A Refugee Crisis: What are refugees, living with PTSD, experiences of counselling? A systematised review of the literature.

Alexander Kelly

BA (Hons) Counselling Practitioner

Abstract

This review aims to provide an overview of qualitive literature exploring the experiences of refugees with PTSD in counselling while also exploring the barriers to mental health support refugees may face when migrating to a westernised democracy such as the UK. This research was deemed necessary due to the current rise in number of displaced people across the globe and the mental health challenges that they may present with. A systematised literature review was utilised to provide a summary into this area of research and as a vehicle for exploration into the aims of this review. Eight studies were chosen through the utilisation of inclusion and exclusion criteria and search terms. Three databases were searched. These included: CINAHL, PsychArticles, and Google Scholar. Through coding each paper twice, three themes, with two sub-themes each, were explored. These included: the healthcare professional, stigma, and attitudes towards western talking therapies. The key findings of this review are that both stigma and language may deter refugees from seeking mental health support. In addition, a strong therapeutic relationship built upon trust is vital for positive counselling outcomes when working with a refugee. Finally, psychoeducation may be beneficial for all refugees as it would allow for them to be educated on the western understanding of mental health, hopefully tackling pre-existing stigmatised beliefs, allowing for self-awareness, and coping strategy development. Future research may explore and compare the experiences of asylum seekers and refugees. Further research could also explore the impact psychoeducation can have on the mental health of refugees and asylum seekers.

Introduction

Psychological studies surrounding the experiences of clients who access professional psychological services has become a prominent area of research, ensuring that clients’ voices, perspectives, and opinions on the counselling services provided are collated and acted upon to enable an ever-improving service (Binder et al., 2009; Corstens et al., 2014; Millar et al., 2016). Unfortunately, this wealth of research provides limited information regarding an ever-growing populus of counselling service users: refugees (Silove et al., 2017; Valibhoy et al., 2016). The noun ‘refugee’ refers to a person who has gained international protection after fleeing from their home country due to experiencing persecution, conflict, disaster, or human rights violations (Khairat et al., 2023). Throughout the past decade, the number of people who have experienced some form of forced displacement has increased dramatically due to conflict and climate change (International Organisation for Migration, 2015; Tribe et al., 2019). By the end of 2013 there were a total of 11.1 million refugees present across the world (UNHCR, 2013). Just under a decade later, in 2022, these numbers have risen greatly to a total of 35.3 million refugees world-wide (UNHCR, 2022). These numbers are expected to continue to increase rapidly due to the ongoing conflict within the Middle East, Africa  and Ukraine, with the latter causing one of the largest refugee crises in recent history (Arash, 2022). Furthermore, this growing crisis could now be exacerbated by the recent conflict between Palestine and Israel. These conflicts have provided a need for further research into the experiences refugees have when accessing western psychological services, as the number of traumatised refugees will only continue to grow.

Refugees often experience distressing events. As a result, this group of people may experience a wide range of mental health challenges which often pose difficult for the mental health system to tackle effectively (Pollard & Howard, 2021). Research indicates that a common diagnosis is post-traumatic stress disorder (PTSD), as individuals may have experienced prolonged exposure to war, torture, rape, and persecution (Steel et al., 2022). PTSD can be simply defined as an anxiety disorder that can occur after experiencing or witnessing a traumatic event (Brady, 1997), something which is common within the refugee community as discussed. Individuals with PTSD will often experience symptoms such as reliving the trauma through flashbacks when confronted with a reminder, distancing themselves from people or places that illicit traumatic memories, and they may feel as if they are always on guard, irritable or startle easily (Hamblen, 2009). Recent findings suggest that PTSD may have a prevalence of up to 31% within refugees globally (Blackmore et al., 2020). Furthermore, individuals with PTSD will most likely suffer from comorbid mental disorders such as major depressive disorder, alcohol and drug abuse, and other anxiety disorders (Sareen, 2014). Despite this knowledge, the number of refugees who access mental health services in their host country remains low (Khairat et al., 2023), further showing the importance of exploring the experiences of refugees in counselling.

