A qualitative evaluation of the use of Problem Management Plus (PM+) among Arabic-speaking migrants with psychological distress in France – The APEX study

ABSTRACT

Background: Feasibility studies with non-French speaking migrants in France are needed to inform appropriate adaptation of psychosocial intervention procedures.

Objective: To test the WHO Problem Management Plus (PM+) intervention protocol for Arabic-speaking migrants in the Paris metropolitan region.

Methods: Between 2019 and 2021 we recruited participants from three accommodation centres receiving asylum seekers or migrants experiencing social and economic difficulties. Participants experiencing psychological distress underwent five PM + sessions with trained helpers. Feasibility was evaluated through 15 interviews with 8 participants, 4 helpers, and 3 study supervisors. Interview topics covered PM + implementation in general and for each component. We also sought to understand problems with delivery and gathered suggestions for improvement. Data were analysed thematically using a deductive approach.

Results: We found implementation of PM + to be feasible, with predominantly positive reactions from participants, helpers and study staff. All intervention components were considered beneficial, with breathing exercises considered easy to implement and often sustained. Selection of problems and strategies to address them were described as challenging to execute. Psychosocial support from and rapport with helpers and the use of the native language were considered key strengths of the programme. However, we observed the need for complementary or higher intensity psychological support in some cases. Findings also highlighted the importance of addressing distress among non-specialist helpers delivering PM + . Finally, local guidance to social resources were suggested to be added in the protocol.

Conclusion: PM + was well-liked and feasible, with cultural adjustments and increased access to community resources for migrants needed.

HIGHLIGHTS

• The World Health Organization Problem Management Plus (PM+) intervention was found to be a feasible and acceptable intervention for Arabic-speaking migrants in the Paris metropolitan region, with participants reporting improved mental health outcomes and satisfaction with the programme.

• The features of psychosocial support from and rapport with non-specialist helpers delivering PM + and the use of the native language were considered key strengths of the programme.

• The study documented perceived benefits of expanding PM + in scope and length, suggests the need for additional mental health services for non-specialist helpers, and highlights the importance of considering cultural and linguistic factors when providing mental health services to asylum seekers or migrants experiencing social and economic difficulties.

Antecedentes: Se necesitan estudios sobre la viabilidad de procedimientos de intervención psicológica en inmigrantes no francófonos en Francia que sirvan como antecedente para su adaptación.

Objetivo: Evaluar el protocolo de intervención del programa Enfrentando Problemas Plus (EP+) de la Organización Mundial de la Salud (OMS) en inmigrantes de habla árabe en la región metropolitana de París.

Métodos: Entre el 2019 y el 2021 se reclutaron participantes de tres centros de acogida para solicitantes de asilo y para migrantes en dificultades sociales y económicas. Los participantes que experimentaron angustia psicológica recibieron cinco sesiones de EP + por parte de facilitadores entrenados. La viabilidad se evaluó mediante 15 entrevistas a 8 participantes, 4 facilitadores y 3 supervisores del estudio. Las entrevistas trataban temas relacionados con la implementación del EP + de forma general y también por cada componente. Asimismo, se buscó comprender los problemas asociados con su ejecución y se recabaron sugerencias de mejora. Se analizó la información por temas empleando un enfoque deductivo.

Resultados: La implementación del EP + es factible, con reacciones predominantemente positivas por parte de los participantes, facilitadores y supervisores del estudio. Se estimó como beneficioso a todo componente de la intervención, considerándose particularmente a los ejercicios de respiración como fáciles de implementar y de generalmente mantenerse en el tiempo. Se describieron como difíciles para ejecutar a la selección de problemas y estrategias para abordarlas. Se consideraron como fortalezas del programa al soporte psicosocial y rapport de los facilitadores, además de haber usado el idioma materno. Sin embargo, se observó la necesidad de brindar soporte psicosocial complementario o de mayor complejidad en algunos casos y, también, la necesidad de abordar la angustia en facilitadores no especialistas que brindan el EP + . Finalmente, se sugirió añadir al protocolo la orientación hacia recursos sociales locales.

Conclusiones: El EP + fue aceptado y considerado viable con ajustes culturales e incrementando el acceso a recursos comunitarios para los inmigrantes que lo necesiten.

KEYWORDS:

• Asylum seekers
• migration
• mental health
• intervention
• Paris
• refugees

PALABRAS CLAVE:

• Solicitantes de asilo
• migración
• salud mental
• intervención
• París
• refugiados

1. Introduction

Refugees are at higher risk of experiencing psychological distress than natives or other migrants (Giacco et al., 2018). Moreover, the cumulative exposure to pre- and post-psychosocial risk factors may lead to the development of psychiatric disorders such as depression, anxiety, PTSD or even psychosis (Tinghög et al., 2017 Dec). Immigration to Europe following unrest in the Middle East and elsewhere substantially increased refugee mental healthcare needs in destination countries (Kien et al., 2019; Pavli & Maltezou, 2017). Therefore, it is important to facilitate access to interventions for psychosocial distress in host countries to avoid further deterioration of refugees’ mental health (Padovese et al., 2014).

