Interpersonal Psychotherapy for Refugees in Malaysia (2024)

Introduction

As cities in the developing world become destinations for about two-thirds of displaced people globally,1 the Greater Kuala Lumpur area and other cities in Malaysia now host about 182,960 refugees and asylum seekers registered with the United Nations High Commissioner for Refugees (UNHCR).2 However, owing to the lack of a legal and administrative framework for asylum and refugee protection, refugeehood in Malaysia is protracted and precarious related to ongoing vulnerability to arrest, whipping, detention, poor and abusive work conditions, extortion by local gangs, and xenophobia.3^,4^,5 Healthcare access is fraught with economic barriers and the risk of arrest at public hospitals. Thus, premigration experiences of violence and loss and postmigration psychosocial impacts of fear, helplessness, and loss continue to be exacerbated during asylum.

Human rights and refugee mental health

Alongside discourses on civil and political rights, the ascendancy of trauma and post-traumatic stress disorder (PTSD) concepts since the 1970s provided a scientific framework to examine and assess the consequences of human rights violations experienced by refugees.6 The Victorian Foundation for Survivors of Torture Trauma Recovery Framework7 and the Adaptation and Development after Persecution and Trauma (ADAPT) model8 are examples of conceptual frameworks that incorporate human rights violations in mental health interventions for refugees fleeing abusive and repressive contexts. Both models pay attention to the role of culture in understanding the experience of trauma and facilitating recovery. Similarly, the Mental Health and Psychosocial Support (MHPSS) interventional framework of the Inter-Agency Standing Committee (2007)^,9 also recognized the psychological sequelae of human rights violations experienced by refugee populations and aims to address the infringements of rights via multilayer supports and services that seek to enhance safety, protection, and mental well-being for displaced people.

In tandem with these developments, the emerging salience of the right to health in the 1990s and 2000s focused on the neglected healthcare needs of disadvantaged populations like refugees and asylum seekers. Considering the suitability of interpersonal psychotherapy (IPT) for refugees,10^,11^,12 expanding access to mental health interventions such as IPT with other psychotherapies would be an instrumental part of a right to health approach to recovery for refugees. Further, specialized mental health interventions like psychotherapy, including IPT, are included in the topmost layer of the MHPSS pyramid, which focuses on specialized services, with the other three layers in descending order being focused nonspecialized support, community and family supports, and basic services and security.9

Health Equity Initiatives

Against this background, Health Equity Initiatives (HEI) is a nonprofit, nongovernmental organization in the Greater Kuala Lumpur area that provides mental health services using the MHPSS approach to address the mental health challenges of refugees and asylum seekers. HEI currently provides mental health services to around 350 patients from Afghanistan, Myanmar, Sri Lanka, Pakistan, and others, including Somalia, Sudan, Yemen, and Iraq. These patients have been diagnosed with mood disorders, anxiety disorders, psychotic disorders, trauma and stress-related disorders, somatic symptoms disorders, substance-related disorders, neurodevelopmental and neurocognitive disorders, and others. In its management of refugees with mental health challenges, HEI has found that it is critical to address the psychosocial needs of refugees before proceeding to use psychological and behavioral therapies, aligning with the literature highlighting the importance of psychosocial support in treatment adherence related to common mental health disorders, symptom reduction, and improved social functioning.13^,14^,15 Thus, an adaptation of IPT for refugees should include addressing the psychosocial needs of these refugees before proceeding to apply IPT for depression and PTSD.

Case studies of refugees who have received IPT

The case studies in this chapter have been selected from those who received IPT in HEI’s mental health services.

Case study 25.1

Ms. M. K., a young woman from a West Asian country, sought treatment at HEI. She was diagnosed as having moderate major depressive disorder, moderate generalized anxiety disorder, and PTSD according to validated psychometric measures and the clinical criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).16

She, her mother, and her elder sister had fled her home country for Malaysia because of threats from her maternal uncle. Her uncle wanted to forcibly marry her widowed mother and her elder sister to men of his choice. He physically and verbally abused M. K.’s mother. The civil war in her home country had begun in early 2015. M. K. heard and felt bombs exploding close to the house, which terrified her. It became unsafe to venture out of her home. Water and electricity supply was often disrupted. M. K., her mother, and her sister fled home with a day’s notice. They had to take 3 flights before arriving in Malaysia. M. K. said that they were very nervous because they feared that her uncle might catch up with them.

