
==== Front
Res Psychother
RIPPPO
Research in Psychotherapy : Psychopathology, Process, and Outcome
2499-7552
2239-8031
PAGEPress Publications, Pavia, Italy

39221907
10.4081/ripppo.2024.796
Article
Trauma focused-cognitive behavioral therapy training effectiveness in promoting professional development of psychotherapists working with unaccompanied minors in Greece: a non-blinded randomized control trial
Yotsidi Vasiliki
Anastasiou Theodora
Doulgeris Konstantinos
Theodosiou Panagiota
Richardson Clive
Contributions: VY, conceptualization, methodology, resources, writing - original draft, writing - review & editing, supervision, project administration. TA, methodology, investigation, data curation, formal analysis, writing - original draft. KD, visualization, resources, writing - original draft. PT, investigation, data curation, formal analysis. CR, formal analysis, writing - review & editing, supervision. Department of Psychology, Panteion University of Social and Political Sciences, Athens, Greece
Department of Psychology, Panteion University of Social and Political Sciences, 136 Andreas Syngrou Avenue, 17671 Athens, Greece. v.yiotsidi@panteion.gr
Conflict of interest: the authors declare no potential conflict of interest.

Ethical approval and consent to participate: ethical approval was obtained from the Research Ethics Committee of Panteion University of Social and Political Sciences (approval number: 40/4-10-2023). The study was conducted following the principles outlined in the Declaration of Helsinki.

Consent for publication: All participants provided written informed consent before participating in the study through Google Forms.

Citation: Yotsidi, V., Anastasiou, T., Doulgeris, K. Theodosiou, P., & Richardson, C. (2024). Trauma focused-cognitive behavioral therapy training effectiveness in promoting professional development of psychotherapists working with unaccompanied minors in Greece: a non-blinded randomized control trial. Research in Psychotherapy: Psychopathology, Process and Outcome, 27(2), 796.

Publisher’s note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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The need to develop psychotherapists’ skills to respond to current treatment challenges, such as addressing trauma due to the refugee crisis, is increasing. However, there is a dearth of evidence-based training for psychotherapists who work with refugees, especially in frontline countries. A randomly selected sample of 80 clinicians working with unaccompanied minors (UAMs) in Greek accommodation centers nationwide participated in an intensive trauma-focused cognitive behavioral therapy (TF-CBT) training (n=44) or a control-group (n=36) and completed the Professional Quality of Life Scale, the Work and Meaning Inventory and a questionnaire to assess knowledge and therapeutic skills, in pre-and-post measurements. Clinicians with 1-3 years of experience with refugees reported higher burnout (p=0.012, M=25.78 vs M=22.04) and secondary traumatic stress than those with less than a year (p=0.014, M=22.03 vs M=18.04). Positive meaning at work increased in both groups at post-test (TF-CBT group: p=0.019, M=15 vs M=13.6, and control group: p<0.001, M=15.17 vs M=13.42). The TF-CBT training group outperformed the control group in knowledge and skills (p=0.021, M=10.15 vs M=8.75) and identified a lower number of children with post-traumatic stress disorder symptoms (p=0.009, M=6.94 vs M=4.33) post-training. This study provides preliminary evidence on TF-CBT training effectiveness in equipping psychotherapists to work with UAMs, while their professional quality of life warrants further research.

Key words

training effectiveness
trauma-focused CBT
professional quality of life
burnout
unaccompanied minors
==== Body
pmcIntroduction

As the field of psychotherapy is constantly evolving with new research data to support clinicians’ practices empirically, continuing education (CE) of psychotherapists is necessary to take place throughout their career (Orlinsky et al., 2024; Rønnestad et al., 2019). Psychotherapists need to receive CE regularly to feel competent, up to date, and well-equipped in their practice (Bradley et al., 2012; Rief, 2021). Furthermore, effective training in psychotherapy is of utmost importance in achieving positive clinical outcomes (Valenstein-Mah et al., 2020). However, mostly nested within the theoretical assumptions of different psychotherapy schools of thought, little congruence has been achieved about the effectiveness of different training methods and modules in psychotherapy (Orlinsky et al., 2024; Rief, 2021). Thus, effective psychotherapy training still holds a large room for improvement and requires continuous research, especially regarding the provision of treatment services to vulnerable populations with complex psychosocial needs (Asfaw et al., 2020; Frank et al., 2020).

The existing substantial empirical data on evidence-based psychotherapies as well as characteristics of effective psychotherapists can help to guide clinical practice through CE (Heinonen & Nissen-Lie, 2019; Rief, 2021; Rønnestad et al., 2019). Specifically, regardless of the teaching modality (i.e., online vs in-person), active training conditions of teaching evidence-based treatments (EBTs) to mental health professionals lead to increased knowledge gains and adherence to the therapeutic model compared to self-guided training or no training (Valenstein-Mah, 2020). Psychotherapists’ own perspectives and the creation of connections with a network of trained therapists have been linked to increased evidence-based practice (Motamedi et al., 2021). High-quality training programs that incorporate EBTs have also included common therapeutic factors and therapists’ interpersonal capacities (Heinonen & Nissen-Lie, 2019). Furthermore, positive attitudes towards an EBT have been found to increase post-training engagement through consultation-seeking regarding the intervention (Nelson et al., 2012). On the other hand, psychotherapists’ competence, and willingness for future adoption of the therapeutic model have not been found to directly stem from effective training in EBTs (Valenstein-Mah, 2020), as other contextual factors may intervene, such as large caseloads and productivity requirements (Pemberton et al., 2015). To deal with practical barriers, online training modalities have gained prominence as an accessible and flexible method for professional development (Mikkonen et al., 2024). Recent research (Baumann et al., 2023) suggests that online psychotherapy training is at least as effective as in-person training in addressing gaps in evidence-based practice.