In France, as in other European countries, the number of asylum seekers has been rising at the same time that the prevalence of psychological distress has increased and access to mental health care has decreased, especially among non-French speaking refugees (Tortelli et al., 2019; Turrini et al., 2019). Refugees and migrants, particularly those who have migrated alone are vulnerable to challenges that contribute to social isolation, including language barriers, cultural differences, and discriminatory attitudes (Abubakar et al., 2018; Johnson et al., 2019; Strang & Quinn, 2021; World Health Organization, 2023). Indeed, despite affordable public mental healthcare in France, services are more focused on providing care for severe psychiatric disorders than on offering psychosocial support (Siffert et al., 2018), particularly in a foreign language (World Health Organization, 2010).

Brief cognitive–behavioural therapies (CBT) are effective in treating anxiety, depression and stress-induced mental health problems, leading to reduced symptoms and improvements in quality of life (Nosè et al., 2017; Turrini et al., 2019). As part of the Mental Health Gap Action Program, the World Health Organization developed Problem Management Plus (PM+) (World Health Organization, United Nations High Commissioner for Refugees, 2015), a psychosocial intervention protocol for adults affected by psychological distress intended for application in settings where access to mental health specialists is limited (Bryant et al., 2017). A pilot study among Syrian migrants in the Netherlands showed that PM + may improve mental health outcomes and psychosocial functioning, and is potentially cost-effective, suggesting the possibility of using PM + across Europe (de Graaff et al., 2020).

In this study we sought to evaluate the feasibility of the use of PM + in the French context, among Arabic-speaking migrants living in accommodation centres in the Paris Region.

2. Methods

The pilot study Accompagnement des Personnes EXilées (APEX) took place in three accommodation centres in the Paris Region serving asylum seekers or people experiencing social and economic difficulties. Recruitment occurred between May 2020 and July 2021 through flyers, oral communication and snowball sampling. Participants were: Arabic-speaking adults (>18 years) exiled in France with psychological distress (a Kessler 10 score of ≥16) and functional impairment (a WHO-Disability Assessment Schedule 2.0 score >16). Written informed consent was obtained prior to screening. Exclusion criteria included treatment for severe and acute psychiatric disorders, suicidal ideation, inability to communicate/understand the intervention, and severe addiction or somatic problems (Ustun et al., 2010).

Helpers for delivery of PM + included nine native-Arabic speaking college graduates who participated in 80-hour PM + training. Five joined the project and delivered PM + sessions. Supervisors included two clinical psychologists and a psychiatrist.

2.1. PM ± intervention

PM + is a low-intensity psychosocial intervention for the management of psychological distress that has been implemented with multiple migrant populations (Akhtar et al., 2020; Alozkan Sever et al., 2020; Alozkan Sever et al., 2021; Coleman et al., 2021; Rahman et al., 2016; Sijbrandij et al., 2017; Sijbrandij et al., 2020; Uygun et al., 2020). It combines problem management with targeted behavioural activation strategies and draws on CBT (Dawson et al., 2015). PM + has four core strategies: managing stress (through relaxation and breathing exercises), managing problems (by choosing and breaking problems down), ‘get going keep doing’ – breaking the inactivity cycle, and strengthening social support.

Sessions were delivered one-on-one in Arabic by helpers in five weekly 90-minute sessions in the accommodation centres. Helpers received two-hour weekly supervision sessions by one of two supervisors throughout intervention delivery.

2.2. Qualitative interviews

We interviewed PM + pilot intervention participants, along with helpers and supervisors to triangulate perspectives. Migrant participants received €10 vouchers. In-depth interviews were carried out by a native Arabic-speaking research assistant with a master’s degree in public health. Two supervisors were interviewed in English, the other in French. Closed-ended questions covered demographic information.

In-depth interviews were conducted using a semi-structured guide utilizing open-ended questions, while probing and exploring topics introduced by the participants. Using an iterative approach to explore the emerging themes, interview guides were revised throughout data collection. Topics covered the usefulness of PM + components, likes/dislikes regarding content and delivery, acceptability of intervention components, and suggestions for improvement.

Participant interviews were conducted in Arabic, audio-recorded, and transcribed verbatim into English or French. Memos were written about observations from the interviews, topics for follow-up and reflexivity (Saldaña, 2011).