Against this background, arriving in Malaysia was a relief for them. They felt safe and enjoyed good amenities. They initially had challenges transitioning to Malaysia. They lived in cramped living quarters, all 3 living in a rented room. They had financial challenges, and M. K. had difficulty resuming school. These challenges were addressed over a period of time. M. K. received a scholarship to a private school. All 3 are currently working. This has allowed them to rent a 3-bedroom apartment. They have rented 1 room to another refugee and are thus able to defray some of the rental expense. At HEI, she has been prescribed an antidepressant and a benzodiazepine. When she did not improve, IPT was offered to her.

The IPT problem areas identified for Ms. M. K. were interpersonal conflict with her uncle, who was threatening her, and grief and loss on the death of her maternal grandmother in her home country. Her Interpersonal Inventory revealed that her support was from her mother, her sister, two friends who had been her classmates in school, and the patient manager of HEI. M. K.’s attachment style was ascertained to be anxious-avoidant.

The interpersonal threat from MK’s uncle, who threatened to kill all 3 women, was addressed individually with M. K. and in a joint session with M. K.’s mother. It was concluded that it was unlikely that M. K.’s uncle would be able to carry out his threat in Malaysia. This reassured M. K. and reduced her anxiety.

The death of her grandmother in her home country filled M. K. with guilt and self-blame. She felt that her grandmother was harassed by her uncle because of her, and that this constant harassment had contributed to her grandmother’s death. The complicated grief she was experiencing was addressed utilizing an adaptation of faith and religion. She found that being a Muslim helped address the grief she was experiencing. Reading verses from the Quran and praying to God assisted her in coping with the loss of her grandmother. During therapy, her faith helped her conclude that her grandmother was in heaven and thus was in a better place. She also cherished her grandmother, who was always nice, kind, and generous and was always there for her and protected her from her uncle. Thus, M. K. firmly believed her grandmother deserved to be in heaven. Talking about her grandmother in the light of faith reduced her psychological pain and feelings of loss, guilt, and self-blame. M. K. added that this was the first time she had talked about her grandmother’s death in detail and the loss she had experienced. The therapy sessions made her grandmother’s death “real” because she previously felt that her grandmother’s death was “unreal” as she could not view her grandmother’s remains.

At the end of 8 sessions of IPT, M. K.’s depression was minimal and anxiety was mild. The gains that she had made in IPT were that she was able to express her thoughts and feelings without being judged, she was able to reduce self-blame related to her grandmother’s death, her mood had improved, and she was able to function independently and with greater self-competence. Monthly maintenance IPT sessions were agreed on.

Case study 25.2

K. Y. was a married lady in her 40s displaced from a neighboring Southeast Asian country. She sought help from HEI for anxiety and depression. She was diagnosed to have moderate depression and mild anxiety according to DSM-5, clinical criteria, and validated psychometric measures. K. Y. had fled her home country in Southeast Asia because of threats to her life and well-being. There was a civil war between the national armed forces and the local resistance army in her home state. She was smuggled over land. The migration journey was fraught with much difficulty and danger. She was relieved when she reached Malaysia safely.

The IPT problem areas identified in her were difficult transitions and complicated grief.

She had arrived in Malaysia in 2008, about 13 years ago, and she was yet to be resettled in a third country. She had watched her friends, who had arrived in Malaysia after her, be resettled. This had affected her mood, and she lacked hope that she would be relocated. She had lost her mother in Malaysia. She had provided care for her mother but felt that she could have done more. Thus, she felt guilty and blamed herself.

The transition to living in Malaysia as a refugee was initially suitable for her but became increasingly difficult as time passed. She said that her freedom was suppressed, and she lived with the constant fear that she might be arrested and detained by the Malaysian police. She said that she was treated like an illegal migrant and was not allowed to open a bank account, and this troubled her because she could not keep money in the bank for safekeeping.

Her interpersonal inventory revealed that although she shared a close relationship with her spouse, her primary sources of support were her sister and two friends, who she felt understood her better as women. Her attachment style was discussed. She had secure attachment in her close relationships and was anxious-avoidant in other relationships.