Moreover, once the refugees arrive at their host country their stressors do not stop, as these displaced individuals must now tackle new challenges to integrate with a new culture and society. Upon arrival, these displaced individuals are met with restrictions to their basic human rights while awaiting a status decision, such as access to education, work, and freedom of movement (Khairat et al., 2023; Morina et al., 2020). In addition, the mere act of engaging with the asylum system put in place by the host country, adapting to a new and diverse culture, and accessing the new health care systems, can have a negative impact on a refugee’s psychological wellbeing (Griffiths & Yeo, 2021; Li et al., 2016; Steel et al., 2017). Further research has also showed that post-migration factors such as language barriers, racism, an extended asylum process, loss of culture and support networks all negatively impact a refugee’s quality of life (Hirsch, 2019; Mollica, 1988; Steel et al., 1999). This is significant as it allows for a further understanding into why mental health challenges are rife within this community.

Previous research within this field has suggested that refugees have negative attitudes towards seeking professional psychological help. This can be attributed to barriers formed due to linguistic differences, cultural differences, stigma towards mental health, and the lack of diverse health practitioners (Century et al., 2007; Kavukcu, 2019; Shannon et al., 2015). Mental health stigma is often cited as the definitive reason as to why refugees do not discuss their symptoms or seek out professional psychological help (Shannon et al., 2015). Stigma was originally defined by Goffman (1963) who argued that it is an attitude that deeply discredits an individual. Goffman (1963) stated that a typical person may become tainted due to stigma surrounding a certain characteristic; in the case of this paper, mental health. Recently, however, scholars have suggested that cultural influences impact these stigmatised views, meaning that there is cultural variation within stigmatised beliefs caused by disparities between cultural norms about what can be classed as unhealthy behaviour (Abdullah & Brown, 2011; Rao et al., 2007).  For example, limited research into the Iraqi perception of mental health suggests that individuals in those communities who require mental health support are seen as ‘crazy’ (Sadik et al., 2010). This is significant as this belief may still be held post-migration, resulting in some Iraqi refugees refusing mental health support.

Even though it is widely agreed that stigma is one of the main reasons for refugees not seeking professional psychological help, there is a dearth of research which acknowledges the interaction of culture and mental health stigma regarding western mental health support. This number further dwindles when research specifically looks at refugee service utilisation and their experiences (de Anstiss et al, 2009). Therefore, the aim of this systematised literature review is to provide an overview and summary of the current literature on refugees receiving professional psychological help for their experiences with PTSD. In addition, this review also aims to explore the challenges of applying the western model of mental health on refugees who may be unfamiliar with these views. Finally, this review will also explore whether stigma is in fact the main reason as to why many refugees do not engage with mental health services. The results of this review will be discussed to ensure that the mental health services provided can improve, and that refugees can access, and benefit from, these services.

Methodology

A systematised literature review will be utilised as it is the aim of this study to provide an overview of the current knowledge surrounding refugees’ experiences within counselling for PTSD. A literature review is a form of secondary research that can be describedas a method of gathering and presenting existing literature on a particular subject (Hewitt-Taylor, 2017). Literature reviews have been utilised largely across counselling research (Khairat et al., 2023; Melibos et al., 2017; Roos & Werbart, 2013), as they allow for a structured synthesis of qualitive research with the aim of collating large themes and metaphors across the data set (Britten et al., 2002).  As the author of this paper is an individual, there is not enough time or resourcing available to conduct a full systematic review. Therefore, this review will be utilising literature review methodology on a smaller scale, but will remain systematic, to review the published research effectively (Aveyard, 2023; Hewitt-Taylor, 2017).