2.2.1. Data analysis

Thematic analyses used deductive categories based on the PM + components (Braun & Clarke, 2006). The process we followed in thematic coding included familiarization with the data, generation of initial codes, searching for themes, defining and naming themes, and generating the final results (Braun & Clarke, 2006). We used this process to discover patterns and themes within predefined topics of interest related to core elements of PM+, including experiences with: breathing exercises, management of problems, the cycle of inactivity, and enhancing social support. Transcripts were read and re-read to identify initial codes/categories and themes based on emerging patterns using an iterative process that can be thought of as moving in analytic circles rather than using a fixed linear approach (Srivastava & Hopwood, 2009). Common themes and sub-themes were identified across the data. Codes were split and merged throughout the process. In this process, within each of the deductive areas of inquiry, we allowed inductive themes to be developed and emerge that were meaningful to the participants that did not fall into our pre-determined deductive categories, a method that is intended to demonstrate the theoretical and interpretative rigor of the findings (Fereday & Muir-Cochrane, 2006; Kuper et al., 2008). Transcripts were coded with Sonal computer-assisted qualitative data analysis software (Université de Tours, Version 2.1.41) and by hand.

3. Results

Of the 20 participants recruited, 14 (70%) were eligible to receive PM + (N = 5, 36% female; N = 10, 71% married; mean age of 44) Of the 14, one was lost to follow-up because of COVID-19 hospitalization. Eight participants, four helpers, and three supervisors were interviewed in 2021 (Table 1).

Table 1. Participant inventory including role, sex, age and country of origin.

Role and interview number	Sex	Age	Country of birth	Residence status	Length of time in France
Participant – P1	Male	54	Tunisia	Irregular^a	6 years
Participant – P2	Male	41	Sudan	Refugee	1 year 4 months
Participant – P3	Male	38	Palestine	Refugee	1 year
Participant – P4	Male	41	Yemen	Refugee	4 years
Participant– P5	Male	30	Syria	Refugee	2 years
Helper – P6	Male	34	Tunisia	Non-refugee migrant	10 years
Helper – P7	Female	37	Syria	Refugee	10 years
Helper – P8	Female	35	Palestine	Refugee	13 years
Participant – P9	Male	48	Tunisia	Non-refugee migrant	23 years
Participant – P10	Female	58	Sudan	Refugee	5.5 years
Supervisor – P11	Female	42	Brazil	Italian citizen	5 years
Participant – P12	Female	43	Algeria	Non-refugee migrant	5 years 4 months
Helper – P13	Male	28	Syria	Refugee	5 years
Supervisor – P14	Female	56	Germany	French citizen	19 years
Supervisor – P15	Female	45	France	French citizen	(since birth)

^a In France, a residence permit is a document that allows its holder to stay in France. It is mandatory for every foreigner that comes to France with the purpose of staying more than three months. P1 had pending registration in France, meaning they had not received a residence permit.

3.1. General comments

Interviewees were uniformly pleased with the programme and felt it helped across diverse domains.

It made me happy to participate … I learned things – and [now] if I have a problem I can count on myself. [Participant-P12]

I learned how to live, how to be patient, how to leave our problems behind … It changed my life. [Participant-P1]

Some participants alluded to how the programme helped them manage stress, build self-confidence, self-control, improve interactions, and was motivating (Table 2).

Table 2. General comments expressed by migrants highlighting diverse positive aspects of the programme.

Benefits described	Illustrative Quotes
Self-control	“In general, I feel better. I've made a lot of progress … I got irritated easily … After the program, I [could] manage to control myself and manage my stress and think about the future.” [Participant-P9]
Self-reliance	This programme made me rely on myself to overcome the problems I have in my life. [Participant-P12]
Motivation	“Even when I felt I didn’t have the energy, the same day of the program, in the same day, you find yourself getting out. So, the situation is good. Without the program, you would just sleep all the time.”[Participant-P3]
Application of techniques learned	“I started from the bottom and went up little by little. I listed the problems, the biggest problem then the smallest the smallest. Of course, I learned this technique from the program, I always keep it in my head and it's my way of life now. In anything. Now I have my priorities.” [Participant-P5].
Moral support	“In general the program gave me moral support … The whole program is important. I learned lots of things … the program [also] helps you in part to solve some other problems.” [Participant-P10]
How to interact with society	“The program was good … It did help me. I would not feel very good, but then through the questions and the conversation, I felt better. It teaches you how to interact in society, this was a good thing.”[Participant-P3]

3.2. Main PM + session content

1. Breathing exercises

Almost everyone interviewed expressed benefitting from the breathing exercises and reported that they were easy to teach or to learn.

It [the breathing exercise] was easy for me. It doesn't take too much effort and it was good when I practiced it. [Participant-P4]

Others explained how it helped them relax:

I am totally another person after the exercise … I feel at ease. [Participant-P9]

A helper explained how it was both helpful and accessible:

It would really help them vent … It was really easy, they would understand it, and they would really practice it. [Helper-P13]

Supervisors and helpers were similarly positive:

They used it a lot … and would feel an amazing feeling of psychological comfort when they would do it. It was useful, and I think one of the most important parts of PM + . [Supervisor-P15]

3.2.1. Extended benefits/use

Beyond dealing with mental distress, participants discussed varied contexts in which the breathing exercises helped them (e.g. when upset, having a job interview, feeling stress) (Table 3).

