and individual psychodynamic therapy in an outpatient setting.

2. Method

2.1. Treatments

The treatments were offered by a publicly funded outpatient clinic in Sweden. The clinic specialises in the treatment of patients with experiences of migration, war, and torture. The therapists included in this study were all licensed psychologists. While their primary training was in the psychodynamic tradition, they had also received training in other methods (e.g. narrative exposure therapy and prolonged exposure). They were interviewed to provide an accurate description of their therapeutic approaches, summarised below.

2.1.1. Individual psychodynamic psychotherapy

The three therapists in this study all used a phase-based approach, where the first phase involved establishing a therapeutic alliance with the patient, and gaining an understanding of their specific context, their relational patterns, affects, defense mechanisms, and wishes and hopes. Each therapist emphasised that it was up to the patient to take the lead during sessions, and that the therapist’s task was to listen carefully and attentively, and provide a sense of safety. Whereas this phase involved making interpretations and drawing connections to the patients’ traumatic history, each therapist also delimited a specifically trauma-focused phase. They entered this phase in agreement with the patient, once both assessed that they were equipped for it. During the trauma-focused phase, the therapist took a more active role, guiding the process. This included detailed explorations of the traumatic memories, followed by what therapists characterised as a mourning process. Depending on the needs of the patient, this final phase also involved treating ongoing vulnerabilities related to, for example, being new in the country, unemployment, or difficulties in the family. Session length was 45 min, and the treatments were not time limited. No treatment fidelity tests were undertaken for this study.

2.1.2. Psychoanalytic group therapy

The treatment manual for Psychoanalytic Group Therapy (PAGT) is rooted in the belief that human beings are inherently structured to function in relation to others, and sees this drive for relatedness as intrinsic and fundamental to our being (Garland, 2010). It further posits that internal object relations, infused with fantasies about the self in relation to primary objects (e.g. parents or caretakers, siblings, etc.), contribute to character formation and are deeply ingrained in one’s personality. Traumatic events, furthermore, can distort both pre- and post-trauma experiences, leading traumatised individuals to retreat from emotional connections with the world by enforcing unconscious personal boundaries to shield themselves from any external intrusion. PAGT aims to counter these tendencies, fostering involvement in others’ lives within a safe space by enhancing awareness of these influential developmental and traumatic experiences, and how these have affected and continue to affect their lives. During the sessions, patients decide what to share in the group, while the therapist attends to group processes and helps them stay focused on its aim. Consequently, PAGT was not exclusively trauma-focused, but such themes were often addressed by the patients.

The therapist in this study was new to conducting group therapy but had extensive experience of working with psychodynamic psychotherapy with refugees and received continuous supervision by the author of the manual. The group consisted of around six to eight members, but its composition shifted over time as new members joined when someone decided to leave (so called ‘slow-open’). The group met weekly for five years, a total of 14 patients participated in the group. Session-length was 90 min. As with the individual therapies, no treatment fidelity tests were undertaken in this study.

2.2. Participants

The therapists were asked to invite former patients to participate in the study. The inclusion criteria required that these patients had been diagnosed with PTSD at the beginning of treatment, attended therapy for a minimum of six months, and had completed their treatment. The determination of whether patients met the criteria for PTSD was based on their therapist’s initial clinical judgment.

2.3. Data collection

The participants were interviewed for about 60 min (range = 53–69) using a semi-structured interview schedule, Psychotherapy Outcome Interview Schedule (POISE; Nilsson et al., 2007). POISE covers six specific domains: nature of recovery, course of recovery, therapists’ methods, therapist and therapeutic relationship, external influences of recovery, and patients’ own contribution to recovery. All interviews were conducted face-to-face, in Swedish by the first author (SZ), in August and September 2021. The interviews were voice recorded and transcribed verbatim.

