For this pilot study, around 600 Afghan refugees will be recruited in Istanbul, Turkey, through advertisements on social media and posters distributed in neighborhoods with large populations of Afghan refugees. Those interested in the program will be randomly
assigned to (1) a manualized Cognitive Behavioral Therapy (CBT) training that teaches coping and emotion regulation skills, (2) an Islamically integrated version of CBT, (3) traditional Islamic sermons on spiritual coping and healing without CBT structure, or (4) a waiting control condition. The sample will include male and female participants. However, due to cultural issues, there will be separate sessions for men and women. As a result, the assignment will through block randomization based on gender.
The CBT condition combines elements from the WHO Self-Help Plus program and START NOW, both psychoeducation programs designed for refugees. START NOW is a cognitive behavioral therapy that integrates building blocks from dialectical-behavioral therapy and acceptance commitment therapy. Originally developed for correctional environments, by Professor Robert Trestman at the University of Connecticut, it has been adapted for use in other settings that face similar resource constraints and an extensive need for effective, reliable, and manual-guided treatment for teaching emotion regulation and coping skills. The program is offered as a group-based training and includes four units: (1) dealing with stressors, (2) understanding and coping with emotions and feelings, (3) building relationships, and (4) setting and reaching goals. The self-Plus program, designed by WHO, focuses on relaxation and emotion regulation skills. In addition, the CBT condition will also include two units on compassion training (Germer and Neff 2019), focusing on skills to mitigate self-blame and promote positive emotions toward others.
The Islamically integrated CBT is modeled after the standard CBT intervention and follows the same structure but incorporates Islamic traditions for coping and healing. It includes the same elements of START NOW, Self-Help Plus, and compassion training. The standard START NOW program teaches relaxation techniques (such as breathing and muscle relaxation) and focuses on cognitive restructuring and positive thinking to help participants evaluate and correct negative cognitions and thoughts that lead to negative emotions. The Islamically integrated CBT teaches relaxation through religious meditation and prayer. For cognitive restructuring and positive thinking, the Islamically integrated version relies on Islamic teachings such as trust in God, patience, and appraising adverse events as opportunities for spiritual growth. In addition, examples of Prophet Mohammad and other Prophets, mentioned in the Quran, who experienced involuntary migration will be used as role models for reinterpretation of adverse conditions and cultivating compassion toward others.
The third group will receive traditional Islamic sermons that discuss Islamic teachings for dealing with adverse conditions. The themes include patience, trust in divine providence, prayer, and seeking divine support and compassion toward others. This treatment arm is delivered as sermons--the same format as Muslim clerics deliver a speech in religious ceremonies--and will lack the CBT structure. The sermons do not include the discussion and exercise of coping skills.
To standardize the format of the three treatment arms and only vary the contents, all three groups will receive seven sessions. The PI has developed manuals for all three treatment arms and has pre-recorded a 30-minute video for each session. For CBT and Islamically integrated CBT, Each video discusses the main coping techniques and exercises discussed in the manuals. Videos will be played by trained facilitators who will help participants practices the exercises discussed in each video. Each session is expected to last between 45 to 60 minutes. Each video for the traditional sermon is also around 40 minutes, but there will be no discussion or practice of coping skills in this treatment arm. Since the contents in all three treatment arms are presented by the same individual (PI) and only the contents vary, the three treatment arms are relatively comparable.
The fourth group will not receive any treatment initially in order to provide comparable control groups. To avoid withholding treatment from those in need of counseling, however, those assigned to the control condition will also be provided the standardized CBT training within 12 to 18 months after the treatment groups complete their sessions and the second wave of the survey has been completed. Nonetheless, to control for the impact of financial compensation on the outcomes of interest, the control group will receive the same financial compensation at the same time as the three treatment arms.
There was a modification to the intervention after the baseline survey and registering the participants. Our final sample included 350 women and 250 men. Because of the smaller sample size of male participants, we removed the traditional sermons condition for men. Please see the document titled "Pre-Analysis Plan Modification 1" for details.