When I am not well. Ma’am [the helper] told me to do it when I am not well or when I am upset. I feel good when I do it. [Participant-P9]

Other benefits included help with sleep and anger management. Some participants described how they taught them to family members and how it led them to explore other relaxation techniques (Table 3).

Table 3. Breathing techniques – examples of situations in which breathing exercises were put to use, spillover applications, and evidence of sustained use (described by participants and helpers).

Applications of breathing exercises	Illustrative quotes
For stress and anger	“When I have a job interview, when I want to talk, when I'm stressed from work, I breathe … Another thing that it has helped me with a lot is anger management – how to breathe, to think before speaking, to control my anger [Participant-P5]”
When alone	“When I am all alone. I take the time to breathe well.”[Migrant-P12]
For sleep problems	“At first, they [the participants] found it strange, and then they felt that they really relaxed … there are some of them that take medication, and they take sleeping medication because they have problems with sleeping– and this [exercise] makes them sleep.” [Faciltlator-P7]
Led to other relaxation techniques	“She gave me breathing exercises and since then I have started meditation.”[Participant-P5]
Sustained use
• Example 1	“I’ve practiced it every day until today. Whenever I think of my family, my children and the problems at home, I do the exercise during periods that are difficult.” [Participant-P4]
• Example 2	“I started to do it well … When I remember to do it, I do it!” [Migrant-P2]
• Example 3	“There were individuals who placed a lot of importance on it [breathing strategies]. And, there were some people who found it useful and they would tell me that they would spend an hour between going out and work, which they would use to relax. And I think that people were convinced by this strategy.” [Helper-P6]
• Example 4	“I asked her [the participant] in the following session if she did it herself at home, and she told me, yes, that she did and [that] she taught it to her husband and her children.”[Helper-P8]

Many participants continued practicing the breathing exercises.

I take a deep breath … It has become a [part of my] lifestyle. Like anything else in life. To protect yourself from the rain, you have an umbrella. To protect against anger, you breathe. [Participant-P5]

3.3. Implementation challenges

Participants reported few difficulties implementing the breathing exercises. Of the few mentioned, the most common were initial uneasiness and difficulty in sustaining interest.

The person at first finds this weird, a little strange. [Helper-P7]

Those who didn't have experience were more resistant to the strategy. Once they accepted the strategy, and they learned how to do it, I think it was not a problem anymore. [Supervisor-P11]

2.	Management of problems

Picking a manageable problem and identifying solutions was considered helpful and viewed positively.

When I would share my problems … she clarified that she would not be able to provide solutions, or a magic solution for the problem. I [should] solve the problem. But she would help me with the thinking … This would allow me to find a solution. Or [she would] ask me, ‘Why did you not do this?’ When you think, next will she will ask me, ‘Did you do this?’ then I would think about doing something useful. The principle was really good. [Participant-P2]

One helper summarized:

They felt that they were in a different place, and once we leave the room and the door is closed, we return to reality … From my perspective, the management of problems is very good and efficient. [Helper-P7]

3.4. Implementation challenges

The delivery team acknowledged challenges in guiding participants to choose a problem, strategize how to handle it, and follow through with their plans.

The most difficult thing is to choose the right problem, a problem that wouldn't be too big or too small or something that you cannot [make] work with PM + . [Supervisor-P11]

A supervisor suggested that helpers could use more problem management training:

It depends also, I think, more on the helper, how to decide which is a good problem to work on and [what is] manageable … that's the part where they – I think they needed a little bit more coaching. [Supervisor-P14]

One helper suggested that inadequate time to establish rapport contributed to these difficulties.

[Problem management] was the hardest session. It is the second session only, so you still don’t have 100% trust built. [Helper-P7]

Another helper described feeling overwhelmed at the range of problems that needed consideration:

Honestly, I had a problem with describing the issue of problem solving. A [participant] that tells me … that my father died, or my children are lost – what do I tell him? The problem is that after the 15 minutes the participant has 100,000 problems. [Helper-P13]

One supervisor mentioned difficulties training others in problem management.

So maybe there were some problems from me in trying to explain and for them in understanding in real life how you can separate problems that are feasible and unfeasible for PM + . So I think this session could be improved a lot. [Supervisor-P11]

Follow-through to address problems could be challenging.

