Mapping trauma support onto the shifting landscape of seeking refuge in Sweden: insights from an ongoing programme of research on refugee minors’ mental health

Back in autumn 2015, the Swedish authorities were overwhelmed by the unprecedented number of refugee arrivals. A particular challenge was that over 35,000 asylum seekers were unaccompanied refugee minors (URM), children who arrived in Sweden without a legal guardian [1].

The adverse impact of war and conflict and the process of seeking refuge on mental health had been recognized for years [2], and so the need to mobilize trauma support services to address the needs of these youth was recognized. However, the sheer scale of the need meant existing service structures fell short of demand [3]. Non-governmental organizations offering trauma support were overwhelmed and were operating with waiting lists up to 12 months. Whereas, many child and adolescent psychiatry units around the country refused to treat children and youth while in the asylum process as they claimed the necessary stability for successful post-traumatic stress (PTSD) treatment was lacking.

The need for low-cost scalable mental health support available to all refugee youth who needed it was apparent and our research group swiftly began an evaluation of a community intervention called Teaching Recovery Techniques (TRT) in 2016 [4].

TRT is a group intervention based on the principles of Trauma Focused—Cognitive Behavioural Therapy [5, 6]. It enables children from 8 years and above to normalize their reactions to trauma, offers emotional support, and provides them with strategies to cope with intrusive thoughts and memories, regulate their arousal, and expose themselves to avoided thoughts and situations. The intervention can be provided by professionals without previous therapeutic experience, but requires a 3-day structured training programme where group leaders learn how to use the manual.

Given the volume of asylum applications, the authorities focused on accommodating the new arrivals. This resulted in a number of group homes being set up to house URM as well as dedicated asylum heath care centres. These venues were ideal settings to offer TRT. The research group successfully conducted an initial evaluation of TRT in the Uppsala region recruiting predominantly via URM group homes and an asylum health care centre. The demand was high, with over 90% of youth screening positive for PTSD symptoms and over 70% of those interested in taking part [4].

The results were promising and the next step was to conduct a larger scale, robust evaluation. Funding was secured for a national randomized trial [7] but, by the time recruitment efforts commenced, the landscape had shifted. The emergency infrastructure built so rapidly in response to the ‘refugee crisis’ was starting to be dismantled. Of the hundreds of professionals who had been trained in TRT, it was challenging to locate those who were actually delivering the intervention. Only a handful of active sites were known by Barnens Rätt i Samhället (Children’s Rights in Society), who were responsible for delivering TRT training in Sweden.

It was at this time, in 2018, that a legislative change was made in Sweden which allowed young people to apply for a residence permit to study at gymnasiet, i.e. upper secondary school, even if their asylum application had been rejected. A dynamic response was required, as now the ideal arena for providing trauma support was at school. We shifted our attention in that direction and throughout 2019 we worked to help schools understand the impact trauma has on learning and the value TRT could have within their school environments. Schools were responsive and, by early 2020, we found ourselves in the midst of recruitment and we were assured that there was still a clear need and demand for the intervention.

Yet, another shift in the landscape was on the horizon. In March 2020, Sweden closed all gymnasiet sites and education was moved online in an effort to slow the spread of COVID-19. A number of active TRT groups were also forced online. This decision was not made without hesitation; we questioned whether the online format would be appropriate for this intervention and if it was the right thing to do. In the end, it seemed clear that to leave these young people without any support at a time when social networks had dissipated and uncertainty at a global scale was aggravating mental health was not an option. In an effort to learn from this unexpected development in the project, we quickly developed a process evaluation of online delivery, which has extended to an evaluation of online training of TRT group leaders.

The land is still moving beneath us and the future is uncertain, a fact that has led to a revelation: we need to be able to move with more agility. If done well, online delivery of TRT could mitigate against future shifts in society and, instead of the stop-start motions we’ve experienced to date, momentum in reaching refugee youth in need could be maintained. This, of course, should not simply mean delivering TRT as we always have but in an online format. Instead, the challenges and opportunities of online delivery need to be weighed and an evidence-informed approach taken to innovate and rework the promising intervention for the digital sphere.

As a research group, we are proud to have patient and public involvement at the core of our ongoing trials. For our evaluation of TRT, our refugee advisors have enlightened our thinking and steered us with their experiential knowledge [8]. Our vision is to co-create the online version of TRT in active partnership with refugees. This would foster the development of an intervention that is simultaneously useful, useable and desirable.

Not only could this support longevity in our efforts to provide trauma support to this population, it could also deliver a solution to other implementation issues that have arisen along the way. Group formations would no longer need to be tied to geographical locality, which means previously held aspirations to hold groups in a common language or by gender could be realized, if a child or young person needs to move to another part of the country they can maintain their involvement in the intervention, and isolated youths in remote geographical locations can be included.

Our research group has the groundwork in place to swiftly develop and rigorously evaluate an online version of TRT. The potential result? A fully-functional virtual trauma intervention that could be ‘airdropped’ any place in Sweden, or the world.

Compliance with ethical standards

Conflict of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.