Internet-Delivered Value Based Counseling (VBC) Aimed at the Reduction of Post-Migration Psychosocial Stress - A Pilot Study

Abstract

Internet-based delivery of evidenced-based Value Based Counseling (VBC) fulfills the demand for a low threshold, culturally-sensitive and short-term intervention located at a level below specialized mental health care which can help those who do not require such specialized care to activate their resources and to regain their everyday functioning quickly. A pretest–posttest design with a historical control group was used to investigate the efficacy of internet-delivered VBC in comparison with in-person VBC provided to 102 help-seeking clients, who included refugees residing mainly in Germany. Intention-to-treat analyses concluded that internet-delivered VBC, comparable to in-person VBC, resulted in a significant reduction of depression, posttraumatic stress symptoms, perceived stress, somatic complaints, and daily functioning impairment at the post-test.

Keywords:

• Culturally and linguistically appropriate mental health care
• Internet-delivered counseling
• refugees
• Value Based Counseling (VBC)
• migrants

Introduction

Migration, especially when forced by intimidation and violence, challenges internal and external resources and might expose migrants, in particular refugees, to a vast array of adjustment difficulties and mental health problems such as depression, anxiety, post-traumatic stress symptoms (PTSD), physical symptoms, and disturbed functioning (Fazel, Wheeler, & Danesh, 2005; M’zah, Lopes Cardozo, & Evans, 2018; Rohlof, Knipscheer, & Kleber, 2014). Internet-delivered mental health interventions can reduce some of the well-investigated barriers to accessibility and utilization of mental health care services among this vulnerable population, including fear of stigmatization, language barriers, cultural differences, fear of negative repercussions, high transportation and service costs, insufficient knowledge of mental health issues and the healthcare system, and long waiting periods due to limited resources in the healthcare systems of host countries (Nickerson et al., 2020; Salami, Salma, & Hegadoren, 2019; Satinsky, Fuhr, Woodward, Sondorp, & Roberts, 2019). Accessibility, flexibility, convenience, anonymity, large-scale implementation and low cost are some of the advantages of internet-delivered counseling (Giotakos & Papadomarkaki, 2016; Wang & Alexander, 2014) that add value to many contexts and for many populations, such as transcultural clients, including refugees (Hassan & Sharif, 2019; Liem, Natari, Hall, & Jimmy, 2021).

Internet-delivered interventions can take the form of videoconferencing-based communication with a counselor in real time, asynchronous text- or audio-based contact with a professional, or a standalone smartphone app that facilitates self-help (Barak, Hen, Boniel-Nissim, & Shapira, 2008; Rummell & Joyce, 2010). Internet-delivered counseling in the present study refers to the use of a secure online platform accessed on a computer, tablet, or smartphone to hold video-chat calls between a client in a location providing privacy, and a certified counselor working from a professional space. Videoconferencing is the most similar online setting to in-person consultation, as it allows social presence and exchange of nonverbal communication cues online (Bolton & Dorstyn, 2015; Germain, Marchand, Bouchard, Guay, & Drouin, 2010). Previous research has provided rigorous evidence for videoconferencing-based interventions in treatments of anxiety (Varker, Brand, Ward, Terhaag, & Phelps, 2019), depression (Dorstyn, Saniotis, & Sobhanian, 2013), PTSD (Bolton & Dorstyn, 2015; Morland et al., 2020), somatic problems (Herbert et al., 2017), and adjustment disorder (Varker et al., 2019). A wide range of psychological modalities have been successfully replicated via videoconferencing, including cognitive-behavioral therapy, problem-solving therapy, behavioral activation, cognitive processing therapy, prolonged exposure, acceptance and commitment therapy, and supportive counseling (Dorstyn et al., 2013; Morland et al., 2020; Varker et al., 2019). Previous research reported similar therapeutic effectiveness of internet-delivered psychological interventions, mostly within adults based in well-developed countries, in comparison to in-person mental health treatments (Barak et al., 2008; Hassan & Sharif, 2019). An average similar effect size (0.53) found within internet-delivered psychological interventions in comparison to in-person therapies (Barak et al., 2008). Evident satisfaction of online clients (Murphy et al., 2009), and reports on a strong therapeutic alliance over the course of internet-delivered treatment, promise a new era for global mental health (Cook & Doyle, 2002; Germain et al., 2010; Holmes & Foster, 2012).