There was a plan that the participant has to go along with in order to find a solution for the problem they are facing … Sometimes, it might be going out with a friend, it could be sometimes that the participant could not leave their house, perhaps for economic reasons, or psychological reasons. This was what I saw was hard. [Helper-P13]

You are showing the person strategies and following up with him. And, the person shows up, and they are not working on it. So you can see they need repetition, and you have to explain again. [Helper-P6]

3.	The cycle of inactivity

Participants agreed that breaking the cycle of inactivity was critical. According to a helper, one migrant cried when he saw the cycle of inactivity diagram, exclaiming, “This is what I am currently living in.”[Migrant-13] Another helper stated: “Mm! They really like this [the inactivity cycle]. They would say, yes, right – right! This is what we are stuck in.” [Helper-P7]

Several participants explained how the cycle resonated with them.

This was really close to her [a participant’s] situation. She could not move or leave the bed. After we talked about this issue, she told me in the next session that she went to visit her father with her kids, that she left the house, she breathed, and she returned. So, it really helped her. [Helper-P8]

The strategies [can be used] when … there is depression. They [the strategies] taught me how I can get out of this cycle … The program is very good. It motivates you to do things and especially [things] that refugees most of the time are not thinking about. [Participant-P4]

After some difficulty explaining his feelings, in referring to a diagram representing the cycle of inactivity, one participant stated:

I do not know how to explain this – what is in the picture, is best. [Participant-P2]

3.5. Implementation challenges

No challenges with the inactivity cycle were described by participants. However, some helpers explained that it could be hard for participants to break the cycle if they were not already motivated.

They would understand, but it depended on the person’s interest. If someone wanted to get rid of this inactivity, it was easier for them to understand. [Helper-P6]

3.5.1. Strategies to break the inactivity cycle

Another goal was to develop strategies to break the cycle, e.g. encouraging activities participants enjoyed.

He [the helper] often asked me what things I like to do … He told me to re-take up what I love to do. He told me to try. That was important for me. [Participant-P4]

Varied activities to break the cycle included dancing, doing sports, going to cafes (Table 4). Social connections were also viewed as important to becoming more active:

Table 4. Examples of strategies to break the cycle of inactivity.

Participation in physical activities	“How to get out of this cycle of inactivity? I told her I could dance, play sports. ”[Participant-P5]
Leisure activities	“I don't stay in bed [anymore]. I watch a series, I listen to music. I listen to the Quran. I go out. I go to a cafe. Yes, I learned.”[Participant-P12]
Engagement with friends	“In addition we talked with my roommate and we bought a ball and each time [we went] we [would] play in the park. We were very motivated at this moment, especially when they suggested this.” [Participant-P4]
Helpers could aid through an expanded curriculum	“If they could add a session … [it] might allow the participant to go out with the helper to a place that is chosen by the program participant. It could be a river, or a library, or a gym.”[Helper-P13]

Or I would dress up and go out and I cheer myself up. Because when you're sad, you don’t meet with anyone. We should take care of ourselves. That's what I learned from this program. I don't need a psychologist. [Participant-P12]

3.6. Implementation challenges

Helpers and supervisors commented on barriers participants had to overcome inactivity.

Where the people have fewer resources, it's not easy. [Supervisor-P14]

The hard part was that there were some people who really did not have interests, or [they] used to have them and they disappeared over time. [But], it was easy, especially for those who had interests in reading, in exercise, in culture. [Helper-P13]

4.	Enhancing social support

3.7. Support from the helper-migrant relationship

An important relationship was between helpers and the migrants themselves. “She has given me psychological support that made me stronger.[Participant-P5]” Many participants valued being listened to: “The fact of already being interested in someone, taking an hour and a half a week for the person, I think that already unconsciously the person feels helped, supported, listened to.” [Supervisor-P15]

Migrants and helpers described this as key to the programme’s success.

It of course helped me, the conversation, to talk. You feel that a person is responsive to you … As long as you feel that someone is listening - allows you to talk, and listens to you - this is something good. This is something I was lacking, honestly … For me personally, this was half of the solution. [Participant-P2]

Some helpers expressed surprise at how easily participants shared:

Someone to listen to their pain – this is the thing that helps them most … They talk about things no one knows. You feel surprised by how quickly this happens. Honestly, there are people who said, ‘I did not tell anyone, my wife does not even know!’ That fast! What made this possible? [Helper-P7]

3.8. Linkage to organizations

Many cited it would be helpful for participants to connect with non-governmental organizations.

The program could guide them to organizations and give them an interest in finding support, and even friends. They would join organizations. In these, they would meet other people. [Helper-P6]

Organizations could also help with linkages to other resources.

She [the helper] tried to make me aware – I didn’t know my rights in France – she tried to help me with that … She told me that you have the right to social supports, social programs. [Participant-P4]

Online resources were shared to solve other problems.

Her problem was with work … she did not have a network. I told her you can find websites for babysitting. It was all in French … I showed her how things work in France. No one is going to knock on your door and say come, please, work for us. [Helper-P8]

One helper suggested that PM + could enhance social support by partnering with community organizations.