A literature search was conducted in multiple databases. These included CINAHL Plus with Full Text, APA PsychArticles and Google Scholar. All chosen databases were chosen in tandem with a librarian to ensure that the search would yield relevant results. To establish the key concepts of this review’s research question, the SPIDER tool for synthesising qualitative literature was employed (Shaw, 2011). This broke the research question down into five separate elements: Sample, Phenomena of Interest, Design, Evaluation and Research Type (Shaw, 2011). These elements assisted with identifying search terms, while also identifying the framework for the exclusion and inclusion criteria. Through the utilisation of this tool, the search terms were developed.

Furthermore, papers  included met the following criteria: published within the last 10 years (published from 2013), peer reviewed, included qualitive based research (this included mixed method studies), included the search terms within the abstract, adhered to ethical guidelines, were primary research, were based on refugees who experience PTSD, focussed on the experience of the refugee in counselling. This review chose to explore literature which had been published within the 10 years due to the dramatic increase of refugee numbers within this time frame (UNHCR, 2022). No restrictions were placed on the country where the literature was published.

The exclusion criteria included papers which solely utilised a quantitative methodology, unpublished papers, those with a focus on just asylum seekers, and lastly, research not published in English. This review focussed on refugees specifically. This is because asylum seekers’ experiences with counselling may differ when compared to refugees. A review with a focus on asylum seekers may be a beneficial area of further research.

The search yielded 53 potential papers for this review (CINAHL: 38, APA PsychArticles: 15), this initial search utilised the search terms derived from the SPIDER tool (see appendix A), the search was filtered using a publication time frame from 2013-2023, and the search was limited to only displaying full texts. All duplicates were removed from the count. Titles were reviewed to determine relevance and retained. 15 papers were examined in full, considering the inclusion and exclusion criteria to determine suitability. Only 2 papers were determined fit for purpose as many published papers within these databases were quantitative based research. All 6 other papers used in this review were found utilising Google Scholar.

To ensure that all papers included in this review were reliable, the strength of these papers were analysed to reduce the chance of unreliable conclusions being drawn from the data. Each paper was given a score through the range of 10 to 30, with 30 representing a strong paper. The papers that were critically appraised for this review ranged from 20-27, ensuring that all papers included were reliable sources of knowledge. All papers were critically appraised through adapting CASP’s (2018) Qualitative Studies Checklist.

This review employed thematic synthesis as the method of analysis. Thematic analysis is an academic method for identifying, collating, and analysing patterns within literature (Boyatzis, 1998), which enabled this research to effectively explore refugees’ views and understanding of their experiences with counselling (Braun & Clarke, 2006; King, 2004). Performing thematic synthesis during a literature review can be beneficial to the subject area as it allows for a deepened understanding of the topic by increasing the breadth of the experiences reported, ensuring that additional themes are discovered when compared to those that were developed in the original studies, while also identifying any additional nuances in the data when viewed as one data set (Hewitt-Taylor, 2017). Thematic analysis is flexible, ensuring that it fits this research question, however, this flexibility can lead to inconsistency when developing themes from the literature (Holloway & Todres, 2003). This disadvantage was difficult to negotiate as the researcher of this paper was an individual, therefore the use of multiple coders to produce rich data analysis was not possible (Church, Dunn, & Prokopy, 2019). Consequently, to reduce the impact of this disadvantage and to promote integrity, each paper was hand coded twice. Furthermore, to reduce bias within this review, the author kept a reflective journal during the research process to record and explore their values, interests, and insights. This resulted in bias being mitigated through critical self-reflection (Lincoln & Guba, 1985; Tobin & Begley, 2004).

Findings

Through the action of coding each of the chosen papers twice and synthesising the data, three overarching themes were developed. These overarching themes included: the healthcare professional, stigma, and attitudes towards western talking therapies.