There is a consensus that internet-delivered counseling can connect migrants, including refugees, with culturally appropriate services in their native language, which in many settings are otherwise inaccessible (Hassan & Sharif, 2019; Wang & Alexander, 2014). In addition, internet-delivered counseling tends to provide quicker access to mental health care, which can be crucial in the context of stressful living conditions provided by many post-migration settings, including lengthy waiting periods for regular mental health care services (Wang & Alexander, 2014). Liem et al. (2021) reviewed internet-delivered mental health interventions for migrants provided over a period of almost two decades and found that insufficient technology literacy, poor internet access, and cultural barriers such as stigmatized mental health problems were the main challenges to the delivery of digital health applications at a large scale. To overcome these challenges, they suggest the provision of culturally sensitive interventions in the native languages of clients, and sufficient technical support.

One of the first international internet-delivered counseling services, established between Denmark and Sweden in 2005, investigated the feasibility of delivering mental health care by videoconferencing to 61 migrants, including refugees, in their native languages. The clients, who had resettled in Denmark, had on average five sessions with providers who spoke the same language and had similar cultural backgrounds. The study found a high level of acceptance and satisfaction with the internet-delivered counseling among the clients. They preferred it to interpreter-assisted care (Mucic, 2010). The high level of acceptance and completion of culturally and linguistically competent internet-delivered counseling was replicated in two other pilot studies among Korean migrants resettled in the USA (Jang et al., 2014; Ye et al., 2012).

The present pilot study examined the efficacy of internet-delivered Value Based Counseling (VBC), a culturally sensitive, short-term psychological counseling approach, provided to a sample of migrants, including refugees, mainly based in Germany. VBC is a low-threshold and strength-based intervention suitable as the first intervention in a stepped care model. If the three to five VBC sessions (45 minutes per session) for which the intervention is designed do not result in a meaningful improvement in daily functioning, a client may need to be referred to specialized mental health care.

VBC was initially developed based on insights of mental health needs and treatment in Afghanistan in 2004/5 and was integrated into the Afghan public health care system in 2009 (Missmahl, 2018; Missmahl & Brugmann, 2019). In 2015 and 2016, a period which saw an open-door policy by Germany toward refugees, the German nonprofit and non-governmental International Psychosocial Organization (Ipso) responded to an increased need for MHPSS services for refugees by training migrants, in particular fellow refugees, as psychosocial counselors in VBC able to provide intracultural, native-language mental health services. Two previous studies, the first investigating the efficacy of VBC in the context of ongoing stress and trauma in Afghanistan (Ayoughi, Missmahl, Weierstall, & Elbert, 2012), and the second investigating the efficacy of VBC provided to migrants, in particular refugees, in Germany, came to the conclusion that the counseling approach led to a significant reduction of participants’ symptoms of depression, anxiety, PTSD, perceived stress, somatic complaints, daily functioning impairment, and mental health service utilization (Orang et al., 2022).

The VBC approach is particularly suitable for internet delivery as a short-term, highly structured and solution-oriented intervention based on a symmetrical relationship between client and counselor (Missmahl, 2018). Entering a virtual space supports such a relationship and can give the client a sense of control because they would be able to end the session at any moment. Anonymity and the fact that the counselor does not have any connection to the local community of the client can also add to the latter’s sense of safety. Previous research suggests that online access to mental health care received in the privacy of one’s own living environment can improve the sense of safety, control and confidentiality, particularly of clients with experiences of trauma, violence and stigmatization (Shore, 2013).

In addition, easy access to VBC increases the likelihood that vulnerable people who suffer from mental health symptoms and do not have easy access to in-person services benefit from the intervention before symptoms increase, become chronic or are pathologized. A study among Filipino migrant workers suggests that easy access to mental health care services motivates migrants with relatively mild symptoms to seek internet-delivered psychological help (Hechanova, Tuliao, Teh, Alianan, & Acosta, 2013).

Finally, VBC matches clients and counselors according to gender, language and cultural background to facilitate intracultural communication. Moreover, instead of pathologizing these symptoms at an individual level, VBC has a salutogenic approach focused on empowering clients by identifying and activating their personal, social and cultural resources from the onset of treatment (Missmahl, 2018; Missmahl & Brugmann, 2019).

The present pilot study aims at investigating whether internet-delivered VBC reduces mental health symptoms of depression, PTSD, perceived stress, somatic problems and daily functioning impairment as effectively as in-person VBC.

Secure internet-delivered platform for VBC provided by the humanitarian NGO Ipso (International Psychosocial Organization)

Table

The internet-delivered platform (www.ipso-care.com) for VBC provided by Ipso is a secure video platform currently available in 17 languages. Clients can register anonymously and only need to provide information on their gender, native language, birth country and the country in which they currently reside to be matched with a counselor and to make an appointment potentially across time zones. For data security, the platform uses a Peer-to-Peer (P2P) connection between client and counselor, which does not require a streaming server.

