Introduction

“Before the pandemic, refugee mental health was severely overlooked. Now it’s a full-blown crisis!1

As of mid-2021, over 84 million people globally had been forcibly displaced, according to the UN Refugee Agency (UNHCR). Since then, it is estimated that millions of additional refugees have fled Ukraine alone. It is difficult to fully fathom the magnitude of those displaced from their homes to escape war, persecution, or natural disasters. It is equally difficult to comprehend the mental health challenges this creates for such populations. An October 2020 report by UNHCR states that “one in five – 22.1 per cent – of the adult population in conflict-affected areas have mental health problems.” While recovery interventions exist to address the trauma inflicted on such people by these conditions, the scale of need these refugees have for these resources overwhelms organizations interested in meeting their needs in any meaningful way.

There is a need for a responsive, adaptable, and scalable approach to address refugee trauma that falls outside of the current repertoire of solutions.

A 2017 Global Mental Health report2 identifies the potential of internet and mobile technologies to address the need for trauma survivors living in low- and middle-income countries (LMIC’s). The report emphasizes the need to “develop cross-problem interventions that can cut across specific disorders.” It stresses the importance of actively exploring the integration of Internet and phone technologies into mental health services.  While there has been significant progress in recent years developing e-mental health solutions, without the corresponding level of human expertise to support their use, such solutions are limited in their ability to scale. This report also stresses the criticality of developing low intensity psychological interventions to make effective e-mental health services available in LMICs.

“To be scalable, mental health interventions will need to be capable of delivery by paraprofessionals or peers, relatively brief, focused as much as possible on self-management, and able to address multiple problems at the same time.”

The Report identifies the lack of research focused on technical solutions to assist mental health workers supporting trauma survivors and promotes the idea of research hubs to foster more research. Based on these recommendations, the Learning2Thrive (L2T) Program represents a new approach to develop, evaluate and deliver mental-health services.  “In all this work, evaluation will be critical. Pilot studies will need to pave the way for larger randomized controlled trials and investigations of effectiveness under real-world conditions.”

L2T is designed as a technological research platform providing a virtual Apothecary of mental health program options for selection and use by local mental health workers (MHWs). Beginning with trauma informed evidence-based exercises, L2T provides multi-lingual tools so local mental health workers can adapt the exercises to be culturally appropriate and contextually valid. The site’s design enables refugees to be collaborators in building their own recovery program. In addition, as research expands to more populations, the Apothecary, too, expands. It will be able to offering of culturally adapted interventions in multiple languages addressing a variety of target topics from which refugees and MHWs can choose. In this way, L2T is designed to foster focused assistance in the areas within a refugee community which may need the most help.

In the same way, the platform can provide the foundation in low-income countries to begin integrating a mental health component into their medical services in a manner that addresses a variety of mental health needs. To that end, local mental health workers can create their own pilot studies which they can design & build, deploy and test.  To help them do this, L2T uses a framework of three interconnected portals that represent both a sequential and cyclical process: Assess, Design & Build, and Deploy

As a sequence, mental health workers (MHWs) and refugees first form a team to assess the context where they plan to deploy their pilot tests. Second, based on the feedback gathered during its assessment process, the team turns to the L2T Design & Build tools to collaborate on what types of interventions would be most culturally-appropriate. The team then builds interventions by combining exercises from specific libraries containing both experiential and cognitive evidence-based exercises.  Finally, the team uses its context assessment feedback to determine how to deploy their pilot tests. 

 As a cycle, the team revisits its assessment process to determine what is working; then adjusts the content through the Design & Build portal. Finally, it deploys the revised programs as it starts a new cohort of pilot groups. Each cycle generates additional research for other programs to build on for future research. It also expands the variety of interventions that researchers/programs can choose to develop their pilot tests/programs.

Learning2Thrive emphasizes the following factors to focus on when building a program:
          1. Keep the focus on helping refugees to define their own cultural concepts of trauma,
          2. Identify the syntax & vocabulary refugees use to articulate their trauma, and
          3. Use the Design & Build tools to adapt the interventions based on these cultural nuances.
Trauma involves not only the experience of a traumatic event itself, but the experience that follows and how a person subsequently adapts.  In the case of refugees, the source of the trauma speaks for itself. These individuals are typically subjected to the horrors of war and are then caught in the limbo of displacement. However, how they deal with and adapt to the experience is less uniform. When trauma is unresolved, an individual’s mind is left vulnerable to a range of context-dependent triggers negatively impacting both mental and physical health.  L2T is sensitive to this and seeks to introduce a design approach that stays as flexible as possible to the context and culture so refugees can find their own rhythm and approach.