We conducted a prospective, descriptive study using qualitative semistructured interviews. The setting was the refugee state registration and reception center “Patrick Henry Village” (PHV), Heidelberg-Kirchheim, Germany. At the PHV, the University Hospital of Heidelberg, in cooperation with physicians in private practice, operates a medical and psychosocial walk-in clinic [38,39]. Between the end of May and early December 2018, refugees who sought help in the psychosocial walk-in clinic [38] and met our study’s inclusion criteria were referred to treatment with the audio-based stabilizing and guided imagery techniques. Due to follow-up interviews conducted two months later, the overall study period (recruitment and follow-up) was from May 2018 until February 2019. Inclusion criteria were a diagnosis of PTSD, access to a personal smartphone for digital audio file delivery, and fluency in speaking and understanding of one of the following languages: English, French, Arabic, Farsi, Turkish, or Serbian. Exclusion criteria were substance addiction, current psychosis, and age under 18 years. All participants had applied for asylum in Germany or were in the process of applying during the intervention.

When indicated, the psychiatrists and psychotherapists of the psychosocial walk-in clinic recommended treatment with the audio-based stabilizing and guided imagery techniques to patients and made a face-to-face appointment for an introductory session. During the introductory session (T1), the patients first were asked to complete a baseline measurement via a tablet. Afterward, the psychologist discussed psychoeducational issues with the patients and informed them of the content of the audio files and the aim of stabilizing and guided imagery techniques. Then, the psychologist and the patients practiced the stabilizing and guided imagery techniques together once using the audio files and subsequently discussed the effects and difficulties of each technique. Finally, the audio file was transferred to the patient’s phone in the appropriate language. The introductory session lasted approximately two hours. The booster session (T2) took place nine days later and particularly focused on counseling and feedback regarding difficulties in practicing the techniques using audio files. Since the focus of this study was put on the self-practice of stabilizing and guided imagery techniques using the provided audio files, no further guided practice sessions were undertaken. An interview was conducted with each patient at the end of the session. Two months after T2, the patients were contacted again by phone and interviewed for a second time (follow-up). Three attempts were made to reach the patients for follow-up interviews. If necessary, a telephone or face-to-face translator was involved during the introductory session and the booster session. Figure 1 provides an overview of the study procedure.

The study was approved by the ethics committee of the University of Heidelberg (S-640/2016), and all participants gave their written informed consent in accordance with the Declaration of Helsinki.

The audio file consisted of three parts, namely (1) mindful breathing, (2) the body scan, and (3) the guided imagery technique “The Inner Safe Place,” which are described in more detail elsewhere [13,14]. The audio files were available in English, Arabic, Farsi, French, Turkish, and Serbian (spoken by about 80% of the refugee population in the PHV). Before, the text material of the techniques had been translated by professional interpreters and translators into the respective language and then digitally recorded by native speakers. Except for the Arabic version, all versions were narrated by a female native speaker. The audio files and written instructions are available free of charge [40]. If desired, a printed instruction booklet is also available for a nominal fee.

Prior to the introductory session (T1), a baseline measurement including the Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) [41], the two-item Patient Health Questionnaire (PHQ-2) [42], the short version of the General Anxiety Disorder questionnaire (GAD-2) [43], the Self-Assessment Manikin scale (SAM) [44], and the distress thermometer of the Refugee Health Screener-15 (RHS-15 distress thermometer) [45] were used to assess participants’ mental distress.

The PC-PTSD-5 [41] assesses PTSD symptoms via a list of different trauma events and five binary questions (0 = “no” and 1 = “yes”) on re-experiencing, avoidance, physical reactions, emotional numbness, and trauma-distorted feelings of guilt and blame [41]. With a total score between 0 and 5, individuals with a score ≥3 are identified as patients with probable PTSD. The PC-PTSD-5 shows good sensitivity (.93), acceptable specificity (.85), and good acceptance by patients [46].

The PHQ-2 [42] assesses major depression via two items on anhedonia and depressed mood. Both items are rated on a scale of 0 (not at all) to 3 (nearly every day) and give a total score of 0 to 6. The PHQ-2 shows good construct validity (r from 0.67-0.87), good internal consistency (α=.83) [47]. An overall cut-off score at ≥3 provides a sensitivity of .61 to.87 and specificity of .86 to .92 for major depression in primary care and medical outpatients [42,47,48].