Not all potential clients have the knowledge, equipment, internet connection and/or private space to arrange and take part in an online counseling session without help. Care points providing technical support and privacy, which are run by partner organizations in locations such as refugee camps in Lebanon, Jordan and Iraq, and in refugee accommodations in Germany and Switzerland, have shown to be an efficient way of increasing access to Ipso’s counseling service to vulnerable populations.

Materials and methods

Study design

To investigate the efficacy of internet-delivered VBC, we employed a non-randomized pretest–posttest design with a historical control group. This group was taken from a previous randomized controlled trial (RCT) which investigated the efficacy of in-person VBC intervention within migrants, mainly refugees residing in Germany, and showed promising results (Orang et al., 2022). For the present paper, we analyzed the data at two levels; we performed pre-posttest analyses across all study measures within the online group to check whether internet-delivered VBC led to significant results and then compared the results of internet-delivered VBC and of VBC provided in person. The posttest assessments were conducted within 10 to 14 days after the end of the internet-delivered and in-person counseling sessions. The protocol received ethic approval by the Charité, University Medicine Berlin, and was registered in the German clinical trials register (DRKS00016981). Each participant electronically signed an informed consent form.

Setting, local team & sampling procedure

Internet-delivered VBC

The Ipso online platform (www.ipso-care.com) has been used to provide migrants, in particular refugees, with VBC sessions worldwide. Awareness of the internet-delivered counseling service was raised through Ipso’s public Facebook page, Ipso’s official website and online flyers. Furthermore, partner organizations made the service available in selected refugee camps in Jordan, providing internet access, technical support and a quiet room for people in need.

Clients who booked an appointment on the platform were informed about the present study and its requirements. If they agreed to participate in the study, the counselor would send them a link containing an information sheet and a consent form in their native language. Upon a client’s digital signature, a second online appointment was made to conduct a baseline assessment in advance of the counseling sessions. Overall, twelve certified VBC counselors conducted counseling and assessment sessions in languages of Arabic, Farsi/Dari, French, and English. The same counselor conducted the baseline assessment and counseling sessions so as not to expose clients to two different counterparts within a short time. A different counselor with a same language and cultural background, however, conducted the post-test assessment.

Online clients who were not willing to participate in the study did not face any negative consequences and were counseled without delay. An Ipso support team provided telephone and email support to clients who had technical difficulties using the platform, mostly during the registration process.

In-person VBC (historical control group)

The in-person VBC participants were based in various parts of Berlin and Brandenburg, including Potsdam, in Germany and attended counseling sessions in the Ipso Care Center located in the center of Berlin. Participants had become aware of the services of the Ipso Care Center through different channels such as awareness raising conducted in refugee accommodations, NGOs supporting refugees, schools, cafés and government offices. Those who showed interest in being counseled received verbal and written information on the study and conditions for participation and were asked to sign a consent form. The counseling and assessment sessions were conducted by 18 certified VBC counselors in languages of Arabic, Dari, Farsi, Kurdish, French, German, Malinke, Pular, or Sussu. Clients and counselors were matched in terms of gender, language and cultural background (for a detailed description of the in-person VBC intervention, please see Orang et al., 2022).

Participants

Internet-delivered VBC

We recruited a sample of 52 participants between January 2019 and March 2020. The inclusion criteria were that participants, preferably migrants with a refugee background, sought help online and were aged 18 years or above. Exclusion criteria were acute suicidality, acute psychosis and severe substance dependence. Current involvement in another mental health intervention was excluded to avoid overlapping effects with the study intervention. Acute suicidality was assessed with the Mini International Neuropsychiatric Interview (MINI) suicidality module. Questions inquiring substance use, psychotic symptoms and current use of another mental health care service were added to the sociodemographic questionnaire. None of the participants met the exclusion criteria. Of 52 potential participants screened, three declined to participate or could not participate, and were referred to appropriate care. Out of 49 attendees, 28 (57.1%) resided in Germany as migrants/refugees at the time of the intervention, and 21 (42.9%) were based in countries other than Germany. A few of the participants who were not migrants (n = 9, 18.4%, citizens of Jordan (n = 4), Ghana (n = 1), Bangladesh (n = 1), India (n = 1), Morocco (n = 1), and Sudan (n = 1)) were included in the online group because they were in urgent need of mental health care due to extreme poverty or domestic violence exposure.

Of the 49 participants who started internet-delivered VBC sessions, nine participants (18.4%) dropped out for different reasons, such as other commitments or physical illness.

In-person VBC (historical control group)

We recruited a sample of 53 participants between March 2018 and May 2019. The inclusion criteria were help-seeking migrants/refugees who were living in Berlin or Brandenburg and aged 18 years or above. The exclusion criteria were the same as in the internet-delivered VBC setting. Of 53 participants who participated in counseling sessions, 11 participants (20.7%) dropped out for different reasons, such as major changes in their life situation (Orang et al., 2022).