Theme 1: The Healthcare Professional

Therapeutic Relationship

Building a therapeutic relationship in any counselling session is a vital part to working towards effective therapy, where growth and development can be facilitated. Concepts such as trust, care, and empathy are echoed throughout the studies, with a focus on the importance of developing trust gradually over therapy sessions (Duden et al., 2020; Jarlby et al., 2018; Valibhoy et al., 2017). Duden et al. (2020) suggested that trust was an essential element of a helpful relationship, and an important aspect of a successful therapy session. However, the development of trust was seen as challenging due to the atrocities refugees may have experienced. Valibhoy et al (2017) further reinforces the importance of a trusting relationship by suggesting that refugees strongly emphasise the relationship with their practitioner as being key to their experience of the service.

On the other hand, a study conducted by Al-Roubaiy et al. (2017) demonstrates how refugees’ attitudes towards their therapists before an empathetic and understanding therapeutic relationship is built can be negative. Here’s how one participant felt about their therapist:

“It really felt like I was seeing yet another person from this elite, but this time I was paying this person, she actually had to sit there and listen to me talk about my problems […] I don’t think someone like her would choose to talk to me outside of this type of relationship.” (Al-Roubaiy et al., 2017).

In addition, one participant in the same study conducted by Al-Roubaiy et al. (2017) described that they refrained from talking about certain issues pertaining to their ethnic minority status as they believed that the therapist would not be able to understand or empathise with them:

“Since she was Swedish I had to know what to avoid basically. I mean I could not really tell her everything I was thinking.” (Al-Roubaiy et al., 2017).

This further shows the challenge, but importance, of building a strong therapeutic relationship built upon trust and empathetic understanding.

Language

To build a strong therapeutic relationship, there needs to be trust and security built between the two parties. This aspect of an effective counselling session can be challenging to attain when met with language barriers (Huminuik et al., 2022; Jarlby et al, 2018; Vaibhoy et al., 2017). It is suggested by Huminuik et al. (2022) that language is one of the most important barriers to refugees receiving mental healthcare, especially in Canada as if the client does not speak English or French, it will be difficult to access therapy in their first language. Furthermore, Jarlby et al. (2018) suggest that language barriers may result in unequal access to, and benefits of, mental healthcare when comparing refugees and those born in the host country.

In these studies, a refugee is appreciative when they are matched with a counsellor who speaks their first language, such is the case with this participant who stated:

“She spoke Arabic, so we could really feel each other. I know she understood not just my language but also my way” (Huminuiket al., 2022).

In addition, one participant within the same study believes that therapy would not be possible unless it was conducted with their first language:

“Though I am fluent in English, I have to work at it and I’m always translating my thoughts and feelings. I need to be able to speak my first language, straight from my heart” (Huminuik et al., 2022).

Language is essential for building an understanding relationship between counsellor and client; therefore, it is vital that the client feels fully understood by the healthcare professional:

“He knows the whole refugee deal … He knew where I was coming from, he knew what was happening. So it was really helpful, he understood everything” (Valibhoy et al., 2017).

On the other hand, some participants disclosed that they did not initially feel safe with being with a counsellor who spoke their language as the refugees believed that someone from their country would not provide safe, trustworthy, unbiased sessions:

“When you first suggested to see someone from my own country, I was afraid. We had some very bad experiences, lots of persecution, and this is why we ran away from there. I cannot be sure that I will be safe with someone from my country.” (Huminuik et al, 2022).

However, when a trusting relationship was built, having a counsellor who was from a similar background was seen as beneficial:

“Trust is more complicated with someone from home, but when it works, it is definitely much better” (Huminuik et al., 2022).

Finally, language barriers can be broken down using creative tasks within the counselling session. For example, some studies suggest that art therapy can be used as a bridge for communication where the art can be used as a form of communication, allowing for therapeutic processes to occur in the absence of language (Akthar & Lovell, 2019; Kalmanowitz, 2016).