Despite the current evidence on psychotherapy training effectiveness, the literature highlights a lack of evidence-based training regarding the implementation of therapeutic interventions to populations with distinct needs (e.g., culturally diverse young people with trauma), paralleled by therapists’ inadequate knowledge and skills in providing the necessary specialized care to these groups (Münz & Melcop, 2018). Moreover, Courtois and Gold (2009) noted a deficiency in the content related to traumatic stress within the clinical training programs of psychologists and other mental health disciplines. The absence of controlled trials of post-traumatic stress disorder (PTSD) in refugee populations (Nickerson et al., 2011) may lead to a tendency to avoid addressing trauma as empirical support is lacking, thus leaving people in need of therapy untreated. Hence, researchers have emphasized the critical importance of integrating trauma-related education into professionals’ clinical training curricula, as this will better equip them to effectively work with individuals who have experienced trauma (Courtois & Gold, 2009). However, training in evidence-based psychotherapy for clinicians who work primarily with refugees in front-line countries is still an underdeveloped field (Bunn et al., 2023).

A widespread lack of familiarity with forced migration phenomena and its implications across refugee contexts poses significant barriers to effective healing processes (Bunn et al., 2023; Shannon et al., 2015). Existing research indicates that a substantial number of mental health providers lack the required knowledge and skills to effectively engage in cross-cultural interactions with individuals from diverse cultural backgrounds, thereby demonstrating a deficiency in cultural competence (Bunn et al., 2023; Chu et al., 2022). According to Asgary and Segar (2011), mental health professionals who have not attained cultural competence face serious challenges in establishing effective therapeutic relationships with their patients. Along with aiming to increase psychotherapists’ cultural competence (Kirmayer, 2012), psychotherapy training to mental health professionals working with refugees should focus on developing therapeutic skills including the establishment of trusting relationships with patients, early identification of mental health needs, proactive resolution of diverse barriers, and effective collaboration with different healthcare providers. Furthermore, they emphasized the critical importance of educating psychotherapists in evidence-based treatments for trauma, along with cultivating a nuanced understanding of the political and cultural contexts from which different refugee groups originate (Shannon et al., 2015). In front line host countries, such as Greece, a particular group facing extremely adverse life conditions are unaccompanied refugee children (Höhne et al., 2022), namely Unaccompanied Minors (UAMs). Despite UAMs’ heightened needs and vulnerability, there is currently a lack of guidelines and best practices to be used by psychotherapists who work with this youth group (Foka et al., 2021).

The existing gap in evidence-based specialized training for psychotherapists who work with refugees is in contrast with findings indicating that psychotherapists who work with traumatized individuals are more prone to feeling distressed, and develop anxiety and depressive symptoms, as well as PTSD (Ray et al., 2013). Burnout and secondary traumatic stress (STS) are two pertinent factors that either exacerbate these symptoms or stem from them (Bourke & Craun, 2014). Specifically, STS can result from indirect exposure to traumatic events, and it pertains to the transference of one’s traumatic symptoms to another person (Bourke & Craun, 2014). It also has a negative effect on the personal and working life of psychotherapists as well as on the effectiveness of the therapeutic services they provide (Hensel et al., 2015). Likewise, burnout consisting of feelings of emotional exhaustion, inability to work, and depersonalization is often manifest in stressful work situations, such as providing therapy to people who face several risk factors (Cieślak et al., 2014). Thus, there is a growing need to enhance psychotherapists’ skills to effectively address prevalent treatment challenges, notably trauma resulting from the refugee crisis (Bryant et al., 2023), not only with the aim to respond better to their patients’ mental health needs but also to promote therapists’ mental wellbeing and professional development.

In recent years, certain evidence-based psychotherapies have begun to be implemented in humanitarian crisis settings (AbdulHamid et al., 2021; Oberg & Sharma, 2023). Consequently, several mental health and psychosocial support programs have been developed and administered by clinicians to refugee populations (Della Rocca et al., 2024). A promising psychotherapy approach that has been internationally applied to young refugee populations is the Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) that was originally developed by Cohen, Mannarino, and Deblinger to provide a comprehensive, short-term treatment for children and adolescents who have experienced trauma (Cohen & Mannarino, 2008; Lewey et al., 2018). TF-CBT is considered a component-based, evidence-based treatment protocol that incorporates individual and conjoint family sessions (Chipalo, 2021).

Typically spanning 12-16 sessions, TF-CBT’s components are adaptable to effectively address the needs of each individual and their caregivers (Jensen et al., 2022). The therapy is comprised of three phases: stabilization, trauma narrative, and integration/consolidation. TF-CBT’s core elements are encapsulated in the acronym PRACTICE, which outlines its primary objectives: Psychoeducation, Parenting skills, Relaxation skills, Affective modulation skills, Cognitive coping skills, Trauma narrative, Cognitive processing of traumatic events, In vivo mastery of trauma reminders, Conjoint child-parent sessions, and Enhancing safety and future development trajectory. Generally, the results on the implementation of TF-CBT in youth have been positive (Chipalo, 2021; Lewey et al., 2018; Unterhitzenberger et al., 2015). However, research on the effectiveness of TF-CBT specifically for UAMs remains primarily limited to case studies, or studies with small sample sizes (Unterhitzenberger et al., 2015, 2019). Moreover, the effectiveness of TF-CBT training is also understudied. The adoption of control groups in studies aiming to assess psychotherapy training changes is essential (Tribe et al., 2017), especially with regard to refugee populations.

