A national mental health cascade training programme for practitioners supporting unaccompanied minors in Greece

Context

Numbers of UAMs continuously fluctuate, depending on policies and external factors, especially war conflicts. Such fluctuation influences accommodation places and supporting budgets. In Greece, all issues related to UAMs are co-ordinated by the Special Secretariat for the Protection of UAMs. These include guardianship, needs assessment, child protection, placement, legal process, service co-ordination, and standards for accommodation centres. Between 2016–2023 44,920 UAMs arrived in Greece, mainly from Afghanistan (25%), Pakistan (14%) and Syria (9%). During the year of this study (2022), there were 2,624 officially classified UAMs across Greece, of whom 1,736 lived in medium-to long-term accommodation centres in the mainland, and which were the focus of the programme (SSP for UAMs, 2023). The remaining UAMs lived in reception, emergency and semi-independent living settings in islands and the mainland. The majority were between 14-18 years (90%) and male (83%).

Accommodation centres are provided by non-governmental organisations (NGOs). In response to government guidelines, each centre is typically staffed by an interdisciplinary team, including caregivers, administrators, cooks, domestics, educationalists, social workers and psychologists, as well as access to interpreters and legal advisers. Some centres had arranged staff supervision and child psychiatry input, whilst the majority referred to the local child and adolescent mental health service (CAMHS). Key reported staff challenges were the high turnover of UAMs, timely planning, and integrated care involving external agencies (Ntagka & Cochliou, 2023). Of the 22 NGOs that hosted 72 accommodation centres with a total 1,083 staff, 20 NGOs and their 69 centres agreed to participate in the cascade or ToT programme.

Care providers were consulted through four focus groups on the content and format of the ToT, and on selection criteria for the trainers. Seventeen consultees were involved, out of 40 invited. These consisted of caregivers (3), social workers (8), psychologists (2), educationalists (2), sociologist (1) and administrator (1). Each of the 20 NGOs subsequently selected one professional to act as trainer. Of the 20 identified trainers, three did not complete the programme because of various work pressures (new job, other commitments). The 17 remaining trainers had professional background in psychology (8), social work (7) and education (2). They operated in the Athens (10), central (2), northern (2), northwest (2) and island (1) regions.

Train-of-trainer (ToT) child mental health programme

Consistent with the literature, the programme was informed by cross-cultural trauma-informed (Im & Swan, 2020) and interprofessional education (Merriman et al., 2020) theories, in conjunction with the child refugee mental health literature (Scharpf et al., 2020). Following co-production with stakeholders, the ToT had previously been piloted, implemented and evaluated in several majority world (also referred to as low- and middle-income) countries in relation to different groups of vulnerable children, including refugee and UAMs (Eruyar et al., 2023; Vostanis et al., 2019).

For the purpose of this programme, the ToT was tailored to four bimonthly modules, each consisting of weekly three-hour sessions. The eight sessions of each module included child mental health topics (four), trainer skills (two), practice of pilot training (one - see details below), and reflection (one). The themes of the four modules were, assessment (cultural concepts and stigma, impact of trauma on child development, risk and protective factors); common child mental health problems (emotional, behavioural and attachment-related); interventions (different frameworks, goal-setting, application with UAMs); and systemic changes (needs analysis, action plans, youth participation, Theory-of-Change) (Figure 1). Training involved blended approaches of theory- and evidence-informed learning, case-based and experiential activities. Supporting materials included a trainer manual, two e-learn modules, psychoeducational resources, and selected bibliography. The ToT was facilitated by the first author (PV) of child psychiatry background through remote sessions, with bimonthly visits to participating centres. The remaining roles of the research team were co-ordination of the programme without direct involvement in the training (PS), facilitation of focus groups (AP) and independent evaluation (MoR). The ToT was overseen by a Ministry-led advisory group, with additional quarterly meetings with NGO managers.OPEN IN VIEWER

Trainers’ pilot training with interprofessional staff groups

Trainers piloted the modules within their accommodation centres. The framework was common across all NGOs, however, trainers tailored delivery approaches to their staff group, for example following internal consultation. All training was delivered to interprofessional staff groups, as this was a key objective of the programme, but the number of staff and sessions varied, as this often reflected the variable size of participating NGOs and their accommodation centres. This was broadly representative of the workforce, rather than ‘just’ psychologists, social workers and educationalists (Table 1). Although all 17 trainers completed the ToT, three trainers did not pilot the training, for various organisational reasons such as staff compliance or other overlapping educational activities. Pilot training activities were, therefore, completed and recorded by 14 trainers.

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Table 1.

Pilot training activities across 14 participating NGOs and their accommodation centres.