2.4. Data analysis

The qualitative analytic procedure followed the stages of open, axial, and selective coding, as described in Strauss and Corbin’s (1998) grounded theory. In the process of open coding, the interview transcripts were systematically analysed using NVivo, coding the main point that the participant conveyed in a given passage (Rennie, 2006). Open coding continued until no new codes were found in the data, that is, when only repeated instances of existing codes were being observed (Urquhart, 2013). This initial coding phase served as a foundation for subsequent axial coding, wherein analytical attention was directed towards establishing relationships between categories and subcategories based on the codes. This was followed by selective coding, which involved integrating and refining the theory, starting with determining a core category representing the main theme, and then examining its relationship with the previously defined categories and subcategories. Throughout the analytic process, constant comparison between codes, categories, and memos were utilised. Memos served as records for analysis, thoughts, questions, and interpretations; they were recorded through a reflective journal as well as voice recordings.

The coding was conducted by the first author (SZ). The second author (MS) supervised the process with regards to questioning the analysis and theory refinement, which involved reviewing the theoretical scheme for consistency, addressing gaps in logic, enhancing poorly developed categories, and validating the scheme (Strauss & Corbin, 1998).

The epistemological core guiding this study was pragmatism (Strübing, 2007). Strauss and Corbin (1998) emphasise that theories are interpretations from specific perspectives. This means that the researcher is always already implicated, not isolated from but within the world, affected by it, interacting with it (Strübing, 2007). It is a mode of inquiry that constitutes a third alternative to deduction and induction, called abduction (Reichertz, 2019).

It is, thus, important to address reflexivity. The researchers of this study had no previous affiliation with the clinic, therapists, or patients, in that way offering an unbiased account of the patients’ experiences of their treatments. However, the researchers have not themselves experienced migration or marginalisation. On the contrary, both authors inhabit a privileged social position, being upper-middle-class white men with Swedish citizenship since birth, state-funded university education, and state-approved licenses in clinical psychology. This is a position with power-knowledge (Foucault, 1976/2020). That is, an authoritative position with regards to accepted forms of knowledge, particularly in the context of mental health. The authors have aimed to be aware of and counter this positionality. However, we acknowledge the inherent fallibility of our theories, which is consistent with the grounded theory approach (Strauss & Corbin, 1994, 1998).

2.5. Ethical considerations

The study was approved by the Swedish Ethical Review Authority (2021-01870) prior to recruitment. The participants were ensured anonymity.

3. Results

A total of 11 patients joined the study, but one withdrew participation for personal reasons. Participants had received either psychoanalytic group therapy (henceforth referred to as PAGT) (n = 5) or individual psychodynamic therapy (henceforth referred to as PDT) (n = 5). Participant demographics can be found in Table 1.

Table 1.

Demographic information.

	PDT	PAGT
Agea	51 (24–55)	50 (47–71)
Gender
Women	3	3
Men	2	2
Region of origin
Middle East	2	3
South America	2	1
Asia	1	0
Europe	0	1
Time in Swedena	23 (6–43)	28 (17–37)
Occupation
Full-time	4	0
Part-time	0	2
Unemployed	1	2
Retired	0	1
Length of therapya	2 (1–5)	3 (1–5)

^ain years, reported as median (range).

3.1. Core category: being reborn vs building a home

As a core category of patients’ experience of PDT, being ‘reborn’ involved an initially painful process of creating a relationship with their therapist, which, for most patients, developed into a sense of trust and, later, relief. As a core category of patients’ experience of PAGT, building a ‘home’ also involved a painful process of laying the groundwork, which, for most patients, developed into a sense of community and relief.

3.1.1. Category 1: the importance of nurturing trust and safety through recognition and validation

PDT. All patients described distrust and apprehension at the start of therapy, ‘in the beginning was very scared and felt very cautious’ (E), ‘I thought, like, what is he [therapist] going to be able to help me with’ (A). Gradually, however, patients described developing feelings of trust and safety in the therapeutic relationship, which they attributed to their therapists’ patience, non-directive listening and empathic validation,

[The therapist] was very patient about me … he’s listening, he didn’t advise anything at the first. Supporting, you know … because of that, I started trusted him. (B)

You can't trust suddenly, it takes time to trust people … From the beginning I had not felt safe, but in the end, I feel, I felt, with [the therapist] was very, I felt very safe. (C)

This nurturance of trust and safety had in itself been therapeutic, ‘because I also have a hard time trusting people so it was also a, a way for me to kind of work on it’ (A).