Intervention method

Counseling sessions were held by certified VBC Counselors. Internet-delivered or in-person VBC sessions usually took 45 minutes free of charge. Both internet-delivered and in-person participants received an average of four counseling sessions, within a range of two to seven sessions. The number of sessions depended on various factors, including clients’ main complaints, their level of awareness of their situation, their readiness for working on their issues, and their personal and cultural resources. Appendix 1 gives a short description of VBC one-year training course.

The VBC method description

VBC is a manualized intervention in two parts. In the first part (Steps 1-3), client and counselor develop a narrative of the client’s biography to develop a mutual understanding of the inner situation of the client in the here and now. They seek to understand which psychosocial stressor triggered the vulnerability of the client expressed in a symptom or problematic behavior. In the second part (Steps 4-6), client and counselor focus on the here and now of the client with the aim to activate the client’s personal, family and cultural resources and to enable them to define a way forward which allows the client to deal with the psychosocial stressor in a meaningful way, improving their daily functionality with the help of interventions that support the way forward defined by the client. In this context, it is important for the client to improve their self-effectiveness. In the last step, the client’s cognitive and emotional process is reviewed and conceptualized as a resource for future personal challenges of the client. This improves the client’s confidence in their own ability to cope with future challenges and thus improves their resilience further (Missmahl, 2018; Missmahl & Brugmann, 2019).

Step 1: Understanding the symptom or presented problem

Development of a shared understanding of the client’s symptoms or presenting problem in terms of intensity, duration and frequency. Exploration of how the client’s daily functioning is affected by the symptoms/problem and by the thoughts and feelings triggered by them. The aim is to understand the meaning of the symptoms/problem in the context of the client’s biographic vulnerability and sociocultural context, not to give a diagnosis.

Step 2: Understanding the psychosocial stressors

Contextualization and development of a shared understanding of the psychosocial stressors; analysis of the human values of the individuals involved in the stressor (involves perspective taking), of the impact of the stressor on the client, and the connection between stressor and symptom.

Step 3: Identification of the dominant feeling tone

Development of an understanding of the dominant feeling tone of the client which hinders daily functioning most. The connection of the feeling tone to the personal vulnerability of the client is explored. This requires a shared empathetic understanding between counselor and client. Unconscious identification with the dominant feeling tone such as guilt or shame usually can be made conscious, enabling the client to understand why their feeling tone has become dominant. This may also be the moment to include a psychoeducational component in the conversation and to give relevant health information if appropriate (e.g., what constitutes PTSD, etc.).

Step 4: Identification of the main complaint

Identification of the main complaint, based on the dominant feeling tone that impairs daily functionality the most.

Step 5: Addressing the main complaint

Identification of a solution to the main complaint. The solution must be personal, manageable and meaningful to the client, will increase their sense of coherence and improve resilience.

Step 6: Psychological Interventions

Development of a personal strategy designed to address the main complaint. The VBC method is integrative in that it employs well-evidenced psychological intervention methods such as reframing or detecting automatic thinking as cognitive behavioral techniques, relaxation exercises, or grounding and distancing techniques for trauma symptoms, or behavioral activation. Psychosocial interventions which support this personal strategy are also applied in this step. This includes the reactivation of personal resources or the development of new resources including provision of homework to strengthen resources.

Step 7: Summary, Consolidation and Outlook

Reflection and anchoring of the process and the insights gained during the process.

Outcome measurements

Sociodemographics and outcome measures were assessed using the same set of questionnaires in both internet-delivered and in-person VBC settings. The present questionnaires were employed because they could easily be conducted in a structured manner, have been validated in the context of different countries and cultures, and because most of them are available in Farsi, Arabic, French, and German translations which are considered as reliable and valid as the original English version.

To assess the primary outcomes of the study, including the intensity of depression, PTSD, perceived stress, and somatic complaints, we employed the Patient Health Questionnaire-9 (PHQ-9) (Spitzer, Williams, Kroenke, et al., 2014), the PTSD Checklist for DSM-5 (PCL-5) (Weathers et al., 2013), the Perceived Stress Scale-10 (PSS-10) (Cohen, Kamarck, & Mermelstein, 1983), and the Patient Health Questionnaire-15 (PHQ-15) (Kroenke, Pitzer, & Williams, 2002), respectively. The Cronbach’s Alphas for the online sample were .81 (PHQ-9), .92 (PCL-5), .85 (PSS-10), and .75 (PHQ-15).