Theme 2: Stigma

Going Against Cultural Norms

Language is not the only barrier refugees may face when receiving professional psychological help as cultural stigma and societal norms may greatly influence their preconceptions of western therapies. Some studies suggest that the act of simply expressing and discussing your emotions is acting against an individual’s upbringing and the societal norms they subscribe to (Duden et al., 2020; Kerbage et al., 2020; Valibhoy et al., 2017). This concept led some participants to question themselves about the effectiveness and benefits of receiving therapy:

“Did I do the right thing about telling … but family says ‘we should be the ones’ … did I do something against my cultural norms, standards, and obligations?” (Valibhoy et al., 2017).

Some participants believed that they had socially transgressed by receiving therapy:

“…like you broke the rule … what you can’t mention in the family, how could you mention outside?” (Valibhoy et al., 2017).

The Importance of De-Stigmatising

A sentiment that was echoed throughout the studies was the idea that mental health treatment was for the “weak” or “crazy”, as some refugees believed that if they received any form of treatment they would be seen as abnormal, permanently disabled, or would be ostracised by peers in their community (Huminuik et al., 2022; Jarlby et al., 2018; Kerbage et al., 2020; Valibhoy et al., 2017). This was the case with one participant who held negative connotations surrounding the idea of receiving professional psychological help. However, these preconceptions were abolished once they had experienced what counselling was like for them:

“At first I was afraid and in shock, and like “why I go to the counsellor” because, you know, in my country just the crazies went [laughing] … I was asking myself, “did I crazy, am I crazy?!” … I was un-believe that I will talk! … When I talk to her I feel confident, directly, at the first day. And I’ve been talking, talking for 2 hours without stop, like I’m booming, booming … Booming like a boom! … Actually it was really good, because I find someone to listen” (Valibhoy et al., 2017).

These preconceptions can lead to refugees denying mental health treatment, either because of their own beliefs or those of others:

“My friend told me, “don’t go to this guy, this guy maybe he’s crazy guy” (Valibhoy et al., 2017).

Some participants highlighted the idea of providing psychoeducation to the refugees which could facilitate an understanding of their own mental health challenges, as well as tackling the stigma attached to these (Duden et al., 2020; Valibhoy et al., 2017).

Theme 3: Attitudes Towards Western Talking Therapies

Positive Attitudes

As discussed, preconceptions can be a barrier for refugees receiving mental health treatment, however, not all refugees arrive with negative connotations. Refugees from Iran for example explain that psychologists are the norm in their home country, so they understand how talking therapy may be beneficial for them (Valibhoy et al., 2017).

Furthermore, positive attitudes towards western talking therapies can be developed over time, with participants expressing how beneficial verbalising one’s thoughts and emotions can be:

“Emotionally I felt better by simply letting out all of these thoughts, talking about all of these feelings” (Al-Roubaiy et al., 2017).

Participants were also able to observe their own progress attained through talking therapies, which included knowledge of effective coping strategies, decreased symptoms, resolution of grief, and more positive feelings about living in the host country (Al-Roubaiy et al., 2017; Huminuik et al., 2022; Valibhoy, 2017).

“When I first came here, I was always thinking about the past. Now I am mostly focused on the present and even a little bit into the future. I have learned how to control my emotions and how to let go of those memories that troubled me.” (Huminuik et al., 2022).

Negative Attitudes

A concept that recurred throughout the reviewed material was the negative attitudes towards exploring the past of the refugees (Duden et al., 2020; Jarlby et al., 2018; Kerbage et al., 2020). Jarlby et al. (2018) discuss how the psychological phenomenon of re-traumatisation could occur when refugees share memories. This has led to some participants viewing counselling as unhelpful and traumatising:

“I have so many problems (…) They [psychologists] always want to talk about my past. If I talk about it, it comes again in my brain, it comes again. In the end, maybe I get crazy. I have so many… I do not want to think about it anymore” (Jarlby et al., 2018).

This is echoed by this participant:

“Actually, if anything, this experience could have potentially harmed me […] it could have destroyed me had I gone on to do more sessions with this person” (Al-Roubaiy et al., 2017).