PAGT. Patients that had attended PAGT described similar initial distrust and apprehension, ‘In the beginning I was very careful and, so, did not want, I just wanted to listen to what the others said’ (G), ‘in the beginning of therapy, I don't dare sit and talk to anyone like that, in the beginning, no’ (J). However, as therapy proceeded, most patients described recognising that others had similar problems as themselves and, also, started developing a sense of trust in the group as a helping community, where they were able to feel close to, care for, and help each other together. Becoming ‘like a family’ (G), or ‘sitting like friends’ (F), where one ‘cared for each other’ (G), and where the group ‘tried to console me’ (I), in a place where you ‘felt safer’ (J), and where you ‘awaken a little bit; it’s not just you, alone’ (F).

Furthermore, patients felt validated and were able to help each other to gain agency when dealing with Swedish social services or navigating the public health-system. As described by I,

We tried to find a way out ourselves. And that, if it happens to me with doctors, then it had happened to others as well, ‘Aha, I have to go and change to another health center for my doctor’ and, ‘It's not unusual’ or stuff like that, ‘Ah, but do as I did.’ Or, ‘Even if it is tough, you have to wait four weeks until their papers arrive’, ‘Sign up at another health center, if you think doctors treat you the wrong way’ or, or, the administrator at the social insurance agency, is an example also, ‘But you know, I also, my administrator, every three months someone else, I don’t know who my administrator is anymore’. So, you call, you ask, and, like that, we helped each other very, very, really, a lot. (I)

In other words, the recognition that others had similar problems as oneself and a supportive stance within the group, was important for the nurturance of trust in PAGT.

3.1.2. Category 2: approaching traumatic memories involved an intensification of distress

PDT. All patients that had received PDT described an intensification of distress at the point of revealing the details of their traumatic pasts, involving fear, sadness, worry, and pain, ‘At the first time when I was talking about that event, I was shaking’ (B), ‘It really hurt, I, I noticed that I got very sad easily when we started talking about it … Emotionally, I felt quite bad.’ (E). Some patients described intense anxiety also as they left the sessions, questioning themselves and what they had done, fearing that revealing their story to their therapist had been a mistake, ‘After [the session] I know it will come, I regret it and I was very sad. … there is anxiety, that … why have I done this?’ (C).

PAGT. Patients that attended PAGT also described an intensification of distress, but with emphasis on hearing about what the other participants had endured. They described intense crying, worry, and fatigue, as well as nightmares and intruding thoughts as they came home from sessions,

It wasn’t easy in the beginning, it was well-very difficult. I felt more that it was very difficult to hear what the others think and what they have had, like, in their bags … I was very sad, when I went home like, and like the tears were flowing … it was so heavy for me, I can’t go to work, I was thinking all the time. (G)

It affected me a lot, their stories … When I got home then I didn't feel well. I didn't want to talk to anyone, avoid my children, I want to recover myself. Mostly I want to sleep, I want to sleep, I don’t want to hear anything, I don't want to, I just want to hide. (I)

3.1.3. Category 3: therapy as a time and place for feeling relief

PDT. In between episodes of heightened distress, the patients described therapy in terms of a place where one was able to rest and, for a moment, be free from the outside world,

I’m really waiting … and speak with him [therapist], and you know, it’s like ‘wooosh’, everything is going out. And after that to be happy … to just, I have empty bag. (B)

when everything was chaos around me, this place was still, where I could kind of rest somehow, collect myself … so it became quite an important place like … it was like a, like a free zone here. (A)

PAGT. The patients that attended PAGT described similar feelings, that the sessions helped them in being able to ‘rest’ (J), to ‘empty the heart (…) of pressure’ (F), and to gain ‘a completely different feeling’ (G), which was ‘more open’ (G), feeling ‘free’ (F), and ‘relieved’ (I). They described that this helped them to gain hope and strength to cope with each new week,