Daily functioning impairment as the secondary outcome was measured using a self-structured daily functioning instrument developed in a refugee health screening study (Kaltenbach, Härdtner, Hermenau, Schauer, & Elbert, 2017). The daily functioning impairment screens dysfunctionality with respect to eight aspects of daily life: relationships with family, with friends, household chores, leisure activities, social engagement, work, education, and general life satisfaction. Each aspect is scored on a 5-point Likert scale, from 0 (not at all) to 4 (severe), over the course of the past four weeks. Higher sum scores represent greater daily functioning impairment. The Cronbach’s Alpha for this scale in the internet-delivered sample was .84.

The Cronbach’s Alphas of the above-mentioned questionnaires for the in-person sample were .79 (PHQ-9), .85 (PCL-5), .85 (PSS-10), .79 (PHQ-15). .76 (daily functioning impairment), .84, respectively.

Sociodemographic data including age, gender, marital status, nationality, language, religion, residence status (in case of residency in Germany), educational level, and medication used in the last week and drug/alcohol use were also collected.

Statistical analyses

Assuming an effect size of Cohen’s d = 1-1.5 and a dropout rate of 10% between pretest and posttest in accordance with power calculations in a previous VBC study (Ayoughi et al., 2012), we considered 40-50 participants in the internet-delivered VBC group adequate to determine whether it leads to a meaningful decrease in the mental health burden.

First, we performed several pairs of dependent T-Tests for each outcome variable within the online sample. Afterwards, we employed several pairs of 2 × 2 Mixed Design ANOVA, with score change as a two-level within-subject variable (pre- vs. post-test) and the study group as a two-level between-subject variable (internet-delivered vs. in-person VBC) to investigate whether internet-delivered and in person VBC produce comparable results. We used Intention-to-treat analyses (ITT) to assess efficacy of the target intervention in both within- and between-group analyses. Within- and between-group effect sizes were also estimated.

Descriptive data were presented as frequencies (%), mean scores, and standard deviations. Potential group differences in sociodemographic characteristics and initial outcome measures across outcome variables were analyzed using chi-squared and Fisher’s exact tests, Independent Sample T-Test, and U Mann-Whitney test. The accepted significance level (α) for two-tailed statistical analyses were p < .05, p < .01, and p < .001.

Following the non-normal distributions of some study variables, mostly at the post-test according to the Shapiro-Wilk test, we employed a two-step approach of data transformation in order to meet the normality assumption of the main analyses (Templeton, 2011). In this regard, we ran the main statistical analyses twice; once on the raw data, and afterwards on the transformed data to check if the results were similar. Upon equivalent, we reported the results drawn from the raw data. Bonferroni correction was used to adjust for multiple testing.

Results

Internet-delivered VBC

Online participants were 18 to 58 years old. Overall, 54.2% were single at the time of the baseline assessment and 45.8% were married or in an intimate relationship. 52.2% of the participants were Muslims, 15.2% Christians, and 32.6% did not endorse any religion. More than half had a school diploma (31.3%) or a university degree (41.7%) (See Tables 1 and 2).

Table 1. Baseline sociodemographic and outcome variables of internet-delivered and in-person VBC clients.

Baseline demographics & outcome variables	Internet-delivered		In-person		p value
	VBC	n	VBC	n
Age		47		53
M (SD) [Range]	29.10 (7.94) [18-58]		30.86 (8.94) [18-62]		.147
Gender; n (%)		48		53
Female	24 (50)		22 (41.5)		.429
Male	24 (50)		31 (58.5)
Marital status; n (%)		48		53
Single	26 (54.2)		23 (43.4)		.013
Married/Partnership Divorced/Widowed	22 (45.8)0 (0)		22 (41.5)8 (15.1)
Religion; n (%)		46		51
Muslim	24 (52.2)		28 (54.9)		1.00
Christian	7 (15.2)		7 (13.7)
No religion	15 (32.6)		16 (31.4)
Education; n (%)		48		53
Elementary/secondary school	11 (22.9)		20 (37.7)		.160
Diploma	15 (31.3)		8 (15.1)
University degree	20 (41.7)		21 (39.6)
No education	2 (4.2)		4 (7.5)
Residence status*; n (%)		26		53
Asylum seeker	17 (65.4)		37 (69.8)
Temporary identification document	8 (30.8)		11 (20.8)		.497
Other	1 (3.8)		5 (9.4)
Medication use**; n (%)		48		53
No	26 (54.2)		20 (37.7)		.098
Yes	22 (45.8)		33 (62.3)
Depression		49		53
M (SD) [Range]	19.08 (5.02) [4-27]		15.22 (5.76) [3-26]		p<.001
PTSD		37		35
M (SD) [Range]	56.21 (14.24) [19-78]		43.31 (15.55) [15-75]		p<.001
Perceived stress		49		53
M (SD) [Range]	32.12 (5.66) [11-40]		25.35 (7.21) [4-37]		p<.001
Somatic symptoms		49		53
M (SD) [Range]	15.10 (4.29) [5-23]		11.83 (5.23) [2-21]		p<.001
Daily functioning impairment		49		53
M (SD) [Range]	24.93 (6.04) [2-32]		18.05 (7.48) [1.33-32]		p<.001

Note. VBC: Value-Based Counseling; * Residence status only of participants residing in Germany; ** Regular use of medication for psychiatric and/or physical health problems.