During the therapy sessions, she identified two timelines resulting in transitions. The first was when she arrived in Malaysia in March 2008, and the second was when the restrictions resulting from the COVID-19 pandemic were implemented in March 2020. On inquiry, she said that this episode of depression was attributed to the March 2020 transition, but the issues of the earlier change continued to bear heavily on her.

Her responsibility to implement COVID control strategies of masking and physical distancing at the workplace brought criticism and resistance from peers. Moreover, transitioning to online modes of work exacerbated the pressure of resource constraints brought about by the need for connectivity and devices. She said that her passion for her work had decreased during this period.

She would also avoid attending farewell parties for her community members who were being resettled because of unpleasant thoughts and emotions that were stirred in her to remind her that she was yet to receive news of resettlement. She added that the therapy sessions had allowed her to discuss these issues openly and without being judged. This helped her feel better.

The technique utilized to address her transitions was identifying the two timelines and discussing the changes in each transition. The positives of these transitions were emphasized: a safer environment in Malaysia, the opportunity to do meaningful work to serve others, and the support from her sister, friends, and ethnic community. She also resorted to her faith in God and rationalized that the consequences of the transitions were God’s will for her.

K. Y. also wanted to discuss the grief that she was experiencing at the loss of her mother. She acknowledged the loss of her mother, a family and community leader who gradually became dependent on others. The family and community had lost a kind and generous person. Most of her family and community members respected and loved her mother. She felt guilty that she could not do more for her mother and should have spent more time with her. She was relieved that her mother’s passing was peaceful. She said she also felt relieved that no one blamed her for her mother’s death. Her family and community members said it was her mother’s “time to go.” She also received support from her community to transport her mother’s remains to her home village for burial.

In the next session, we continued to discuss her grief. She acknowledged the loss of her mother. She said that even though her mother had passed away, she felt her mother was still with her. Staying in the same room reminded her of her mother. Sometimes she would talk to her mother as if her mother was still with her. She used to feel lonely and was able to fill her loneliness with work and the presence of her colleagues and students.

She held a faith perspective on her mother’s death. She believed her mother had returned to God. This belief consoled her. The structure of the IPT sessions for K. Y. was 2 initial sessions, 7 middle sessions, and 1 terminal session. Monthly maintenance sessions were agreed on at the end of the tenth session.

In the final session, we reviewed her gains in therapy. The gains were the opportunity to talk openly about her transitions and her grief in a safe and nonjudgmental space, and she was also able to avail of support within the extended therapeutic relationship (therapist and HEI patient manager) and outside of therapy (her sister and her two colleagues). At the end of 10 sessions, she had psychometric scores indicating mild depression and minimal anxiety.

Discussion

Despite IPT being effective for the refugees in Case Study 25.1 and Case Study 25.2, it is challenging to do IPT with refugees who have experienced multiple traumatic experiences, sexual- and gender-based violence (SGBV), and severe ongoing stressors. IPT is relevant for treating refugees with depression because it can address problem areas typical of refugees.17 Some of the problem areas distinct for refugees and the following adaptations are discussed here.

The migration journey

In our work with refugees, our initial assessment includes exploring the refugee’s migration journey. Entry into Malaysia is by air, sea, or land. The migration experiences over sea and land are often stressful, traumatic, and fraught with difficulties and adversities. Asylum seekers from Myanmar are often smuggled into Malaysia via Thailand by land. Rohingya refugees are known to have traveled a treacherous journey by sea.18 Arrest and detention can occur in a transit country like Thailand or Indonesia, and this experience can be very stressful and traumatic, resulting in depression, anxiety, and PTSD. Thus, an adaptation of IPT for refugees who live in Malaysia would need to address the migration journey.

Transitions

The migration from the country of origin to a transit country like Malaysia is a significant transition because of multiple transit journeys. In the past, Afghan asylum seekers of Hazara ethnicity would initially migrate to Iran because of similarities in language and religion. They then would migrate to Malaysia directly or via Indonesia. Afghan refugees are also known to arrive in Malaysia via India.

Refugees find living in Malaysia difficult. Although Kuala Lumpur has a UNHCR office, Malaysia is not a signatory of the 1951 Refugee Convention or its 1967 Protocol. This limits opportunities for work for adult refugees and education for children.