I had no one, such as a mother or a sister near me … but when we came here I thought, I, we are free … I got somehow from here … something like a pat on the shoulder, it will get easier for me, it will be okay. (G)

Thus, patients developed fond feelings for that day, G, a mother, said that ‘we got used to it … Thursdays are mommy’s day’. And as described by J,

I fell in love with that day … Always after the meeting, every Thursday when I got home, on the way home, so it feels like, just like had-I had someone, I carry a hundred kilos on my shoulders, but right now, I rest. And so tomorrow I'll carry it again. (J)

3.1.4. Category 4: PDT involved persistent intrapersonal change, including a lasting improvement of posttraumatic symptoms, whereas PAGT involved a temporary feeling of relief, but few intrapersonal improvements lasted past the end of therapy

PDT. Most of the patients that had received PDT described how the therapy had elucidated how their previous experiences had affected them, and that this understanding made them less aversive towards themselves, others, and the world. They described that they were better able to understand and manage their emotions, trust friends and partners, felt validated in their life choices, and believed more in themselves. They also described reaching a point where they reinterpreted their experiences from a new perspective. A, for instance, mentioned ‘getting in touch with myself,’ while also referencing how it ‘opened up … a part of the sky that I had not seen … I had such “Aha” experiences about myself.’ Another participant, B, described that ‘I started to growing. Changing my mind to see the things in other way … a new [me] was born.’ And, as described by E, ‘I could accept that part of me, [and], when I felt more confident about it, it made it easier to come out or to talk about what had happened to me.’ Furthermore, they described a lasting improvement of posttraumatic symptoms, including reduced stress and anxiety, reduced somatic symptoms like pain and shaking, reduced nightmares, flashbacks, and intruding thoughts, reduced fear and reactivity, and reduced avoidance,

At the first time when I was talking about that event, I was shaking. But in the end, I’m talking about very fast, strongly, there is no shaking, everything fine. … I’m comparing myself with before, I’m totally different (B)

I had huge problems and-such as, had huge pain in my whole body and had a lot of stress and anxiety but reduced a lot … I felt a little safe and could be at ease … For example, when you go to your friends’ house in the evening, so you feel you don’t have to worry too much that it’s evening and you’re going a long way or that something will happen to you. (C)

While they, too, experienced that their symptoms returned at times, the symptoms were described as more manageable than they had been before the treatment.

PAGT. Most patients who had attended PAGT, on the other hand, described how the weekly meetings was a helping community which they remembered fondly, but few intrapersonal improvements seem to have lasted past the dissolution of the group, as exemplified in the following exchange,

SZ: So if I understand you correctly then it was still, there was something very good about Thursdays, like it was a relief and you felt good on Fridays-

J: Yes, like that. Yes, yes.

SZ: But still that the nightmares, the fear-

J: It always comes. It’s always there.

One patient, I, described this with disappointment,

I can’t say that therapy was entirely wrong, but I say, I don’t know how, how much it helped me, really … I felt ‘Aha, we stopped but what did I get out of it, all these years?’ … I thought, I haven't gotten anywhere. And I went for such a long time, I thought, ‘did I get any sign that I had gotten anywhere? What was the purpose of my being here?’ (I)

Out of the patients that had attended PAGT, none reported any persistent improvement in posttraumatic symptoms past the dissolution of the group. Despite this, most described that PAGT had been valuable.

3.2. Individual differences

While the findings thus far have been reported in terms of general accordance, notable individual differences also emerged. D, for example, had received PDT but did not describe the same intrapersonal improvements as the others. He stood apart by retaining a sense ambivalence about whether to open up about untold aspects of his experiences,

I think I was in here, I came this way, then stopped, went out. It still has this … left. I want to come back and tell you a little more, more and more. But still, I’m afraid to come forward. I want to, and I do not want to. (D)

In addition, he did not experience the sense of relief as the others did, ‘Every time you get there then I thought I will release so much here, I come without the weight in my body. But it did not work’ (D). Rather, he described feeling relieved upon ending therapy, ‘It was good [to end therapy]. I thought, let it go, thinking so much. … I thought this was like a job, a very strenuous job’. (D).

