Addressing trauma in Southeast Asia

The Southeast Asian country of Malaysia has emerged as the largest recipient of refugees and asylum-seekers in the region, hosting a substantial population of displaced individuals. Recent reports place the number of registered refugees at 180,440. Additional estimates suggest there may be as many as 140,000 unregistered individuals seeking asylum in Malaysia.

Many of these asylum-seekers experienced war trauma and torture, which places them at a higher risk of developing serious psychiatric illnesses, including post-traumatic stress disorder and major depression. Thus, a need for evidenced-based, trauma-focused, and culturally adapted training for the treatment of refugee trauma survivors is urgently needed.

Mahinder Kaur is a psychoanalyst from Malaysia living in St. Paul. In 2021, she had been supervising school-based practitioners who were working with child trauma survivors from refugee families in Kuala Lumpur, the Malaysian capital. It was her involvement with the school that became the impetus to set up a trauma treatment training program. “Many of the practitioners did not have training in trauma treatment to help refugee families with trauma-related symptoms and problems,” says Patricia Shannon, a licensed psychologist and an associate professor in the School of Social Work. “Dr. Mahinder had been searching for a way to bring trauma education to Malaysia and she reached out to me due to my background teaching trauma treatment and providing treatment to refugees and asylum seekers from around the world.”

Shannon recognized the need and saw a huge opportunity in the possibilities that Zoom might offer for international training. “I wondered if we might leverage this technology to provide international access to continuing education,” she says.

She then contacted fellow experts Chris Mehus, a research assistant professor in the Department of Family Social Science, and Julie Rohovit, the director of the Center for Practice Transformation (CPT). “I wanted to invite Dr. Mehus due to his expertise in teaching evidence-based trauma treatment for refugee populations,” she says.

CPT was contacted because of its history of providing effective and engaging virtual training. “Given that CPT had the platform and expertise in offering professional development workshops and training to a national and global audience, Dr. Shannon approached us to support the logistics and execution of the trauma-informed training,” Rohovit says.

The objective of the project was to collaboratively develop and evaluate the feasibility of a practical, scalable, and sustainable model for international trauma training for mental health practitioners. “We also hoped to develop decolonizing and community-based models for sustainable trauma training by critically engaging Malaysian partners in the development and evaluation of inclusive curriculum and in planning toward sustainable, train-the-trainer processes for ongoing education,” Shannon says.

This approach is essential in that it addresses concerns about Western practitioners attempting to solve problems in communities without adequately involving local stakeholders. The collaborative approach, involving local participants and stakeholders, ensures that the training aligns with their needs.

“This training was designed not only to enhance the clinicians’ understanding of trauma and its effects, but also to provide them with practical tools and techniques for effectively assisting refugees who have experienced severe stress and trauma,”

Dr. Mahinder says. “By doing so, the intention was to improve the overall quality of mental health services available to this vulnerable group.”

30-hour virtual curriculum

A 30-hour, 10-week curriculum was ultimately developed and evaluated in partnership with local stakeholders, including Dr. Mahinder and other educators and providers. The virtual curriculum incorporates elements such as understanding secondary trauma and self-care, assessment and diagnosis, and culturally adapted treatment interventions, all of which were developed in partnership with Malaysian providers, like psychiatrist Dr. Andrew Mohanraj, president of the Malaysian Mental Health Association and a university professor in Malaysia. He provided locally relevant education on intersections between trauma therapy and psychiatric treatment in Malaysia. When Dr. Mohanraj was invited to come on board the training faculty, his immediate response was, “I would be happy to be part of the training even if it is only for one module. I see the value and importance of such a training, and I will do all I can to support this training and it will be an honor to be on the UMN faculty.”

As part of the training, the participants received instruction in Narrative Exposure Therapy, or NET, Mehus says. “NET is an evidence-based treatment for post-traumatic stress disorder, particularly for survivors of multiple or complex traumatic experiences. NET was originally designed to be relatively easy to implement in any setting and has been used effectively in countries all around the world,” he says. Mehus has 10 years’ experience in providing training in NET.

Also brought on the project was Will Carlson, a licensed clinical social worker and doctoral candidate in the School of Social Work. “I previously worked with Dr. Shannon as a doctoral research assistant on various projects related to refugee mental health,” he says. “She invited me to join this project due to my prior experience with NET and providing therapy for refugee clients.”

Carlson says participant evaluations of the training indicate significant improvement in their confidence and comfort providing mental health treatment. “The course appears to have increased participant’s perception of the treatability of post-traumatic stress overall,” he says. “They noted that the course’s emphasis on cultural adaptation of evidence-based practices increased the on-the-ground applicability of their learning. This has been further verified by their subsequent uptake of NET in their professional practice.”

On a fundamental level, the training sought to foster greater awareness among clinicians about the complexities of trauma, especially in the context of the refugee experience, Dr. Mahinder says. “By empowering these professionals with a deeper understanding and practical approaches to trauma treatment, the hope was to enhance the therapeutic outcomes for refugees, leading to improved mental health and well-being,” she adds.

Pam Guneratnam, a clinician and founder of HumanKind, an organization that works with refugee clients, says that she feels fortunate to have taken the training. “NET has become a very important tool that we use in our work,” she says. “The approach is simple and effective, which makes it very practical for our work here in Malaysia.”

Clinical psychologist Ang Wen Fang has been involved in refugee work for nine years. “The program is one of the most comprehensive evidence-based, trauma-focused treatments that I’ve attended thus far,” she says. “I have already started using NET with four refugee patients with PTSD and I can see significant improvements in symptoms throughout the sessions. A Pakistani refugee patient that I have worked with through 13 sessions of NET demonstrated a significant reduction in PTSD symptoms.”

Thulasi Munisamy, a social worker with Protect and Save the Children says one of the most important things she learned was the universality of NET. “The course focused on refugees, but it can be applied and made accessible to any client who has experienced traumatic events in their lives,” she says, adding that she will be applying her new knowledge in her advocacy work.

As the project continues, Rohovit says two central goals for its future are decolonization and accessibility. “We are exploring ways to make it sustainable by sharing and transferring the trauma expertise to Malaysian trainers and practitioners,” she says. “Likewise, this project may serve as a model for others with similar aims.”

Mohamed Faiz, a registered clinical psychologist and senior lecturer at one of the main universities in Malaysia, is already working on sharing what he’s learned. “I started to integrate the knowledge from the course into our academic curriculum at the doctoral level, which focuses on trauma,” he says. “I see a huge potential to train others, especially our in-house clinical trainees at the postgraduate level.”

Although this project is currently based in Malaysia, a longer-term goal involves building a collaborative center for trauma education serving all of Southeast Asia.

One of the systemic challenges to sustainability continues to be cost and currency valuation between countries with different economies. The International Trauma Treatment Education Fund was developed by Dr. Mahinder to help provide future scholarships to offset training costs.

“Creating a local network of providers and trainers who can eventually support one another through peer consultation and support the next generation of refugee-focused providers by providing trauma treatment education has always been the long-term goal of this project,” Carlson says.

Through its collaborative approach and commitment to decolonizing knowledge, this pioneering effort stands as a beacon of progress in the field and offers hope for improved mental health outcomes in Southeast Asia and beyond.

Support the International Trauma Treatment Education Fund: z.umn.edu/ITTEF

-KEVIN MOE