If there were a partner to PM+, like an organization [or cultural center] which could bring people together and introduce them, I think this would be a very important step. So the person could meet others and not feel alone. [Helper-P13]

3.9. Implementation challenges

Participants described being lonely, isolated and lacking trust. “I feel totally alone”[Participant-P9]. “No one around me wishes me well. So [with] my problems, I am the one who overcomes them.”[Participant-P12] This lack of trust extended to the refugee community: “There is no trust. Even among refugees, there is no trust. You empathize with them … These are people coming from Afghanistan to Paris walking. So these are people who are mentally unwell.” [Participant-P2]

Participants reported how structural factors beyond the scope of PM + made building social support difficult.

The policies for integration in France, I see them as very negative. They do not help people to integrate at all. It is so bad. Teaching the language, bad. Social support, bad. I feel like there is political interest to gather migrants in a particular area, so they stay isolated. [Helper-P13]

3.10. Strengths, limitations and suggestions

3.10.1. Role of relationships and the native language

One strength of the programme was the rapport established, in part because of use of the native language, which helped bridge cultural gaps and enable full expression.

Reflecting on a particular participant, a helper described the importance of rapport:

I really think that 60% or 70% of his improvement goes back to one reason, which was his need to talk to someone who understands him … when I would understand him and he would understand me. He was so happy. He started crying at the first time, he said, ‘It has been a long time since I emptied my heart and talk this way.’ [Helper-P13]

The importance of language was emphasized:

In French, we cannot understand anything. In Arabic, it was very clear. My French is more for saying hello or running errands. Not philosophical. [Participant-P1]

Language helped facilitate the link to culture.

I understand them … This is something that really, really helped. Another issue is religion, when they spoke of it, it made sense. The language was the principal component that led to the success of this intervention. The language and the proximity of culture. [Helper-P7]

Cultural references in Arabic helped clarify the curriculum:

‘One hand does not clap’, ‘Paradise without people is not worth stepping foot in’ [examples of Arabic proverbs]. Right away, they will say, right! They say, right! Because this saying or example, they understand it! They get it. Right away you reach the goal. Without explaining too much or taking too long or spinning in circles. [Helper-P7]

3.11. Comprehension of materials

Study staff agreed that the PM + materials were translated poorly and too literally.

I did not like this Arabic booklet … .Here is Session 5. I mean just look at this translation … Very weird. But I want you to see the session which shows you the introduction to the person you are interested in. Look at this term, tadakhol [invasiveness in Arabic]. [Helper-P7]

A supervisor described the helpers’ critiques of the translations:

They didn't like it – the translation – at all and they said many times that it was very badly done. And then this is when we said, OK … we worked on the translation … so they found out common terms to use, but it was very different from what was written in the protocol. [Supervisor-P11]

3.12. Expansion of PM + scope

• Desire for more sessions

The most common criticism was that PM + was too brief. Almost all participants suggested that the programme would benefit from more or longer sessions.

After it ended, they would say ‘Why is it only 5 sessions’? … I am sure they would say that there should be more sessions. [Helper-P7]

Yes, the hour went by fast. One hour a week was not enough. [Participant-P2]

I wanted it to be ten. Ten sessions would be fine. Because during that time we were going through a difficult period … and you suddenly abandon us after the five sessions. [Participant-P4]

Helpers and supervisors agreed: “I think the strategy of managing problems is very hard to be understood in [only] 5 sessions.”[Supervisor-P11] “Perhaps there [should] be more sessions, for one hour or more. Five sessions were not enough to solve all of the problems … Two times a week … no, no. I don’t think the frequency of meetings is effective … We ask them for time to implement what they learned … I would make it 1 hour only and add sessions. Maybe 7 or 8 sessions … An hour is okay – an hour and a half, if the person is not focused.”[Helper- P6]

Another helper described how he felt cut off:

There [should] be 7 or 8 sessions, I mean, why not? … Why not have 2 months and here you really leave the person when they are comfortable. You feel 5 weeks, [slaps hand], cut off. [Helper-P7]

• Expansion of programme content

As described earlier for the purpose of enhancing social support, interviews revealed interested in connect participants with organizations. “Add more sessions, try to find gyms, places that people like.”[Participant-P4] Suggesting that these places could be chosen by the participant. “It could be a river, or a library, or a gym.”[Helper-P13]

Some participants also described needing more tangible help, i.e. for housing (or employment).

I felt that this program helps with psychological problems but how can you solve psychological problems if the program does not solve these [heating, housing] problems. It would be better if the program solved housing problems too. [Migrant-P10]

Several helpers discussed expanding PM + to link to services. “Yes, this is really important. I imagine the center itself has this list [of organizations], but why not [provide it].”[Helper-P8]

3.13. Distress among the helpers

Interviews emphasized the distress experienced among helpers, due to working with migrants who had experienced trauma. Helpers described being frustrated about needing to distance themselves.