Sessions	Total = 50 Mean = 4 Median = 4 Range = 1–10
Staff trained	Total = 199 a Mean = 15 Median = 10 Range = 3–84 b
Professional role represented in NGO training c	Psychologist: 13 Caregiver: 12 Social worker: 11 Educationalist: 10 Interpreter: 5 Legal representative: 4 Cook: 4 Domestic: 3 Administrator: 3 Nurse: 2 Driver: 1

Data collection

Stakeholders in the programme shared their experiences and perspectives through focus group discussions. Focus groups can engage participants in ‘collective conversations’ in relation to their insights, and in negotiating ideas and solutions (Adler et al., 2019). The topic guide explored how mental health provision was conceptualised in relation to different roles, knowledge and skills (existing, acquired and desired) to fulfil these roles, ToT implementation process, and organisational issues. Focus groups were facilitated remotely by an independent researcher. Ethics approval was obtained from the Sociology Research Ethics Committee of Leicester University in the UK. Participants provided verbal consent at the beginning of the recorded remote sessions, as they came from different regions.

Through purposive sampling, to capture voices across the stakeholder spectrum (roles and geography), a sub-sample attended four focus groups with staff who had attended pilot training (n = 33), one focus group with trainers (n = 6), and one focus group with centre managers or co-ordinators (n = 9). Each focus group involved between 6-9 participants. Sessions were conducted in Greek language and were video-recorded. Participants’ professional roles are summarised in Table 2.

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Table 2.

Professional roles of focus group participants.

Practitioners who attended pilot training	Psychologist: 8Caregiver: 7Social worker: 6Administrator: 4Educationalist: 3Interpreter: 3Cook: 2Total staff: 33
Managers or co-ordinators	9
Trainers	6

Data analysis

We utilised thematic analysis (Braun & Clarke, 2006), and particularly engaged with a codebook form, to allow for conflation of inductive and deductive coding processes (Braun & Clarke, 2022). Stakeholders’ data were integrated, to explore all perspectives in relation to the research questions. Interviews were transcribed in Greek by AP, translated to English and coded by PV, and returned to MoR for validation of meaning. The codebook was revisited by the whole research team, to refine codes and resolve any discrepancies.

Theme 1: Contextual knowledge

Baseline knowledge and relevance of topics provided by the ToT appeared to relate differently to broadly three staff groups, psychologists, social workers/educationalists and all other staff. This challenge was apparent within groups, for example topics were usually familiar to psychologists, but the process and approach provided a new perspective to some. Trainers had to adapt accordingly, and considered how complementary training levels could be possible in future.

“…as a psychologist, I already apply what we heard in the meetings. Therefore, these [topics] were more-or-less familiar.”

In contrast, there was a previous gap in mental health knowledge and skills for residential caregivers and other ‘non-psychosocial’ staff. For this reason, these staff groups welcomed their involvement and found the training appropriate in strengthening their practical experience. For many, this was their first educational exposure, at least to mental health topics.

“Even though caregivers are a part, a link, of the shelter between the children and the social workers or psychologists, they are a neglected part.”

New knowledge and understanding enabled staff to deal with incidents in the centre in a different or more assured way. This was particularly important for emergencies and high risk incidents when they had to provide a quick response.

“Each time there were examples that I applied in my job. Continuously. You hear what is discussed and, when faced with the problem and crisis, you think that I need to approach the child differently, s/he has a different issue, at that moment you remember what had been discussed. I have seen it in a situation that troubled me but was resolved within five minutes.”

Participants reported that they were enabled to make more links between parallel children’s and staff relationships and dynamics. Such reflection was especially important in setting boundaries and managing aggressive outbursts, while maintaining a safe and nurturing environment.

“…there will be a need for some boundary-setting, some guidelines. Then the child feels that all their previous privileges are taken away…it also helped me to see that the relationships they possibly had in their family environment, are maybe mirrored in their relationship with the caregiver.”

Although most topics related to trauma may not have been new to staff, linking theory with practice, and using tools for assessment and interventions, were viewed as important. Caregivers in particular felt empowered with this layer of knowledge on top of their empirical experience.

“We confirmed a few practices we were using without knowing them.”

Both managers and trainers were conscious of this gap in evidence-based and informed decision-making. The ToT thus provided an opportunity for adopting a framework and toolsets.

“...new colleagues, as well as old ones with experience, managed through these trainings to systematise their experience, and to see that what they were doing anyway was useful.”

Although participants generally welcomed these new skills and applications, they positioned them within their continuing professional development, which overlaps with Theme 3 on sustainability.

“It is never-ending for me, because through this we self-improve both as professionals and as people.”

In summary, training was challenging in meeting diverse staff needs. This was, however, positively received, especially by professionals without previous mental health training, and who often felt excluded from education, thus undermined, despite spending all their working time with vulnerable children. The main reported benefit was being provided with a framework and tools to maximise their experience and observations.

Theme 2: Learning process

Although all centres had staff group forums, interprofessional training opportunities were relatively new for many, mostly those without ‘psychosocial’ qualifications. Learning as a team was viewed positively by most participants, including those who were familiar with the topics, because this training enabled them to understand better different perspectives.

“I am a psychologist. Next to me sits my colleague who is interpreter of Arabic. We attended together some training groups.”