Based on the evidence gleaned so far, this nonblinded randomized controlled trial (RCT) aims to evaluate the effectiveness of Greek psychotherapists’ training on TF-CBT for UAMs. In accordance with best practices for transparency and reproducibility, the present RCT study was registered on the Open Science Framework (OSF). Psychotherapists engaged in working with refugees within accommodation centers in Greece are usually recent graduates and less experienced. This may be due to the increased number of UAMs in recent years and the urgent need to provide them with psychosocial support, but also because of the challenging working conditions in the Accommodation Centers that may attract mental health professionals with fewer qualifications (Apostolara et al., 2023; Yotsidi & Anastasiou, 2022). Thus, it was considered necessary to provide front line therapists with evidence-based psychotherapy training to promote their professional development in the field as well as to equip them with adequate therapeutic skills that may assist them to tackle the clinical challenges and demanding working conditions in providing mental health services to UAMs (Yotsidi, & Anastasiou, 2022). This study is part of an ongoing RCT aimed at assessing the effectiveness of TF-CBT within a cohort of UAMs in Greece in the framework of a PhD research protocol (Anastasiou et al. 2024).

Research aims and hypotheses

Aims

Assess the effectiveness of online intensive TF-CBT training in terms of knowledge and skills (e.g., diagnosis of PTSD symptoms) in a sample of psychotherapists working in refugee accommodation centers nationwide.

Assess the role of online intensive TF-CBT training on psychotherapists’ burnout, STS, and meaning in work.

Assess the role of psychotherapists’ prior work experience and prior psychotherapy training in burnout, STS, and meaning in work.

Hypotheses

TF-CBT and trauma-related knowledge is increased in the TF-CBT training group compared with the control group.

PTSD diagnoses are reduced in the TF-CBT training group compared with the control group.

TF-CBT training is related to therapists’ STS levels and meaning at work.

Years of clinical experience with refugee population and prior psychotherapy training is related to psychotherapists’ burnout, STS, and meaning in work.

Methods

Participants

Overall, 114 psychologists providing psychotherapy in 66 refugee accommodation centers of the total number of 21 relevant organizations in Greece agreed to participate in the study. The inclusion criteria were for participants to be psychologists providing psychotherapy to UAMs and providing a written consent form to participate in the study. For the purposes of the RCT study, the stratified sampling method was utilized, based on the specific geographic area where the refugee accommodation centers were located as well as the total number of therapists working in each setting. The stratification strategy led to the formation of an intervention group (n=60), which would receive the TF-CBT training, and a control group (n=54), which would receive no training and continue providing treatment as usual (TAU). That is, the standard care typically provided at the Accommodation Centers in Greece as part of routine care, including weekly sessions of non-specific, brief, supportive counseling, which mainly involve general support, active listening, and non-directive problem-solving. The randomization procedure of the population of the study is depicted in Figure 1.

From the total number of the initial group, 87 psychotherapists continued and 80 of them were enrolled either in the intensive TFCBT training (n=44) or the control-group (n=36) and completed the pre-training assessment. Half of them (i.e., 40 participants) completed the post-training assessment, and thus pre-and-post analyses were conducted. The majority of the participants (78%) were women, and almost half (49%) were aged 26-30 years old. Most of them worked in the city of Athens (47%), followed by those working in Thessaloniki, Northern Greece (13%) and in the Aegean Island of Lesvos (11%), while the rest were in other regions across the country. Participants had a bachelor’s (47.5%) or held a master’s degree (40%) in psychology, while 2.5% had a PhD. A percentage of 40% of the therapists reported having one to three years of clinical experience overall, while 28% had less than a year. Almost half of the participants (52%) had one to three years of clinical experience with refugees and 20% of them had less than a year. A percentage of 44% did not have previous training in any therapeutic approach prior to TF-CBT training, 42% were currently trained in another therapeutic approach, and 14% had completed mainly CBT or systemic–family therapy training before their involvement in TF-CBT training.

Procedure

The present study was conducted in cooperation with the SOS Children’s Villages of Greece, and the General Secretariat of Vulnerable Citizens and Institutional Protection of the Greek Ministry of Migration and Asylum, via the Mental Health Hub project. The study has received permission from the Research Ethics Committee of Panteion University of Social and Political Sciences (approval number: 40/4-10-2023). Furthermore, as is foreseen for any intervention in UAMs residing in Accommodation Centers in Greece, the Supreme Civil and Criminal Court of Greece and Prosecutors of Athens and Thessaloniki was informed of the study through a letter (protocol number: 155681) sent on 15.3.2023 by the General Secretariat for Vulnerable Persons and Institutional Protection of the Ministry of Migration and Asylum of Greece. Also, all the individual agencies participating in the study gave consent for their participation through the Scientific Officers of each agency. All participants were initially informed about the broader study protocol (i.e., 2-day intensive training in TF-CBT, team supervision sessions every 2 weeks, providing TF-CBT therapy to UAMs with PTSD symptoms, etc.) before their consent was formally asked for participating in the study. An individual anonymous code was used by each participant to enable comparisons between pre-and-post measurements.

