Rethinking cross-cultural psychotherapy: experiences of refugees and psychotherapists in London

The burden of mental health problems among Asylum Seekers and Refugees (ASRs) is very high. Though some
refugees remain resilient, the pre-migration experience, the torture and trauma during the actual migration phase, and the
process of resettlement in the host country have a cumulative effect on ASRs and make them vulnerable to different kinds of
mental disorders including complex post-traumatic stress disorder (complex PTSD) - a disorder characterized by severe
problems in affect regulation, negative self-concept, persistent difficulties in forming and sustaining relationships, and the core
symptoms of PTSD (i.e. intrusive memories of the traumatic event, avoidance of associated thoughts or people, and
hypervigilance). In overcoming these major mental disorders, psychotherapy approaches including Narrative Exposure
Therapy (NET) and trauma-focused Cognitive Behavioral Therapy (CBT) have been proven to be effective.
In practice, however, multiple barriers have been identified in the uptake and effectiveness of these services and there
is limited knowledge about how mental healthcare can be effectively delivered to ASRs. These barriers in 'cross-cultural
psychotherapy (CCP)' include differences in culture to language and issues around the use of interpreters in therapy. For
instance, differences in understanding of their illnesses between clients and their psychotherapists challenge the provision of
responsive and effective mental healthcare services. The influence of culture and difficulty in communication is not
limited to the therapeutic settings but also shape the illness symptoms, expectations of recovery, coping strategies, and the
overall recovery process. Moreover, the influence of culture can also impact diagnosis, adherence to treatment, and
treatment strategies in cross-cultural psychotherapy.
Effective communication in CCP settings can also influence therapeutic outcomes. Because there are idioms of
distress through which different cultures express experience and cope with distress, they challenge clinicians' capacity to
detect problems, interpret them correctly and address them effectively. This is especially true for those psychotherapists with
limited cross-cultural psychiatry training.
In overcoming such barriers, different solution mechanisms have been proposed - ranging from transcultural
training[16] to the use of 'cultural brokers'[18]. Though important in their own right, the main focus in the slim existing body
of literature is a relatively superficial description of barriers like language and cultural variation in the expression of
symptoms[18, 20] and proposed solutions such as the use of interpreters[16].