The January BABCP Article of the Month is from Behavioural and Cognitive Psychotherapy (BCP) and is entitled Mapping evidence-based interventions to the care of unaccompanied minor refugees using a group formulation approach by Veronika Dobler, Judith Nestler, Maren Konzelmann and Helen Kennerley 

‘Stop the boats’ slogans dominate current headlines. Imagine zooming in on one of these boats. You see an emaciated teenage boy, fear or relief – it’s difficult to tell- written over his face. Fast forward 6 years: you hardly recognise the young man, confident, hard working, promoted within his company. These remarkable stories are rarely heard. One reason for writing this paper was to relay the hope and potential of working with unaccompanied minor sanctuary seeking young people.

Many of the 45 million forcibly displaced children worldwide are unaccompanied. They have suffered extreme trauma and are faced with multiple challenges on arrival in host countries, including discrimination, lack of social support, years of uncertainty and multiple barriers to mental health care. Supporting unaccompanied minors can feel overwhelming, especially given there is paucity of research into what helps whom, where and when.  Another reason for writing this paper was to share a pragmatic approach to the complex clinical challenge of helping these children.

Aaron T Beck was devoted to alleviating human suffering through study and ‘application of psychological principles’ (Beck & Fleming, 2021). This reminds us to consider the broad psychological foundation of any intervention.  Curiosity and being open to learning are also regarded a powerful and necessary characteristics of CBT practitioners (Padesky & Kennerley, 2023), beginning with clinical observation, application of theory, repeated experimental testing and review to progressively evolve interventions (Beck et al, 1979). This dynamic established the foundation for our initial treatment programme. 

We developed an eclectic group programme based on pertinent theoretical principles. Problem conceptualisation addressed both individual and group needs and resources. It embraced theory on developmental and cognitive psychology, group dynamics, cultural diversity, neurophysiology as well as specific cognitive-behavioural approaches. It was iteratively adapted by qualitatively evaluating feedback. Adaptations included alternative learning approaches, visual learning aids, addressing problem solving of day-to-day hassles, lifetime trauma and deportation.  Later groups achieved good attendance and indicated clinical improvements. 

While our paper is limited by small numbers, the pilot study is shaped by well-established Beckian guidelines and aligned with a more widely recognised need for a change in paradigm when researching and developing complex interventions (Skivington et al., 2021).

Unaccompanied minors are vulnerable. Hence all practice needs to remain open to scrutiny. The open-source program is intended to build a community of practice inviting both adaptation and rigour of review (STAR — STrenghts based Adaptive manuals for sanctuaRy seeking children (annafreud.org)).

We are humbled by these incredibly brave young people.

Beck, A. T. et al. (1979). Cognitive therapy of depression. New York: Guilford Press.

Beck, J.S. & Fleming, S. (2021). A Brief History of Aaron T. Beck, MD, and Cognitive Behavior Therapy. Clin PsycholEur. Jun 18;3(2): e6701. doi: 10.32872/cpe.6701. PMID: 36397957; PMCID: PMC9667129

Padesky, C. A., & Kennerley, H. (2023). Dialogues for Discovery: Improving Psychotherapy’s Effectiveness. Oxford: Oxford University Press.

Skivington, K., Matthews, L., Simpson, S. A., Craig, P., Baird, J., Blazeby, J. M., Boyd, K. A., Craig, N., French, D. P., McIntosh, E., Petticrew, M., Rycroft-Malone, J., White, M., & Moore, L. (2021). A new framework for developing and evaluating complex interventions: update of Medical Research Council guidance. BMJ, n2061. https://doi.org/10.1136/bmj.n2061

From Paul Salkovskis, the Editor-in-Chief of BCP: Why I chose this article 

In the hurly burly of providing help to people caught up in events beyond their control, it can be hard to apply “best practice” and to strike a good balance between clinical art, clinical science and clinical imperatives. One of the great assets of Cognitive Behavioural approaches is how flexible it is in adapting to a diverse range of problems to find better ways of alleviating suffering whilst maintining such a balance. Supporting unaccompanied minor refugees presents challenges that would confound most of us working to help people experiencing mental health problems from a relatively more stable background. A key question these authors set out to answer is this: how to set about conceptualising the problems experienced by young people who have been traumatised by a wide range of factors including but not confined to total dislocation from everything (and everyone) who is familiar. If we can get our heads round that, then there is the further challenge posed by delivering effective help to those people. In this paper, Dobler and colleagues clearly describe and evaluate the processes they deployed meeting the challenges faced in this context in ways which I think are likely to help others seeking to break new ground in similarly challenging contexts. This paper is an important description of how to set about applying CBT in an empirically grounded way with people who merit the best help that can be offered in particularly difficult contexts. Equally importantly, it is framed in a compassionate and caring way which is not only an example to therapists but also to those involved in the formulation and implementation of national and international policy.

Author Bios:

Veronika Dobler, PhD, MRCPsych is a consultant child and adolescence psychiatrist for the Cambridgeshire and Peterborough NHS foundation trust, where she currently leads an intensive home treatment service for adolescents who would otherwise be in hospital. She supports the local authorities and virtual schools in the region to develop mental health provision for unaccompanied asylum-seeking minors. She has extensive experience in the UK, Germany and Austria developing innovative services and psychological interventions for traumatised asylum-seeking and other youth with complex and developmental trauma in clinics, schools, and children’s homes. She has trained in a broad range of psychological interventions, and completed a PhD in neurosciences in Cambridge, where she also held an academic clinic lecturer post, studying the impact of early life adversity on adolescence mental health.  

Helen Kennerley, D.Phil, is a Consultant Clinical Psychologist working with Oxford Health NHS Foundation Trust and a Senior Associate Tutor with the University of Oxford. She has practiced CBT for over 30 years, having trained in Oxford and the US and has specialized in helping those with a history of personal adversity and psychological trauma.  She is a founder member of the Oxford Cognitive Therapy Centre (OCTC), where she is now the Lead for the University of Oxford Postgraduate Certificates in Supervision & Training and in Psychological Trauma & Personality Development.