A key reported benefit of joint training was the holistic understanding of children’s needs and behaviours, consequently integrated care planning and response. Several participants appreciated what other team members could contribute through experience, theory or techniques, even if some of these views could take them out of their comfort zone.

“Being on a shift with psychologists, social workers or educationalists, while managing crises at the same time in the centre, was completely new for them. We are talking about serious incidents. The training is not only for caregivers but also for the professional team.”

Such training culture reinforced team and joint working, which managers wanted to promote across settings. Nevertheless, they, as well as trainers, acknowledged that delivery should account for different training requirements.

“We did not separate the psychosocial team on their own, the caregivers on their own and the domestics on their own. We mixed them, so that the standards rise…some topics need adjusting for certain disciplines, while they roll better with others.”

Participants were exposed to various delivery approaches. They related better to interactive, experiential and case-based activities, as these enabled them to apply new knowledge immediately during the training event and subsequently in their centre. Consistent with their previously described appreciation for an underpinning framework, they valued links between theory and practice, elaborating views that only theoretical teaching was experienced as non-engaging.

“We split into groups to analyse practices of dealing with cases. In general, there was a lot of interaction beyond the theory, which I believe helps to better register issues.”

This improved capacity to relate to everyday practice, drove managers and trainers to link training events with existing service meetings, case incidents and ‘real’ concerns in the centre, as staff could thus make more sense of new knowledge.

“This somehow is part of case management, some scenarios which had to do with mental health, and we asked different roles to contribute somehow on how this situation be managed.”

Despite receiving supervision, this training offered much needed experiential, reflective and case-based approaches to their own emotional needs and required support. Working in a constantly changing and emotionally ‘charged’ environment, as all children had suffered some degree of trauma, placed additional strain on staff.

“Burnout because of rejection…there are advantages [working in the refugee field] but is also exhausting. Therefore, it is very nice to externalise a few issues and to come back lighter.”

Exchanging ideas and reflecting with colleagues from different professional backgrounds and working in different settings enabled a new kind of shared learning for many participants.

“I believe that there are several topics which are worth opening, so that we can discuss them without fear of saying something wrong…so that we have the mental reserves needed for this job.”

In this theme, participants predominantly considered how they valued training in an interprofessional context. This enabled them to understand each other’s role, complement skills and respond holistically to children’s needs. In terms of delivery approach, theoretical principles were appreciated, as long as these were demonstrated and practiced through case-based and experiential activities.

Theme 3: Sustainability

Participants considered extensively future training needs following the ToT. Although there was consensus that training should be ongoing, more specific suggestions were made on an educational model that could also account for organisational challenges, in particular staff turnover. A hybrid combination of induction and continuing training was thus put forward.

“But we also have new people, new arrivals of personnel. Therefore, they need to be integrated in the already formed [training] teams.”

Managers and trainers had initiated or were considering the integration of mental health to existing mandatory training such as on child protection. They reported that the ToT had provided them with new ideas, delivery approaches and materials.

“We have a format of monthly trainings attended by all staff, which concern child protection issues. In trainings on psychosocial issues, we have incorporated characteristics of the themes we discussed [during the ToT].

The interdisciplinarity and integration of training to staff forums was viewed as having direct benefits on team functioning and quality of care. Participants highlighted improved communication, clarity on professional roles and holistic case management.

“It was possible to work on communication, which often has gaps among colleagues. There was an opportunity to bridge these gaps.”

By incorporating or adjoining training to existing staff forums in some centres, this was not experienced as distinct to everyday duties.

“It works very well for us to add a training topic to staff meetings.”

Several logistical barriers were considered in ensuring staff attendance and engagement. Caregivers’ shifts, work pressures (crises, external agencies, competing meetings), and multiple centres for certain NGOs were particularly challenging for practitioners, trainers and managers.

“The only challenge is that I am on night shifts.”

Practitioners expressed a clear preference for face-to-face rather than remote training, as this was experienced as more engaging and interactive. Training in neutral venues and mixing with other staff groups were other perceived advantages, although not often logistically easy, with some NGOs hosting centres in different regions.

“Training outside the working environment, in [name of city], was like a breath of fresh air that week. I would also like to host individuals from other centres in our space.”

A particular feature of the ToT was that trainers worked in the same centre as their trained colleagues, some of whom may have been more experienced. For NGOs that hosted several centres, trainers were usually, albeit not always, known to other staff groups. This new dynamic was largely viewed as positive because trainers were familiar with staff needs, but also required some adjustments in working relationships.

“It was a different experience, because you see them [trainer] daily in one way, then you have to work with them in another, to present [the training]. It was a new arrangement.”

When participants explored reasons for feeling more comfortable with a familiar trainer, they reflected on wishing to feel safe without being criticised.

“Because we knew each other, we could even argue, express our thoughts. We would have definitely been more cautious with a stranger.”

Here, participants considered how the training programme could be sustained in future. The main challenges concerned work pressures, staff turnover and working across different settings. These could be overcome by incorporating mental health to existing mandatory and continuing education, and by regularly providing intensive introductory courses for new staff.