The most common role transition for married refugee men is the difficulty or inability to provide for the family. Refugees are not allowed to work formally; thus, much stress is experienced because of a lack of steady income to support themselves and their families. This also poses a challenge for refugees who are single mothers. They need to be gainfully employed to provide for their families. Teenagers and young adults have limited access to formal education and thus cannot enter tertiary educational institutions. This becomes a stressor for not only the young adult but also the parents of these young people.

Safety and security become an issue in this transition to living in Malaysia. Since the Malaysian government does not recognize refugee status, a refugee in Malaysia is under constant threat of arrest and detention by the Malaysian police and Malaysian immigration. This precarity of refugee life in Malaysia was exacerbated during COVID-19 when they lost jobs, experienced housing and food insecurity, and had to endure ongoing mobility restrictions and lockdowns.19 The psychosocial needs that arise as a result of forced migration, and thus the transition of migration, must be addressed as an adaptation of IPT for refugees.

Grief and loss

Refugees suffer much loss. They often lose everything they possess when they are forcibly displaced. The loss of loved ones is also a common experience for refugees. Afghan Hazara refugees have witnessed the murder of relatives. Myanmar refugees have experienced losing their family members at the hands of military personnel. Sri Lankan Tamil refugees have experienced the disappearance of family members.

Complicated grief is a common experience for refugees. The inability to be at the dying relative’s side, attend the dead relative’s funeral, or bury the deceased relative contribute to complicated grief. Our experience doing IPT with refugees shows that discussing the loss of loved ones in a safe and nonjudgmental environment contributes to healing.

Interpersonal disputes/conflicts

Some refugees experience family conflicts in their home country and face threats to their lives and well-being. There are refugee women who are forced to marry a man of the family’s choice. Some Afghan and Yemeni women refugees have fled their home country because they disagree with this spouse choice. This becomes an issue of family honor, and these women are threatened with death.

Domestic violence is also prevalent among refugees. Some refugee men abuse their partners or spouses physically and verbally. SGBV is commonplace in not only families of refugees but also their ethnic communities. Conflict with the government and the Army has been the experience of ethnic Kachin, Shan, and Rohingya in Myanmar. It used to be an issue for Sri Lankan Tamil refugees until 2015. The most severe interpersonal trauma experienced by refugees includes abuse and torture in detention. It is very challenging to treat these victims of abuse and torture, including trying to treat them with IPT.

Trust and the therapeutic relationship

Many refugees have difficulty trusting others. The therapeutic relationship in IPT allows the refugee patient to build trust again. The refugees who have undergone IPT have listed a confidential, trusting, and nonjudgmental therapeutic environment as one of their favorable experiences in therapy. This allows healing to take place in the therapeutic relationship. The therapeutic relationship is also a relationship that contributes to more secure attachment styles for the refugee patient.

Adaptations of faith, religion, and religious community support in treating refugees with IPT

Many of the refugees in Malaysia are people who profess faith in God and are affiliated with a particular religion. Many are also persecuted because of the faith they profess. In treating refugee patients with IPT, some patients include God in the Interpersonal Inventory. Many refugees have been waiting for years to be resettled, and hope can be eroded. Trusting in God helps instill hope. It has been found that the faith communities provide social and material support for refugees, especially Christians and Muslims. Shared prayer and communitarian sharing from religious books have been used as adaptations in IPT treatment of refugees and the local population who profess faith in God and belong to a religious community.20

Conclusion: Adaptations and training—IPT for displaced people

Adaptations of IPT for the refugee population are not new. The adaptations and training of Verdeli et al., who implemented group IPT for depressed youth in internally displaced people camps in Northern Uganda, were groundbreaking in addressing a specific refugee population in Uganda.21 In collaboration with Schultz et al., Verdeli and colleagues also developed an adapted stepped-care brief IPT intervention for psychologically distressed women displaced by conflict in Bogota, Columbia.22 Susan Meffert and associates successfully carried out a randomized pilot trial of IPT for Sudanese refugees in Cairo, Egypt.11

The case studies in this chapter, based in an Asian upper-middle income country, add to the existing work of adapting IPT for refugee populations in a different geographical and refugee protection context and demonstrate the suitability and fruitfulness of IPT for this population. However, as the context of flight, asylum, and durable solutions vary across the globe, the adaptation of IPT for this population would require context specificity.

References