Table 2. Countries of origin, native languages, and countries of residence at the time of baseline assessment within the online participants.

Nationalities; n (%)	Country of residence; n (%)	Native language; n (%)
Syria: 17 (34.7); Iran: 4 (8.2); Jordan: 4 (8.2); Afghanistan: 3 (6.1); India: 3 (6.1); Bangladesh: 1 (2); Cyprus: 1 (2); Egypt: 1 (2); Ghana: 1 (2); Iraq: 1 (2); Kurdistan: 1 (2); Malaysia: 1 (2); Mexico: 1 (2); Morocco: 1 (2); Nepal: 1 (2); Turkey: 1 (2); Palestine: 1 (2); South Korea: 1 (2); Sudan: 1 (2); Yemen: 1 (2).	Germany: 28 (57.1); Jordan: 8 (16.3); India: 2 (4.1); The United Arab Emirates: 2 (4.1); Bangladesh: 1 (2); Denmark: 1 (2); France: 1 (2); Ghana: 1 (2); Morocco: 1 (2); Philippine: 1 (2); Sudan: 1 (2); Spain: 1 (2); Turkey: 1 (2)	Arabic: 26 (55.3); Dari: 3 (6.4); Farsi: 4 (8.5); English: 3 (6.4); Kurdish: 3 (6.4); Hindi: 3 (6.4); Korean: 1 (2.1); Nepali: 1 (2.1); Spanish: 1 (2.1); Turkish: 1 (2.1); Bengali: 1 (2.1).

We found that of 49 online participants, based on a cutoff score of 10 on PHQ-9 (21), 46 participants (94%) suffered from moderate to severe depressive symptoms, with a sum score ranging from 10 to 27. In addition, of 49 online participants, 37 participants (75%) suffered from PTSD symptoms (M = 56.21, SD = 14.24) at baseline following at least one traumatic experience, with a PTSD sum score range of 19 to 78. Of these 37 participants, 12 (33%) had experienced multiple traumatic events, 11 (31%) reported one single traumatic event, and 13 (36%) had suffered from one continuous and repetitive traumatic event. The most frequent traumatic events were family violence (n = 10), rape and sexual abuse (n = 9), and war experiences (n = 7). Moreover, perceived stress was frequent in the present sample (M = 32.12, SD= 5.66), ranging between 11 and 40. Finally, following a cutoff point of ≥10 on the somatic symptom scale of PHQ-15 (25), 44 participants (90%) reported medium to high somatic symptom severity within a sum score range of 10 to 23.

Furthermore, performing several pairs of Dependent T-Test for each outcome variable within the online sample (n = 49), we found that on average, online participants experienced significantly fewer psychological symptoms of depression, PTSD, perceived stress, somatic complaints, and daily functionality impairment after the index intervention at the post-test assessments in comparison to the baseline assessments. The means and standard deviations at each level of assessments, the test statistic, its degrees of freedom and the probability value of the test statistic, and the effect size for each outcome variable within the online group are reported in Table 3.

Table 3. Descriptive statistics and paired-samples t-test results within the internet-delivered VBC intervention.

	Pretest		Posttest			95% CI for Mean Difference
Outcome	M	SD	M	SD	n		r	t	df	p value	Effect size
Depression	19.08	5.02	4.67	5.16	49	12.16, 16.65	-.17	12.89	48	p< .001	1.85
PTSD	56.30	14.43	14.38	16.39	36	33.69, 50.13	-.24	10.34	35	p< .001	1.72
Perceived stress	32.12	5.66	13.00	8.31	49	16.12, 22.10	-.07	12.86	48	p< .001	1.87
Somatic symptoms	15.10	4.29	4.71	5.00	49	8.55, 12.23	.05	11.37	48	p< .001	1.62
Functionality impairment	24.93	6.04	6.25	8.64	49	15.65, 21.70	.00	12.42	48	p< .001	1.79

In-person VBC

The historical control group included in-person participants aged 18 to 62 years old. Of the 53 participants, 23 (43.4%) were single and 22 (41.5%) were married or in an intimate relationship at the time of baseline assessment. More than half (54.9%) of the participants were Muslims, 13.7% Christians, and 31.4% did not endorse any religion. More than half had a school diploma (15.1%) or a university degree (39.6%). Table 1 shows baseline sociodemographic characteristics for the in-person VBC group. For a detailed description of sociodemographic characteristics and mental health status of the in-person VBC group, please see Orang et al. (2022).