Furthermore, H, who had attended PAGT, was particularly critical about what she perceived to be a lack of focus during the sessions, describing that it had been ‘pretty unnecessary’ (H) and that it had little value, because,

No one talked about their experiences, why they were there, what they want, no. … It did not suit me. I think that whoever is in that group must say it is a group therapy to talk about how feelings and what happened, how to move on, with everything that has happened, but they only talked about [the Swedish Social Insurance Agency] and [unemployment benefit funds]. (H)

Thus, this patient did not experience the sense of community that was shared by the others.

4. Discussion

This study explored and compared refugees’ treatment experiences of group and individual psychodynamic therapy for PTSD. There were similarities in their experiences, including the importance of nurturing trust and safety through recognition and validation and that therapy was a time and place for feeling relief. These results are also consistent with those reported in earlier qualitative studies. That is, the importance of recognition and validation within therapy and building a human connection within the therapeutic relationship (Khairat et al., 2023). Specifically, patients in this study were in accord with participants across previous studies that have emphasised the importance of the gradual development of trust in order to engage in therapy, for example; ‘I could say everything that I had in mind, and someone listened to me and understood’ (Khairat et al., 2023, p. 821), ‘the treatment I received and the behaviour and the loving care that I received from Kate [therapist] is affecting me directly and putting a positive effect on my health, she just gives me the strength to trust again.’ (p. 821). Whereas, for participants in the current as well as previous studies, when patients did not experience this validation from therapists, they described feeling uncomfortable and misunderstood, for example; ‘I don't know if they really understand that kind of fear and pain’ (Khairat et al., 2023, p. 820), ‘psychologist should ask the client first, ‘what you like to talk, and about what you don't like to talk?’ Don't just ask whatever they like!’ (p. 821).

Furthermore, approaching traumatic memories involved an intensification of distress, regardless of whether this was in individual or in group therapy. This is also consistent with some of the participants in previous studies, for whom trauma interventions were associated with re-experiencing trauma, feelings of anxiety and shame, for example:

When you come, you have to really like talk about it and how you're feeling and that brings it like to the surface and it's really raw and that's really hard and sometimes, you know, you don't feel like doing that ‘cause it's painful’ (Khairat et al., 2023, p. 822)

There were also important differences in how the participants experienced group and individual therapy. Firstly, patients that attended PAGT described experiences similar to those described by Bunn et al. (2016), that is, fostering a sense of community, mitigating feelings of isolation, and facilitating the exchange of support among participants. Secondly, the patients that received PAGT emphasised the value of recognising that others had similar problems as themselves and that they were able to help each other with practical advice. Arguably, this aligns with the theme of the value of practical interventions, as described in Khairat et al. (2023), for example; ‘If I need some help regarding my accommodation or other things … they also give me some advice on this, like they don't mind if I ask them something which will be otherwise look silly to someone else, like other doctors’ (p. 823).

Lastly, PDT appears to have involved persistent intrapersonal change, including a lasting improvement of posttraumatic symptoms, whereas PAGT seems to have involved a temporary feeling of relief, but few intrapersonal improvements lasted past the end of therapy. The core categories of being reborn and building a home could offer a clue as to why. Boulanger (2008) describes the experience of psychodynamic psychotherapy with traumatised patients as one where she, as therapist, steps into the experience of the patient, and that her ‘bearing witness’ to the patient begins a process of reanimation of the patient’s object world. In other words, where it was successful, recovering from trauma was not described as an individual, independent, or autonomous experience, but as a relational and interdependent event. It involved both a deep and trusting interpersonal connection with the therapist, and the insights that guided patients’ recovery seemed to be borne out of their relationship. This is also emphasised by Khairat et al. (2023), where participants demonstrated how the engagement in effective trauma work was closely linked to having a trusting relationship with the therapist, for example; ‘It was as if I was drowning and then I was pulled at the last minute from this water’ (p. 823). However, as the patients in PAGT mainly recalled experiencing distress from hearing about other patients’ traumatic memories, such ‘bearing witness’ might have been too demanding. Consequently, the relational and interdependent event of ‘being reborn’ might have been lost in group therapy.