This is further reinforced by Akthar & Lovell (2019) and Kalamonowitz (2016) who both argue that talking therapies are not a suitable approach when working with trauma and would like to see art therapy being utilised more within the trauma-based counselling world. This is a sentiment shared by a participant from Akthar & Lovell’s (2019) study:

“Counselling is not the right thing for trauma, with art therapy it’s setting up that safe space, question of choice … which all creates safety and attachment” (Akthar & Lovell, 2019).

Discussion

This current systematised literature review aimed to explore the experiences refugees have regarding their counselling and whether they effectively engage with, and benefit from, the services provided. In addition, this review aimed to understand the challenges that are presented when applying the western model of talking therapy to improve the mental health of refugees and whether stigma is the main barrier when it comes to refugees’ seeking professional psychological help.

Firstly, these findings suggest that refugees’ experience of counselling is intrinsically linked with the healthcare professional and the therapeutic relationship that can be established between the two parties (Duden et al., 2020; Jarlby et al., 2018; Valibhoy et al., 2017). A strong and positive therapeutic relationship is vital for an effective counselling session to transpire despite the healthcare professional’s modality and individual differences (Charura & Paul, 2014; Lambert & Barley, 2001). It has also been reported that factors such as trust, empathy, warmth, and a strong therapeutic relationship correlate highly with a positive client outcome (Lambert & Barley, 2001). Therefore, due to trust issues some refugees possess (Duden et al., 2020; Valibhoy et al., 2017), it can be suggested that establishing a trusting therapeutic relationship with a refugee may be more challenging when compared to a regular client. This mistrust may also be exacerbated by an individual’s PTSD (Bell et al., 2019; Taylor et al., 2022). Without a strong therapeutic relationship some topics may become taboo, resulting in the refugee not being able to gain as much as they could from the therapeutic sessions (Al-Roubaiy et al., 2017). The concept that a strong and trusting therapeutic relationship is key to a positive counselling experience regarding refugees aligns with previous research surrounding this topic area (Duden & Martins-Borges, 2021; Khairat et al, 2023). Consequently, it is vital that the healthcare professional is adept at building trust gradually to ensure that a trusting therapeutic relationship can occur, while also ensuring that the refugee client can become more comfortable as time passes.

Trust needs to be developed when building a strong therapeutic relationship with a refugee, however, this may be difficult to attain when faced with a language barrier (Huminuik et al., 2022; Jarlby et al., 2018; Valibhoy et al., 2017). Through these findings, it is suggested that language may be one of the most daunting barriers refugees may face when accessing mental health treatment (Huminuik et al., 2022). Language is an integral part of being able to communicate effectively. Therefore, engaging in counselling through an individual’s second language may cause a barrier to impactful counselling sessions. It has been suggested by previous research that conducting counselling sessions in the client’s second language can have a detrimental impact on the effectiveness of the sessions. This may be because of missed cultural nuances, misunderstanding idioms, metaphors and similes, and not being able to find the right words to best portray emotions (Oquendo, 1996; Rolland et al., 2021). This inability to speak authentically was portrayed in the findings of this review. On the contrary, these findings also suggest that many refugees may struggle to initially trust a counsellor from their own country due to their past experiences, however, once a trusting therapeutic relationship was built this was seen as a benefit (Huminuik et al., 2022).