Internet-delivered VBC vs. in-person VBC

Before running Mixed Design ANOVA to compare the two VBC delivery modes, we performed several pairs of independent T-tests, Chi-square and Fisher’s exact tests between the two groups at baseline to identify whether there were any significant differences in sociodemographic variables and outcome measures initially. Such baseline comparison was particularly important, as 43% of the online clients resided in countries other than Germany, for example Jordan, at the time of the intervention, and therefore experienced living conditions which were likely to be markedly different from Germany. We found that on average, participants in the internet-delivered VBC group showed in statistical terms significantly higher scores of depression (t (100) = −3.58, p<.001), PTSD (t (70) = −3.67, p<.001), perceived stress (t (100) = −5.23, p<.001), somatic symptoms (t (100)= −3.43, p<.001), and daily functioning impairment (t (100) = −5.08, p<.001) at the baseline assessments than the in-person VBC group.

In regard to the baseline sociodemographic characteristics across the internet-delivered and in-person groups, we did not find statistically significant differences between the two groups in terms of gender, religion, and education (Gender: Pearson Chi-Square X² (1, n = 101) = 0.73, p = .429; religion: Pearson Chi-Square X² (2, n = 97) = 0.82, p = 1.00; education levels: Fisher’s exact test; X² (3, n = 101) = 5.12, p = .160). In regard to marital status, we found a statistically significant association between marital status and the type of group (Fisher’s exact test; X² (2, n = 101) = 8.51, p = .013). Post Hoc Test after the Chi-Square Test with a Bonferroni Correction revealed a significantly higher number of divorced or widowed participants among the in-person group than in the internet-delivered group. Our analysis did not reveal any statistically significant association between the type of group and the use of medication (Pearson Chi-Square X² (1, n = 101) = 2.74, p = .098).

We investigated residence status as a variable only within the online clients who resided in Germany at the time of study, as we did not inquire the residence status of online clients in countries other than Germany. We reclassified the residence status of online and in-person clients into the three groups of asylum seekers/refugees, individuals with a temporary identification document, and other (including EU citizen). The analysis did not reveal any statistically significant association between the residence status and the type of intervention group (Fisher’s exact test; X² (2, n = 79) = 1.36, p = .497). Table 1 shows detailed statistics for outcome variables and sociodemographic characteristics at baseline across the two intervention groups.

After adjusting discrepancies between the two groups at baseline into Mixed Design ANOVA, we did not find statistically significant differences between the two groups in regard to the reduction of depression (Bonferroni adjusted mean difference 2.04, 95% CI −0.26, 4.34, p = .082, effect size 0.35), PTSD (Bonferroni adjusted mean difference 4.75, 95% CI −3.03, 12.54, p = .228, effect size 0.31), perceived stress (Bonferroni adjusted mean difference −0.59, 95% CI −4.20, 3.02, p = .746, effect size 0.27), somatic symptoms (Bonferroni adjusted mean difference 0.91, 95% CI −1.03, 2.85, p = .355, effect size 0.33), and daily functioning impairment (Bonferroni adjusted mean difference 1.68, 95% CI −1.61, 4.97, p = .315, effect size 0.39) at the posttest assessments.

Finally, we found that nine participants (18.4%) dropped out of the internet-delivered VBC setting. Comparing to the dropouts in the in-person VBC (n = 11), we did not find any statistically significant association between the number of dropouts and the type of VBC delivery (i.e., internet-delivered vs. in-person) (Pearson Chi-Square X² (1, n = 102) = 0.92, p = .807). On average, online participants had more counseling sessions (M = 4.40, SD= 1.13, n = 32, range [2-7]) than those who participated in in-person sessions (M = 3.97, SD= 1.15, n = 42, range [2-7]). Nevertheless, this difference was not statistically significant t (72) = −1.59, p = .114; effect size Hedges’ g = 0.37.