Nevertheless, the significance ascribed by participants to PAGT warrants serious consideration, even in the absence of discernible intrapersonal improvements post the conclusion of therapy. According to Tucker and Price (2007), the rebuilding of ‘home’ in a new country can be difficult and painful. Considering this, group psychotherapy may work through providing a safe structure in which patients give form to ‘home’, constituted as a regained sense of safety, care, and belongingness. Building a community in which they, together, constituted a supportive environment, may have been empowering and disalienating by itself.

4.1. Strengths and limitations

The findings of this study should be considered in light of both strengths and limitations. An advantage lies in the study's exploration of a refugee population with PTSD in an outpatient clinic, which is underrepresented in research. However, it should be viewed as an initial investigation that requires further research with a larger scope and sample size to validate its claims and establish generalizability. Furthermore, concerns regarding validity and reliability arise since the first author conducted the qualitative analysis independently without external quality assurance. To address this, reflective journaling and voice recordings were utilised throughout the study, and supervision by the second author (MS) was maintained.

Furthermore, a more rigorous data collection (e.g. multiple interviews, focus groups) would have more fully been able to capture and triangulate the participants’ experiences. This iterative process of collecting data repeatedly to reach theoretical saturation is also a central tenet of grounded theory, which this study admittedly was forced to neglect. The reason for this was two-fold. Firstly, the study was limited in time and resources, and such rigorousness was not possible. And, more importantly, some of the patients included in this study were still suffering from their mental health, and as such, due to the risk of exacerbating discomfort and distress, the iterative process did not seem neither ethical nor feasible for this study, considering our limited resources.

Moreover, the risk of bias is acknowledged due to therapists recruiting their own previous patients, potentially leading to a selection bias. Therapists in PDT may have favoured patients with perceived treatment success, whereas all group psychotherapy attendees were contacted for recruitment, introducing variability in experiences among the 14 PAGT patients compared to those from PDT.

Finally, despite therapists primarily being trained in the psychodynamic tradition, their additional training in diverse methods may be considered both a limitation and a strength, reflecting the integrative approach often seen in clinical practice.

5. Conclusion

In summary, this study presents patient perspectives on two PTSD treatments for refugees, emphasising the pivotal role of trust in the therapeutic relationship. Despite group therapy not ensuring lasting recovery from posttraumatic symptoms, it was deemed valuable by its participants. The present study thus adds to the initial proposal of Bunn et al. (2016), that group therapy may be particularly well-suited to address the unique vulnerabilities of refugees, and the recommendations proposed by Jolof et al. (2024), advocating for the implementation of group-based peer support as part of participants’ treatments. Furthermore, as previous studies have suggested that social support may predict PTSD trajectory, supporting group cohesion post-therapy termination is suggested (Steinert et al., 2015). However, qualitative research in this area is still limited, warranting further exploration in future studies.

An unresolved question pertains to whether and how the act of sharing traumatic memories contributes to the perceived value of group therapy. Participants in this study reported distress upon hearing others’ traumatic memories, and prior research suggests potential benefits of group therapy even without such disclosures (Schwartze et al., 2019; Turrini et al., 2019). Conversely, participants also described feelings of safety, care, community, and belongingness within the group. Consequently, the extent to which sharing traumatic memories induces insecurity and distress, versus enhancing the perception of the group as an intimate and supportive community, remains uncertain.

Finally, the favourable outcomes observed with PDT in this study warrant attention and should stimulate interest in future research endeavours that rigorously assess the specific benefits of employing psychodynamic approaches in working with trauma-affected refugees.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data underlying this article will be shared on reasonable request to the corresponding author.

Author contributions

Sebastian Zinfandel: Conceptualisation, Methodology, Formal analysis, Investigation, Data curation, Writing – Original Draft, Writing – Review & Editing, Visualisation, Project administration; Martin Svensson: Conceptualisation, Methodology, Supervision.