It has also been suggested by previous research that one of the main barriers refugees may face is stigmatised beliefs surrounding mental health and counselling (Shannon et al., 2015). This sentiment was echoed within the results of this review as stigma was discussed throughout many of the reviewed papers (Huminuik et al., 2022; Jarlby et al., 2018; Kerbage et al., 2020; Valibhoy et al., 2017). This review has demonstrated that some refugees will arrive at their host country with a different understanding of mental health than the dominant narratives in their host nation. This was portrayed by the participants of the papers discussing how receiving counselling, or discussing their emotions with others, was seen as going against their cultural norms and values. Receiving counselling may be an unfamiliar and confusing concept for some of the refugees as they may believe that one should not discuss their intimate feelings with anyone who is not close family (Valibhoy et al., 2017); this belief aligns with previous research and demonstrates how applying a western-orientated model of counselling can be challenging for the refugee (Burnett & Peel, 2001; Byrow et al., 2019). Furthermore, families, friends and the wider community can have a negative impact on an individual’s attitude to seeking professional psychological help due to stigmatised beliefs, these include the belief that speaking about feelings should be reserved for relatives and that seeing a therapist could cause the individual to be branded as ‘crazy’ and ‘insane’. This review confirms that these beliefs are a barrier for refugees seeking support (Byrow et al., 2019; Satinsky et al., 2019 Valibhoy et al., 2017).

Both Duden et al. (2020) and Valibhoy et al. (2017) highlighted the idea of tackling the stigmatised beliefs surrounding therapy and mental health by offering refugees psychoeducation. Not only would this educate refugees on the positive impact mental health awareness can have on themselves and their peers, but it may also encourage sceptical refugees to seek support. Furthermore, this psychoeducation could be tailored for certain communities of refugees to ensure that the education is culturally informed, further increasing the likelihood that stigma could be abolished (Im et al., 2018). In addition, psychoeducation could work in tandem with counselling to ensure that the refugees are aware of problems such as trauma, mourning, guilt, and substance abuse, as well as allowing for a space where refugees could work with their community to develop self-awareness and coping strategies (Im et al., 2018; Uitterhaegen, 2005). This would significantly tackle stigmatised beliefs that refugees may arrive in their host country with, providing a way to break down the barrier of stigma when refugees seek mental health support.

Finally, this review explored both the positive and negative attitudes refugees had towards their experiences with the counselling services provided. Through coding it became apparent that negative attitudes outweighed the positive attitudes within the papers reviewed. As this review had a focus on refugees who experience PTSD, the notion that trauma-based counselling practises were re-traumatising the individuals who were experiencing the counselling was recurrent (Jarlby et al., 2018). The concept that therapy can re-traumatise clients is not a new phenomenon and has been explored in depth by the psychologists in this field (Banks, 2006; Courtois, 2012). However, due to the intense experiences of the refugees it can be suggested this risk could be further increased within the refugee community (Lambert & Alhassoon, 2015). Both Akthar & Lovell (2019) and Kalamonowitz (2016) argue this to be the case and suggest that art therapy could be used as a more suitable way of tackling trauma-based issues in a therapeutic manner. Not only could art therapy allow for an exploration of trauma in a less daunting way, but it could also result in the breaking down of language barriers, as emotions could be explored using images over words (Akthar & Lovell, 2019).

Conclusion

This review explored three main themes: the healthcare professional, stigma, and attitudes towards western-talking therapies to explore the experiences of refugees with PTSD who access counselling services. It also explored the barriers some refugees may face when seeking mental health support. Through this exploration, it has been highlighted that both stigma and language barriers create negative attitudes towards western orientated counselling services and may deter refugees from seeking mental health support (Huminuik et al., 2022; Jarlby et al, 2018; Vaibhoy et al., 2017). Also, the numerous benefits psychoeducation could have on refugees was explored and reinforced through this review (Duden et al., 2020; Im et al., 2018).

This review was conducted by one researcher, meaning that this was not a comprehensive literature review on all the knowledge in this field. However, steps were taken to ensure the integrity of the review findings. This included quality control via inclusion and exclusion criteria for papers, hand coding each twice, and reflective practises to mitigate bias. Further research could work towards understanding of how the experiences of asylum seekers may differ when compared to the experiences of refugees in a counselling setting. In addition, research into the effectiveness of art therapy as a form of trauma-based therapy in the refugee community could be beneficial. Finally, further research could also explore the impact psychoeducation could have on the mental health of refugees and asylum seekers.

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