Discussion

The present pilot study investigated whether migrants, including refugees, can benefit from VBC, an evidence-based psychological intervention, delivered through a secure online platform, and found that internet-delivered VBC resulted in large effect sizes and a significant reduction of psychological symptoms, including depression, PTSD symptoms, perceived stress, somatic complaints and daily functioning impairment from pretest to post-test assessment. Furthermore, these positive results were comparable to the significant changes resulting from in-person VBC (Orang et al., 2022), with a small effect size in favor of the internet-delivered VBC setting. The results are in line with previous studies suggesting that videoconferencing-based mental health interventions are successful in the treatment of anxiety (Varker et al., 2019), depression (Dorstyn et al., 2013), PTSD (Bolton & Dorstyn, 2015; Morland et al., 2020), somatic problems (Herbert et al., 2017), and adjustment disorder (Varker et al., 2019), and that internet-delivered mental health interventions, particularly CBT, psychoeducational and behavioral approaches, have a therapeutic effectiveness within adults similar to in-person treatment (Barak et al., 2008; Hassan & Sharif, 2019). This finding is particularly important in regard to the role of preventive measures in the context of a stepped care model, as providing easy access to internet-delivered mental health counseling to vulnerable migrants encourages them to seek help, activating their resources and helping them to regain their everyday functioning before symptoms become chronic and require specialized mental health care (Bajbouj et al., 2018; Böge et al., 2020; Hechanova et al., 2013).

Systematic research revealed that internet delivery of mental health interventions to migrants, including refugees, can increase timely access to culturally competent professional care in clients’ native languages (Hassan & Sharif, 2019; Wang & Alexander, 2014). It can also help to overcome fears of stigmatization or of facing negative consequences common within this population (Salami et al., 2019). Internet-based delivery of VBC fulfilling demands on a short-term intervention that is culturally-sensitive and in the native language of a client is in line with elements reported to be responsible for the high efficacy of internet-delivered counseling and evident satisfaction of online clients (Murphy et al., 2009).

Interestingly, we found in our study that the online clients suffered from levels of depression, PTSD, perceived stress, somatic complaints and daily functioning impairment at the baseline assessment that were significantly higher than those of clients who attended in-person VBC sessions. One reason could be that about 43% of online participants were based in countries other than Germany at the time of index intervention, for example Jordan, where living standards and the infrastructure were most likely not as supportive as those in Germany. In addition, the substantive mental health burden of the online clients may indicate that internet-delivered counseling is more accessible to vulnerable populations in critical need than in-person counseling, because there is less fear of stigmatization, less of a language barrier, more resources to match counselors and clients, fewer fears of negative repercussions, no transportation costs, lower service costs, insufficient knowledge of the local healthcare system, or an increased mental health burden due to long waiting periods for in-person services (Nickerson et al., 2020; Salami et al., 2019; Satinsky et al., 2019).

Furthermore, we did not find statistically significant differences in main sociodemographic variables such as age, gender, education level, and psychiatric and physical medication utilization between the internet-delivered and in-person VBC groups at the baseline, which is different from previous findings that report on the high use of internet-delivered counseling among young and educated people and female participants compared to other subsections of society (Holmes & Foster, 2012; Varker et al., 2019). This may be the consequence of matching counselors with clients in regard to language, gender and cultural background, along with technical support and internet access which Ipso offers to vulnerable people in cooperation with agencies in refugee camps/accommodations. Previous research suggests that insufficient technology literacy and poor internet access as well as cultural barriers are the main challenges to the delivery of scalable digital health applications within this population (Liem et al., 2021). We also did not find a statistically significant difference between internet-delivered and in-person VBC in terms of dropout numbers. This finding, in line with previous research, may be an indication of the feasibility and convenience of internet-delivered counseling, encouraging clients to complete the course of treatment (Giotakos & Papadomarkaki, 2016; Wang & Alexander, 2014).

The present findings need to be treated with caution, as the study findings were based upon a historical control group, which might influence the strength of the results and their generalizability. In addition, the non-randomized and non-homogeneous sampling may also impact the quality of the results. We are aware that putting online clients residing in different countries in one group and comparing them with migrants living in Germany challenges our findings, as the living standards and infrastructure available to migrants in Germany in comparison to refugee camps in other countries such as Jordan are very different. Therefore, a long-term large-scale randomized controlled study with a homogenous sample are warranted to further assess the efficacy of internet-delivered VBC. Finally, a comparison between internet-delivered VBC and other well-evidenced online psychological interventions, such as CBT, would help to reexamine the present promising results and cast more light on online therapeutic settings.

Conclusion

Internet-delivered VBC provided to migrants, including refugees, showed positive results comparable to in-person VBC sessions. In view of the high need among migrants for easily accessible culturally sensitive mental health support provided in their respective native language as they experience post-migration stressful living conditions, internet-delivered counseling has huge potential. Access can be improved with care points providing the necessary equipment, privacy and technical support in locations easily accessible to vulnerable migrants.

Disclosure statement

No potential conflict of interest was reported by the authors.

Data availability statement

The data that support the findings of this study are available on request from the corresponding author, [MO]. The data are not publicly available to protect the privacy of research participants.

Additional information

Funding

The study was funded by the German Ministry of Health (Grant number 2517MIG013).