Study phases

The study consisted of two phases. First, the 2-day intensive training on TF-CBT for the psychotherapists in the intervention group, and an informative session about the broader study procedure on the control group were conducted. The TF-CBT training took place in two 8-hour online sessions via Zoom platform. During the training, which was conducted by the second author who is an experienced certified CBT therapist and trainer specialized in TF-CBT, the theoretical framework of TF-CBT was presented, emphasizing each of its components, as these are encapsulated in the aforementioned acronym PRACTICE. The training program was meticulously designed to impart a comprehensive, step-bystep framework for implementing the therapeutic protocol, which also put emphasis on developing common therapeutic competencies such as active listening, empathy, and establishment of trusting relationships with patients. Each module concluded with a dedicated session that addressed potential therapeutic challenges, cultural considerations, and adaptations necessary for the therapeutic process. To enhance the assimilation of the information taught, team exercises and role-playing between the participants were included. Furthermore, case studies were presented and worked on via break-out sessions. Time was also dedicated to addressing questions and concerns regarding the treatment model.

Figure 1. Flowchart of random assignment of participants.

During the first day of the training, all sections up to the trauma narration were taught, leaving the rest for the second day.

The study included pre-and-post measurement before and after the TF-CBT training, respectively. All participants in the intervention group and the control group completed the same measures at specific time points for between-groups comparisons to be possible. The pre-test took place on the first training day prior to the commencement of the training process. Meanwhile, practitioners in the control group were informed in advance about the evaluation process and received the assessment via email simultaneously. One week following the end of the training, all participants received an email reminder prompting them to complete the post-assessment. The pre-and-post training assessments were conducted online via Google Forms. The effect of TF-CBT training on psychotherapists was examined in terms of TF-CBT and trauma-related knowledge and skills (primary outcome) and several variables pertaining to professional quality of life (secondary outcome), including STS, burnout, and meaning-making from work. The assessment included two self-report questionnaires about professional quality of life, and a custom-made questionnaire concerning participants’ knowledge about TF-CBT and trauma, based on the relevant literature (Appendix 1). The sequence of the administered questionnaires was different during each phase, to limit the effects of learning and memory. In addition to the baseline (pre-training) and post-training assessment, a third post-prevention measurement at the end of the implementation of TF-CBT therapy intervention was also foreseen. However, this has not been completed yet, as the broader RCT study of TF-CBT effectiveness in UAMs is in process. Nevertheless, during the implementation of TF-CBT in the intervention group, 2 hours of clinical supervision is provided fortnightly. Supervision includes consultation about therapeutic challenges and obstacles as well as cultural adaptations to the TF-CBT model. The control group also meets with the researcher monthly, to provide updates on the clinical status of their cases. TAU consists of routine clinical management provided at the accommodation centers, in non-directive supportive conditions. Interpreters are available to all psychotherapists throughout the intervention for their TF-CBT sessions.

Measures

Professional Quality of Life scale

The Professional Quality of Life Scale-5 (ProQol-5) is one of the well-known assessment tools concerning professional quality of life (Hemsworth et al., 2018). It includes Compassion Satisfaction (CS) and Compassion Fatigue (CF) subscales. Compassion Fatigue is also comprised of two concepts: Burnout (BO) and Secondary Traumatic Stress (STS) (Hemsworth et al., 2018). Its convergent and discriminant validity have been found to be adequate (Hemsworth et al., 2018). It has been suggested that the BO and STS scales be revised in future psychometric improvements, mainly due to coding considerations (Hemsworth et al., 2018). The 5th version has been translated and adapted for use in Greek populations, where its reliability and validity were found adequate (Misouridou et al., 2021). The subscales and the total ProQOL–5 scale showed adequate reliability in our study, as Cronbach’s alpha was greater than .70 for each one.

Work and Meaning Inventory

Meaning is considered a significant component of work, and as such it has been examined through suitable psychometric tools when professional and organizational needs are assessed in recent years (Puchalska-Kamińska et al., 2019). The Work and Meaning Inventory (WAMI) scale measures the meaning that work provides to a person, through a set of three criteria: positive meaning, greater good motivations, and meaning making through work (Steger et al., 2012). These criteria compose the three subscales of WAMI, and a three-factor structure has thus been proposed for this inventory (Steger et al., 2012). Validity and reliability measurements have shown adequate results (Puchalska-Kamińska et al., 2019; Steger et al., 2012). The WAMI was translated and adapted to the Greek language for this study (Appendix 1). Cronbach’s alpha was found to be high for the Meaning Making Through Work subscale and total score, but it was lower than the acceptable threshold (.70) for the Positive Meaning and Greater Good Motivations subscales (Appendix 2).

Knowledge and skills about trauma and Trauma-Focused Cognitive Behavioral Therapy Questionnaire

A Knowledge and Skills about Trauma and TF-CBT Questionnaire was developed for the purposes of this study (Appendix 1). This questionnaire mostly reflected existing TF-CBT knowledge and skills questionnaires, but it was modified to adjust to the current UAMs’ conditions (e.g., no caregivers). Particularly, it was based on relevant German questionnaires administered to therapists trained online in TF-CBT for children and adolescents by the Catholic University of Eichstätt-Ingolstadt. A few questions were taken verbatim and translated into Greek, and some questions were added as new ones by the researchers, based on the relevant literature on refugee trauma and TF-CBT. The questionnaire consisted of 24 questions (i.e., 23 multiple choice and 1 right/wrong). Each TF-CBT component was represented in at least one of those questions.

Demographics

A short questionnaire for the participants’ demographics included their gender, age, years of clinical experience, level of education, marital status, previous psychotherapeutic training, number of clients per day, and psychotherapeutic experience with trauma. These questions were asked only once, during the pretraining assessment phase.

Statistical analysis

Quantitative variables were presented as mean values (SD). Qualitative variables were expressed as absolute and relative frequencies (N, %). All continuous variables were tested for normality assumption using Kolmogorov-Smirnov and Shapiro-Wilk tests. Participants’ characteristics on pre-measurement were compared using the parametric t-test for independent sample and the non-parametric Mann-Whitney test. To assess the differences between pre-test and post-test, paired sample t-test and Wilcoxon signed-rank test were computed. Post hoc power calculations using the G*Power program (version 3.1.9.4) (Faul et al., 2007) showed that, given the achieved sample size in the post-training comparison, a population effect size of 0.95 would be required for detection at the conventional power level of 80% in an independent samples t-test with a 5% significance level. Given the pre-training sample sizes of 44 and 36, moderate effect sizes of 0.64 would have been detected with this power. Pearson and Spearman correlation coefficients were used to evaluate the relationships between continuous variables. One-way ANOVA analysis of variance was applied to investigate the relationship between the independent variable training in therapeutic approach and STS. Statistical analyses were performed using IBM SPSS Statistics 25.0. All the statistical tests were two-sided and were performed at a .05 significance level.

Results

Pre- and post-measurement differences between active and control conditions

Primary outcomes

Therapists participating in the TF-CBT training group performed better at the post-measurement in the Knowledge and Skills Questionnaire (i.e., increased number of correct responses) than the control group (p=0.021, M=10.15 vs M=8.75). In contrast, as shown in Table 1, a significant decrease was observed in correct responses in the control group at the post-measurement (p=0.017, M=11.08 vs M=8.75). Additionally, after the training, psychotherapists in the TF-CBT training group reported a lower number of children with PTSD symptoms in their clinical practice (p=0.009, M=6.94 vs M=4.33) compared to the corresponding estimated number prior to the training, while no significant difference was found in the control group (Table 1).

Secondary outcomes

A comparison between pre-post measurements showed an increase in Positive Meaning, indicating a greater sense of purpose in the psychotherapists’ work, in both the TF-CBT training group (p=0.019, M=15 vs M=13.6) and the control group (p<0.001, M=15.17 vs M=13.42). Although non statistically significant, lower levels of secondary traumatic stress and a slight increase in compassion satisfaction were reported by therapists in the TFCBT training group after their training (Appendix 2, Table 6).

Professional quality of life in relation to therapists’ profile

Significant differences emerged between demographic groups of therapists in the study. Women overall reported higher burnout levels than men (M=25.09 vs M=21.79, p=0.027). Participants with less than a year of experience with refugees reported higher meaning making through work compared to those with more than four years of experience (M=12.80 vs M=10.83, p=0.040). Additionally, participants with a university degree exhibited slightly higher burnout and STS, while those with a postgraduate (Master’s) or PhD degree had a higher score on the compassion satisfaction scale.

A one-way ANOVA analysis revealed no statistically significant difference in STS levels among participants based on their training in a therapeutic approach previous status (i.e., completed, in progress, or none) [F (2, 77)=2.577, p=0.083] (Appendix 2). However, when the completed and in progress training categories were combined and compared to the no training group, the t-test for independent samples showed a statistically significant and pronounced difference of 2.7 scale points [t (78)=2.064, p=0.042, Cohen’s d=0.911]. Specifically, therapists with completed or ongoing training had on average significantly lower STS than those without training in a therapeutic approach (M=18.8, SD=5.3 and M=21.5, SD=6.6, respectively).

Correlates of therapists’ professional quality of life

Therapists with high levels of compassion satisfaction tended to experience their work as meaningful. Conversely, therapists reporting high levels of burnout tended to perceive an absence of meaning in their work. In particular, as shown in Table 2, a significant positive correlation was found between the CS scale and the WAMI scales (Positive Meaning: r=0.673, p<0.001, Meaning Making Through Work: r=0.611, p<0.001, Greater Good Motivations: r=0.558, p<0.001, Overall score: r=0.729, p<0.001). In contrast, there was a significant negative correlation between the Burnout scale and the WAMI scales (Positive Meaning: r=-0.528, p<0.001, Meaning Making Through Work: r=-0.473, p<0.001, Greater Good Motivations: r=-0.464, p<0.001, Overall score: r=-0.580, p<0.001). No significant correlation was observed between the Secondary Traumatic Stress scale and the WAMI scales. Notably, a significant negative correlation was found between the CS scale and the number of correct responses (r=-0.236, p<0.05). That is, a higher level of compassion satisfaction was associated with a lower number of correct responses in the Knowledge and Skills Questionnaire.

A linear regression analysis was conducted to explore whether demographic factors (i.e., gender, years of clinical experience with refugee population, number of clients) may influence ProQOL scales (Table 3). No significant association was found between compassion satisfaction and demographic characteristics. Therapists with 1-3 years of experience with refugees reported higher burnout (p=0.012, M=25.78 vs M=22.04) and secondary traumatic stress than those with less than a year (p=0.014, M=22.03 vs M=18.04). Furthermore, therapists with less than a year of experience with refugees had lower burnout than those with more than four years (b=-3.172, p=0.041). In addition, it was found that therapists who treated 1-5 UAMs had lower secondary traumatic stress score than those who treated more than 10 UAMs per day (b=-3.730, p=0.030).

Table 1. Mean scores on pre and post scales, knowledge and skills by group (training group vs control group).

Measure	TF-CBT training group	Control group	
	Pre	Post	p	Pre	Post	p	
	M	SD	M	SD		M	SD	M	SD		
Positive meaning	13.6	±1.76	15	±2.05	0.019	13.42	±1.38	15.17	±1.8	<0.001	
Meaning making through work	12.75	±1.8	12.3	±1.81	0.394	12	±2.09	11.92	±1.88	0.845	
Greater good motivations	12.05	±2.06	12.45	±1.88	0.202	11.83	±1.7	11.58	±1.31	0.571	
Overall meaningful work	38.40	±4.80	39.75	±4.25	0.181	37.25	±3.44	38.67	±3.72	0.09	
Correct responses	11.40	±2.21	10.15	±1.56	0.011	11.08	±2.23	8.75	±1.60	0.017	
Number of children with PTSD	6.94	±6.58	4.33	±4.05	0.009	5.42	±5.68	4.50	±6.75	0.546	
TF-CBT, trauma-focused cognitive behavioral therapy; M, mean; SD, standard deviation; Pre, Pre-training; Post, Post-training; PTSD, post-traumatic stress disorder.

Discussion

The purpose of this study was to examine the effect of TFCBT training on psychotherapists who work with UAMs in Greece as well as to assess their professional quality of life and work meaning. This trial examines the effect only on the mental health providers and it does not include the impact of the intervention on the health outcomes of UAMs. To the best of our knowledge, this is the first RCT study evaluating the effectiveness of psychotherapy training in frontline mental health professionals in Greece. Recent years have seen a surge of forced migration, leading to increased numbers of refugees in European countries, a lot of whom are UAMs (Moutsou et al., 2023). Trauma and PTSD symptoms are considered the main threats to those minors’ mental health, and as such, effective psychotherapy is necessary (Genç, 2022). Nevertheless, psychotherapists who work with UAMs lack the therapeutic knowledge and skills to respond to the mental health needs of unaccompanied refugee children, especially in front line countries such as Greece. Moreover, therapists’ wellbeing and professional quality of life is often jeopardized due to the lack of adequate therapeutic resources and adverse working conditions (Apostolara et al., 2023). Our study adds to the current body of knowledge by providing preliminary empirical evidence on psychotherapy training effectiveness in an understudied area in the field of psychotherapy.

Primary outcomes

According to the main findings of the study, the TF-CBT training improved the relevant trauma-related knowledge of psychotherapists who participated in the training program compared to the control group. This was evidenced by the increased knowledge gains among the trained psychotherapists, while a decrease was observed in the control group. Furthermore, post-training, the trained psychotherapists reported a lower number of children with PTSD symptoms, highlighting a potential enhancement in their diagnostic accuracy. No significant change was noted in the control group. The training emphasized the development of specific therapeutic competencies, such as active listening, empathy, and the application of Socratic dialogue, alongside cultural competence and the management of associated challenges. This holistic approach likely contributed to the observed improvement in diagnostic accuracy among the trained psychotherapists. A ubiquitous objective in the mental health field is to avoid over-pathologizing by imposing Western mental health standards on non-western populations (Cherepanov, 2023). To achieve that, the diagnostic process needs to consider cultural and political aspects, instead of solely focusing on symptoms. In our study, TFCBT training seems to have assisted psychotherapists to acquire the necessary trauma-related knowledge to better connect clinical experience with empirical evidence. To our knowledge, there is currently no previous study that investigates whether training mental health professionals in TF-CBT enhances their skills in diagnosing PTSD in refugee children.

Table 2. Pearson and Spearman correlation matrix.

Variable	1	2	3	4	5	6	7	8	
1. Compassion satisfaction	-								
2. Burnout	-0.740**	-							
3. Secondary traumatic stress	-0.197	0.562**	-						
4. Positive meaning	0.673**	-0.528**	-0.122	-					
5. Meaning making through work	0.611**	-0.473**	-0.138	0.672**	-				
6. Greater good motivations	0.558**	-0.464**	-0.193	0.574**	0.453**	-			
7. Overall meaningful work	0.729**	-0.580**	-0.165	0.866**	0.832**	0.783**	-		
8. Correct responses	-0.236*	0.195	0.058	-0.124	0.015	-0.192	-0.112	-	
*p<0.05; **p<0.001.

Table 3. Linear regression analysis with dependent variable Professional Quality of Life Scale.

Dependent variable	Independent variables	b	95% CI	p	
			LL	UL		
Compassion satisfaction (pre)	Gender: male
Years of clinical experience with refugee population	0.552	-3	4.11	0.758	
	Less than a year vs above 4 years	3.030	-0.62	6.68	0.102	
	1-3 vs above 4 years How many people do you serve per day?	0.111	-3.32	3.54	0.949	
	1-5 vs above 10	-1.267	-4.85	2.31	0.483	
	5-10 vs above 10	0.175	-4.06	4.41	0.935	
Burnout (pre)	Gender: male
Years of clinical experience with refugee population	-2.554	-5.52	0.41	0.090	
	Less than a year vs above 4 years	-3.172	-6.21	-0.13	0.041*	
	1-3 vs above 4 years How many people do you serve per day?	0.098	-2.76	2.95	0.945	
	1-5 vs above 10	-0.056	-3.04	2.93	0.970	
	5-10 vs above 10	0.183	-3.34	3.71	0.918	
Secondary traumatic stress (pre)	Gender: male
Years of clinical experience with refugee population	-2.406	-5.75	0.93	0.155	
	Less than a year vs above 4 years	-0.920	-4.35	2.51	0.594	
	1-3 vs above 4 years How many people do you serve per day?	2.961	-0.26	6.18	0.071	
	1-5 vs above 10	-3.730	-7.09	-0.37	0.030*	
	5-10 vs above 10	-0.041	-4.02	3.93	0.984	
CI, confidence interval, LL, lower limit, UL, upper limit. *statistically significant.

Relevant to our area of interest, the study by Finch et al. (2020) examined the impact of training in different PTSD treatments on clinicians’ confidence in diagnosing PTSD in children. Their findings indicated that both training and supervision are important predictors of professionals’ confidence in diagnosing and treating PTSD. However, in the same study (Finch et al., 2020), correct responses were similarly increased in both groups after the training was completed, without reaching statistical significance from baseline to retest. Also, Jensen-Doss et al. (2007) explored the impact of TF-CBT training on therapists’ perceptions and behavior. The findings revealed that following training in TF-CBT, therapists demonstrated a more positive attitude towards the TF-CBT approach. However, the training did not impact the therapists’ behavior during clinical sessions, as there were no significant changes observed in the techniques being employed post-training. An explanation regarding the lack of positive effect of TF-CBT training was stated to be its inconsistency with the therapists’ therapeutic backgrounds (Jensen-Doss et al., 2007). In the present study, the TF-CBT training group outperformed the control group in knowledge and skills, while identifying a lower number of children with PTSD symptoms post-training, despite the diverse therapeutic backgrounds of the psychotherapists involved. Additionally, in the aforementioned study, changes in therapeutic techniques were assessed after a 3-month period, whereas in our study, knowledge and skill acquisition in TF-CBT were evaluated soon after the end of training. Nevertheless, upon completion of the supervised TF-CBT intervention, it is foreseen to conduct a comprehensive re-evaluation of the therapists’ knowledge and skills to provide new insights into the long-term effects of TF-CBT training.

Secondary outcomes

TF-CBT training was found in our study to have no effect on therapists’ professional quality of life except of positive meaning, representing the sense of purpose in one’s work, which however was enhanced in both groups (i.e., TF-CBT training group and control group). Particularly, no significant differences were observed between the two groups in terms of burnout, secondary traumatic stress, meaning making through work, and compassion satisfaction. Secondary traumatic stress decreased slightly after the end of the study in both groups, whereas compassion satisfaction was slightly increased, but these differences were of no statistical significance. Overall, both the TF-CBT training and the control condition seem to have enhanced therapists’ professional quality of life, but further research is needed to confirm these tendencies. The present findings could indicate that involvement in the study, rather than TF-CBT training specifically, had a positive effect in both groups. Along with the need to conduct similar studies in larger samples of mental health professionals, therapists may also require more time to assimilate the knowledge gained from the TF-CBT training, and supervised implementation could also contribute to having positive effects of psychotherapy training.

Professional quality of life of therapists working with unaccompanied minors

According to the results of this study, women therapists, and clinicians with 1-3 years of experience working with refugees, exhibited higher burnout levels than men and clinicians with less than one year’s experience, respectively. Secondary traumatic stress levels were also elevated in psychotherapists with 1-3 years of experience with refugees as well as in those providing mental health services to more than 10 UAMs per day. Meaning making through work was higher in therapists with less than one year working with refugees, compared to those working over four years with this population. Hence, this group of mental health professionals was found to be burdened, which may be due to the challenging working conditions within this clinical field, wherein therapists are required to extend the work beyond their clinical duties to address various practical and administrative challenges (Apostolara et al., 2023).

Notably, our findings diverge from those reported in previous studies. Mavratza et al. (2021) identified a negative correlation between years of work experience and compassion fatigue. Similarly, Kim (2017) identified that years of experience working with refugees act as a protective factor against the occurrence of mental health issues such as emotional exhaustion, which is a component of burnout. These differences in the results of the present study compared to previous ones may be attributed to the working conditions within accommodation centers for UAMs in Greece. As mentioned above, clinicians in these settings are often tasked with addressing responsibilities beyond clinical duties, leading to a cumulative workload that can adversely impact their mental health and well-being over time unless continuous support and specialized psychotherapy training are provided.

Interestingly, though, when conducting an independent samples t-test, it was found that practitioners with previously completed or ongoing therapeutic training in other approaches, apart from the current TF-CBT training, exhibited significantly lower secondary traumatic stress compared to practitioners without any previous therapeutic training. The pertinent literature concerning associations between these variables is limited. Butler et al. (2017) stressed that education as a broader concept (not specifically focused on a therapeutic approach) appears as a significant factor in secondary traumatic stress. Avieli et al. (2016) also noted that professionals who have received training do not exhibit STS levels as high as untrained volunteers in mental health-related matters. On the same note, Sualp et al. (2021) highlighted the necessity of providing ongoing supervision and training to prevent the onset of indirect trauma and emphasized the importance of implementing interventions targeted at addressing STS among professionals working with refugees. However, there is a lack of research on this subject, which may stem from the ambiguity surrounding definitions of terms such as clinical training, or training in general, as the term training is often employed in a broad and unspecified manner (Rief, 2021).