You need distance, because if you do not take distance, it will start to impact your life … I wanted to solve all of her problems. It affects you. So it started to affect me a lot. Every time I would see her, I wanted to cry. [Helper-P8]

Another helper described frustration with the limits of the intervention.

The hardest thing of the program was that you can both help them and you cannot help them … We had really tough cases … We were prohibited from our side to help anyone. Prohibited. This, this is very hard … You see someone who is really really really need of your help … And of course, the goal is not to give them the solution. The goal is that they can help themselves. [Helper-P7]

One supervisor reflected on balancing distance and empathy.

I don't know if you would call it empathy … We're using cognitive methods to get hold of a problem that is much more complex. And, to have this understanding, you have to get touched a little bit by the problem. You can't have a distance. [Supervisor-P14]

The supervision team reinforced the need for more psychological support for the helpers:

There was this time that I did two, almost three hours, of supervision … for their mental health … Some of the participants really touched the group [of helpers with] their history, and the reasons they fled. [Supervisor-P11]

Another supervisor noted that the attrition of the helpers who were trained was a reflection of their stress.

Of course there is stress in relation to the intervention … The proof [is] that there are several – half of the [recruited helper] group did not continue. [Supervisor-P15]

In one case a supervisor even offered to refer a helper for psychological care.

We had very, very difficult personal histories and quite challenging migration journeys … It was hard … I referred one helper to a psychological program … They could not stop thinking about the problems of the participant … He [the helper] would have nightmares. It was, it was very, very serious. [Supervisor-P11]

4. Discussion

This is the first study exploring the adaptation and implementation of PM + in Arabic language, among non-French speaking migrants in France (Tortelli et al., 2019). We found that implementation was feasible, and that Arabic-speaking migrants and study staff had predominantly positively reactions. A unique feature was our systematic investigation of each intervention component, which has not been reported in other assessments of PM + delivery (Acarturk et al., 2022; Coleman et al., 2021; de Graaff et al., 2020; Ghimire & Shrestha, 2021), and that facilitated refined recommendations about the programme content.

Breathing relaxation exercises were well-liked and considered easy to learn and teach. In fact, many participants described continuing to practice and integrate these techniques into multiple facets of their lives. Choosing problems to work on and the implementation of strategies to address one’s problems were considered beneficial, but that were also viewed as challenging to execute. Migrants considered the cycle of inactivity to be highly relevant, but linguistic and social isolation and poor linkage to community organizations were barriers to breaking that cycle. Regarding social support, participants highlighted the relationships they built with intervention helpers, which were bolstered by use of the native language.

Other studies implementing PM + among Arabic-speaking refugees in European countries, including the Netherlands, Switzerland, and Turkey, have also found that PM + is largely perceived as feasible, acceptable, and safe among participants (Acarturk et al., 2022; de Graaff et al., 2020; Sijbrandij et al., 2020; Spaaij et al., 2022). In these studies, most participants stated that they had benefited from the programme across various domains including improvements in mental health symptoms (de Graaff et al., 2020; Sijbrandij et al., 2020), increased capacity to deal with their problems (Acarturk et al., 2022; Sijbrandij et al., 2020), knowledge of how to cope with adversity (Sijbrandij et al., 2020; Spaaij et al., 2022), as well in social interactions (Sijbrandij et al., 2020).

While our study assessed a pilot of PM+, another qualitative assessment of PM + has noted similar positive feedback from participants regarding its content and the delivery of PM + by Arabic-speaking helpers (de Graaff et al., 2020). For example, in the implementation of PM + in the Netherlands, helpers noted that participants felt more confident about PM + after applying a learned strategy for the first time (de Graaff et al., 2020) – likewise, we found migrants reported more confidence and ease using the breathing techniques after more experience with them. This is consistent with our finding that participants expressed that PM + sessions were positive for their overall well-being.

Participants and helpers emphasized that delivery of sessions in the native language was critical (Acarturk et al., 2022; Alozkan Sever et al., 2020; Coleman et al., 2021). Similarly, rapport was established between helpers and Syrian refugee participants during PM + implementations in the Switzerland and in the Netherlands, particularly due to the ability to speak openly in Arabic (de Graaff et al., 2020; Spaaij et al., 2022). While our participants emphasized the significance of building a relationship with their helpers, shared ethnic background between participants and helpers (i.e. Syrian) in the Netherlands caused initial apprehension and was reported to have led to increased distrust and calls to ‘professionalize’ the helpers (de Graaff et al., 2020). This aligns with findings from PM + implementation among Syrian refugees in Switzerland, highlighting potential barriers to implementation e.g. mental health stigma and feelings of distrust (Balidemaj & Small, 2019). Therefore, having a diversity of helpers with various ethnic backgrounds (i.e. different from that of the participant), as in the case of our pilot, could be useful to mitigate potential distrust of disclosure to someone with a shared ethnic identity.