The GAD-2 [43] assesses anxiety disorders via two items on anxiousness and worrying. The GAD-2 ranges from 0 (not at all) to 3 (nearly every day) with a cut-off score of ≥3. The GAD-2 shows a sensitivity of .89 and specificity of .83 for generalized anxiety disorder [43,49]. Internal consistency reliability is acceptable (α=.83) [50].

The SAM [44] is a nonverbal, cross-cultural rating scale [51] widely used for diverse groups of patients, such as for traumatized patients or refugees [52-55]. The individual can choose between five manikin pictures representing the present affective state on the dimensions valence (sad to happy), arousal (exited to calm), and dominance (weak to strong) [53].

The RHS-15 [45] was developed specifically for refugees and asylum seekers. It comprises 14 symptom items that can be answered on a 5-point Likert-Scale. A “distress thermometer” assesses perceived distress on a visual analog scale ranging from 0 to 10. The RHS-15 authors define a screening as positive with a cut-off score set at ≥12 for the symptom items or ≥5 if the distress thermometer is used. The RHS-15 distress thermometer can be used independently and has a good sensitivity (.81-.95) and specificity (.86-.89) [45].

We used qualitative, semistructured interviews to obtain data illuminating the participants’ experiences with the audio files and audio-based stabilizing and guided imagery techniques. The semistructured interviews comprised key questions, which were followed by probing questions; for further details, clarifying questions could be added. Multimedia Appendix 1 shows the interview guidelines and key questions.

Quantitative statistical analysis was carried out by using the Statistical Package for the Social Sciences program version 24 [56]. Demographic variables and baseline characteristics were analyzed using descriptive statistics (frequencies, means, and standard deviations). The qualitative interviews were digitally recorded and transcribed verbatim by independent co-workers using the guidelines for interview transcription presented in Mayring [57]. Statements regarding the refugees’ practicing behavior were analyzed descriptively. The other research questions were analyzed with the software MAXQDA [58] following the principles of inductive content analysis described by Mayring [57]. Here, sentences are identified as the most basic units of meaning [59], summarized into relevant categories, and further grouped into main themes. The categories and main themes were subsequently discussed to reach consensus or to be adjusted if required [57]. The T2 and follow-up statements have been summarized to facilitate presentation; noteworthy differences between T2 and follow-up interviews are explicitly highlighted.

A total of 83 patients attending the psychosocial walk-in clinic in PHV were referred to treatment with audio-based stabilizing and guided imagery techniques. Of these, 42 patients (50%) attended the introductory session (T1). All patients attending the introductory session consented to participate. They were aged between 19 and 51 years (mean 33.67, SD 8.3). All patients were invited to attend a booster session nine days later. The booster session (T2) was attended by 19 of 42 patients (45%). Reasons for non-attendance were reallocation (n=7, 17%), self-initiated departure from PHV (n=4, 10%), conflicting appointments (n=2, 5%), as well as reported as inactive (n=1, 2%), hospital stay (n=1, 2%), and imprisonment (n=1, 2%). We do not know why the remaining 7 (17%) patients did not attend. For the follow-up interviews, we attempted to contact as many of the 42 patients as possible. We were unable to reach 18 patients (43%) owing to inactive or incorrect phone numbers, while 7 (17%) patients were not successfully contacted after three attempts. In total, we conducted follow-up interviews with 19 of the participating patients (45%). Table 1 shows the sample characteristics for the total sample of 42 patients attending at least the first session.

The baseline scores for PTSD, depression, anxiety disorders, perceived distress, and affective state are presented in Table 1. On average, the patients reported four trauma experiences (mean 4.02, SD 1.71, range 1-7). The most frequently reported traumatic events were experiencing torture (27/42, 64%), being physically or sexually assaulted or abused (25/42, 60%), being imprisoned (23/42, 55%), seeing someone being killed or seriously injured (23/42, 55%), experiencing a war (20/42, 48%), and losing a loved one through homicide or suicide (16/42, 38%). Except for one patient, all patients confirmed three trauma symptoms and fulfilled the criteria of a possible PTSD according to the PC-PTSD-5. