authors: Stefan Flegelskamp and Milena Mutafchieva

Introduction

The idea for the Evidence-Based-Trauma-Stabilisation (EBTS) project was born in 2015 in the need in Europe for more effective work with refugee, asylum seeking, and immigrant families. As of May 2023, more than 110 million individuals were forcibly displaced worldwide. This marks the largest ever single-year increase in forced displacement (The UN Refugee Agency, 2023). Armed conflicts in many countries, state arbitrariness and oppression, restrictions on the freedom of expression, and disregard of human rights not only force many adults from home, but they also have a fatal impact on children and their development.

The prevalence of psychological problems among refugees varies across studies. Nonetheless, high rates of PTSD are a common finding in surveys. High rates of mood disorders (43%), anxiety disorders (44%), and PTSD (33%) were reported in a study of war-exposed adult refugees resettled in Europe (Bogic et al., 2012). A meta-analysis by Fazel et al. (2005) summarised the results of 20 surveys exploring 6,743 adult refugees from seven countries and found that about one in ten adult refugees in western countries suffers from PTSD, about one in 20 experiences major depression, and about one in 25 has generalised anxiety disorder.

Although there is considerable debate over the conceptualisation of refugee mental health concerns and the specific rates of psychopathology among refugees vary tremendously, there is a necessity for culturally appropriate, short-term mental health interventions that can provide “first-aid” help and support to both parents and children.

Why EBTS?

EBTS is a short-term method to prevent trauma consequences through stabilisation for children and their families. Many training programmes for experts who work with refugee, asylum seeking, and immigrant families exist but most of them are focused on material survival or social integration and adaptation. They are mostly long-term therapies and not focused on family relations.

The EBTS-Programme is easily conducted by a wide range of experts that work with refugees (social workers, educators, psychologists) and does not require psychotherapeutic competences of the experts that will work with parents. The training of the parents and children can take place even in refugee camps and can be performed with families from different cultures and in large groups. Part of the pragmatism of EBTS is that the method can be implemented with success across contexts and cultures with minimal adaptations and resources even in crisis areas.

The EBTS-Programme is innovative because:

• it is a short-term programme (10 sessions)
• it focuses on stabilisation, not on psychotherapy
• it re-connects traumatised children to their parents and thus to their most important resource – attachment
• it uses the language of the children – playing
• it combines psychoeducation on trauma with child-friendly and playful stabilisation techniques
• it provides helpers with the latest knowledge in the field of trauma using experience- and action-oriented methods
• it stabilises children, parents, and EBTS-Leaders by enhancing resilience
• it focuses on resources and joyful self-care

EBTS-Programme

Theoretical background of the EBTS-Programme

The EBTS-Programme provides traumatised families with an action-oriented first-aid kit for the stabilisation of traumatised children and the reinforcement of the most important factor providing resilience: the parent-child relationship. It is a structured and ritualised psychodrama-based training divided into two different parts – psychoeducation and playing sessions. During psychoeducation, parents are informed about trauma management and consequences of experiencing severe stress. In the second part, parents play together with their children to stabilise attachment and have mutual joyful experiences.

The basic idea is that playful everyday exercises and rituals can reduce the physical states of anxiety in the parent and child. Trauma therapists agree that the most important factor that protects a person from emotional and psychological injuries is a secure attachment (Ainsworth, 1989). As van der Kolk (2014) pointed out, the reactions of children to painful events are determined to a great extent by the reactions of their parents – whether they are calm or stressed. If the parents succeed in calming themselves and their children, a small but immensely important first step has been taken.

The Structure of the EBTS-Programme

The EBTS-Programme includes 10 sessions – 5 psychoeducational sessions and 5 play sessions. In the psychoeducational part of the training, the caregivers are provided with the basic information about trauma (see the topics of the sessions on Fig. 1). Psychodramatic techniques are used to train all this content so that active learning is possible.

Figure 1 Topics of the psychoeducation sessions for parents

The 5 play sessions (Fig. 2) are attended by a parent and a child aged between 3 and 12 years. The goal of the sessions is to satisfy the 4 basic needs of parents and children: safety and attachment, control and self-efficacy, self-esteem, and joy (for details look below). The playing processes respect the need for safety and stabilise the attachment between a parent and a child. The story takes place in the Bear Valley and caregivers and children take the powerful roles of bear-cubs and bear-parents.

Figure 2 Topics of the play sessions for parents and children.

Needs of children:

EBTS adapts the theory of Klaus Grawe for stabilisation of traumatised children and it is based on psychodrama with children approach, created by Alfons Aichinger (Aichinger & Holl, 2017). Grawe states that the violation or permanent non-satisfaction of the basic psychological needs can influence mental health and well-being (Grawe, 2004). This corresponds to the general attitude of EBTS that the needs’ satisfaction can be seen as a general, cross-disorder therapeutic goal.

Grawe (2004, 2007) named 4 important basic needs of humans:

• Need for attachment: “I want to be close to other people and to have someone I can rely on.”
• Need for orientation and control: “I do not want to be helpless, but to get my life in order. I need to have control over my environment and relationships in order to achieve my goals.”
• Need for self-esteem: “I want to be proud of myself! I want to believe that I am a person of worth and value.”
• Need of pleasure maximisation and pain minimisation: “I want to seek and experience joy. I need to avoid painful and unpleasant things.”

Need of parents:

The needs of adults are very similar to the needs of children. EBTS addresses the need to be successful and reliable in the role of a parent. Parents can re-stabilise the bond with the child, radiate security, be self-efficient in parenting and convey self-worth to the children. Parents and their children experience the joy of playing together.

Evidence-Based Trauma Stabilisation Training

The EBTS-Training is targeted for professionals, who work with families with traumatic experiences. The goal is to expand their professional competencies by having:

• more profound knowledge about trauma theory, trauma management, and resilience
• a tool for trauma management by having an expertise to perform the EBTS-Programme
• a manual with clear guidelines how to use the EBTS-Programme in their everyday work
• knowledge about secondary traumatisation, how to take care of themselves and to avoid burn-out

Learning by doing is one of the leading pedagogics in professional training today. Its basic idea is to connect the learning of skills and competencies to practice and concrete doing so that the learner themselves can be an active agent in the learning event. In the EBTS-Training, we enhance the experiential learning based on psychodrama and sociometry, which connects theoretical learning with practice, and uses experiences and social relations of participants as a resource for learning.

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Information about the authors:
Stefans Flegelskamp:  https://interplayinstitute.eu/team
Milena Mutafchieva: https://cognitiva.bg/en/team