From the helper perspective, there continued to be gaps in the PM + protocol that are substantial, including poor translation of the PM + guide, which required additional time from helpers to come up with adequate Arabic phrases and idioms. One possible reason is that there were differences in the Arabic spoken depending on country of origin and education level. Adaptations of PM + in other contexts, (e.g. Rwanda, Peru, Malawi), have also recommended modifying the language (including idioms), images, and diagrams used in the PM + protocol to fit participant literacy level (Alozkan Sever et al., 2021; Coleman et al., 2021).

Our helpers also noted the large responsibility they felt in delivering PM + and reports of distress experienced vicariously while providing PM + sessions, highlighting the need for supervision by a psychologist. To our knowledge this has not been reported in other studies. Also, due to lack of formal health care training, some helpers may have had trouble establishing boundaries with the participants, who shared migrant background and were in the role of a participant’s ‘peer’.

Participants suggested increasing the number of sessions and to be given additional forms of support and guidance (i.e. linkage to social organizations for housing or social connections), in the cycle of inactivity intervention component. Indeed, PM + was first used in humanitarian camps where social resources are scarce. However, this context– where social resources are accessible and participants are operating in a foreign language – adjustments of the intervention are called for. While more sessions may substantially improve trust between helpers and PM + participants (an issue that has been flagged in the implementations of PM + in other contexts (Tortelli et al., 2019)) deeper involvement may also lead to further helper distress; leading some to emphasize distance for maintaining boundaries in intervention delivery (Acarturk et al., 2022; de Graaff et al., 2020; Spaaij et al., 2022). These findings may reveal the limits of such intervention to manage stress over time and the need of a higher-level accessible psychological support.

One main study limitation was the inclusion of only a small number of migrants, including only two women. Nonetheless, we were able to gather complementary perspectives from PM + supervisors and helpers. These perspectives allowed us to also gain information about aspects of programme delivery that participants would be unable to comment on (e.g. the quality of the materials, training needs, mental health needs of helpers, etc.). Given the small number and diverse backgrounds of the participating migrants (e.g. country of origin), we were unable to capture differences in the needs of the programme across different Arabic-speaking cultural groups. Another limitation could have been social desirability bias in participants’ responses. We found that participating migrants tended to be very positive about the programme and made very few comments about difficulties or dislikes about it (even when solicited), which may have in part had to do with their feeling grateful for being included in the programme, making them reluctant to criticize it. The fact that PM + can deliver psychological support feasibly and acceptably in accommodation centres (rather than in mental health facilities), supports the fact that such interventions complement local mental health care offered, rather than replace it.

In summary, results of this pilot study in metropolitan Paris strongly suggest benefits of implementation of PM + among Arabic-speaking migrants with mental distress and that it should be extended to other languages. The programme was considered useful, but migrants desired a longer intervention with a broader scope (including linkage to service organizations), suggesting adjustments in the intervention tools for use in contexts where more resources are available. Results reveal difficulties in language translation due to different education levels and origins. Finally, more psychological support should be offered to the helpers delivering the intervention. Future studies are needed to establish the effectiveness of PM + in this population as well as with women and in other migrant groups.

Ethical approval

The pilot study was approved by the French Committee for Personal Protection – Sud Est V (No. ID RCB: 2019–A02251-56).

Acknowledgements

We are very thankful to the staff of the two centres where the study was conducted. Two emergency shelters for asylum seekers (HUDA) administered by Habitat et Humanisme participated in the study as recruitment centres: HUDA Montrouge and HUDA La Villette. HUDA Montrouge was established in 2018 and offers 156 beds. HUDA La Villette has been operating since 2020 and offers 90 beds. The other site, Lumières du Nord (Association Aurore), is an emergency shelter in central Paris that offers 350 beds to persons who are homeless. Most of its residents are foreigners and have had long migratory journeys, often punctuated by various stressful experiences and traumas.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This article was supported by a FIAS fellowship at the Paris Institut d’études avancées de Parise for Advanced Study (France). It has received funding from the European Union’s HORIZON EUROPE Marie Sklodowska-Curie Actions 2020 research and innovation programme under the Marie Skłodowska-Curie grant agreement No 945408, and from the French Collaborative Institute on Migration State programme “Investissements d’avenir”, managed by the Agence Nationale de la Recherche Régionale de Santé Île-de-France Nationale de la Recherche (ANR-11-LABX-0027-01 Labex RFIEA+). Funding for the APEX project was obtained from the Ile de France Regional Health Agency (Agence Régionale de Santé), the French Collaborative Institute on Migration (ICM), the Sanofi Espoir Foundation, Fondation de France and in association with Habitat et Humanisme.