It is thus necessary to expand our research efforts towards investigating the role of psychotherapy training on therapists’ mental wellbeing and professional resilience.

In the context of work meaning, a statistically significant difference was found in the present study between therapists with completed/ongoing psychotherapeutic training and those without any previous psychotherapy training. Specifically, the former tended to attribute significantly lower meaning to their work compared to their colleagues who lacked previous psychotherapy training. A plausible explanation for this intriguing result may be that mental health professionals working with refugees encounter several challenges in applying their psychotherapy training in clinical practice due to numerous obstacles that arise in their work, including high refugee dropout rates, assigned tasks not aligned with their professional roles, or inadequate supervision. Our findings align with those of Kjellenberg et al. (2014), who found a positive correlation between years of experience and compassion fatigue – a term frequently linked or associated with burnout. However, they also noted that as practitioners’ compassion fatigue increased, so did their post-traumatic growth, possibly due to coping strategies developed to manage compassion fatigue. Other studies have found that support from colleagues and the healthcare organization, and secondary post-traumatic growth are associated with higher levels of work meaning among professionals working with refugees (Posselt et al., 2019; Rizkalla & Segal, 2020). These findings lay bare the importance of customized psychotherapy training programs that would promote psychological resilience and self-care (Mette et al., 2020), especially in the therapeutic work with refugees.

Limitations and directions for future research

This study was not without limitations. The small sample size may have not allowed statistically significant relationships between the variables to be depicted. Future studies with larger samples are warranted to examine further the relationships between the variables as well as the possible effect of the distinct components of the TF-CBT training on therapists’ work. Another limitation is the gender imbalance within the sample, as most of the therapists were women. This may limit the generalizability of the findings, particularly in understanding how TF-CBT training impacts male therapists’ knowledge, skills, and professional quality of life. Additionally, this was a nonblinded RCT and participants were aware of their group assignment, which could potentially influence their responses. Thus, comparisons made between the two groups should be further confirmed in future studies. Given that the present study had a single informant nature based on self-reports from the participating therapists, future research should also consider incorporating multiple sources of data, such as client assessments, supervisor evaluations, or objective measures of clinical outcomes, to provide a more comprehensive assessment of the training’s impact.

The heterogeneity of the sample in terms of their therapeutic background (e.g., some participants had prior training in CBT while others did not) may have posed a limitation, although TFCBT can be effectively taught to non-mental health professionals, suggesting that the therapeutic background may not be a determining factor. However, it would be beneficial to investigate the extent to which the therapeutic background influences psychotherapists’ ability to comprehend and integrate the knowledge and skills acquired through TF-CBT training. Understanding how different therapeutic backgrounds impact the uptake and application of TF-CBT could provide valuable insights for optimizing training strategies and enhancing outcomes for psychotherapists working with refugee populations. Another limitation of the study was that only half of the participants completed the post-test measurement, which may be indicative of a lack of a well-established clinical research culture in the field as well as systemic factors, such as therapists’ insecurity due to the unstable status of their contracts, delays in payments, and multiple roles in their everyday practice. It should also be noted that the implementation of the supervision of therapists as outlined in the research protocol has not been completed, thus this study does not include a follow-up. Therefore, it would be valuable to conduct a follow-up to further assess the impact of TF-CBT training.

The magnitude of the refugee crisis and the literature on therapeutic interventions for refugees underscore the necessity for further RCTs and longitudinal designs. Future research could also focus on detecting the factors that lead to effective training, such as examining the concurrent training to different psychotherapy models as well as the effects of different approaches to teaching (e.g., online vs in-person training, hands-on vs theory-focused). Qualitative research and ideographic measures could also contribute to the existing literature in the psychotherapy training field to meet current needs, including training to culturally sensitive therapeutic approaches across different cultural and clinical settings. Lastly, the findings of our study underline the necessity for additional research in TF-CBT training for psychotherapists working with refugee children exhibiting trauma symptoms as well as further research on therapists’ professional quality of life.

Conclusions

This study provides preliminary evidence on TF-CBT training effectiveness in equipping psychotherapists to work with UAMs and sheds light on their professional quality of life. To the best of our knowledge, this is the first RCT study evaluating the effectiveness of TF-CBT psychotherapy training in frontline mental health professionals. Based on a stratified sample of Greek practitioners nationwide, TF-CBT training was found to be effective regarding the therapists’ increased knowledge and trauma-related skills, while their professional quality of life warrants further research.

Acknowledgements

The authors would like to express sincere gratitude to SOS Children's Villages of Greece and the General Secretariat for Vulnerable Persons and Institutional Protection of the Ministry of Migration and Asylum of Greece for their invaluable contributions and support throughout the study. They also extend their thanks to all the psychologists and interpreters who contributed with their efforts and made this research possible. Preliminary results were presented at the 2023 European Congress on Tropical Medicine and International Health (ECTMIH).

Availability of data and materials

The datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request. Restrictions may apply to the availability of certain data due to privacy or ethical considerations. Materials used in this study, including survey instruments, are also available upon request.
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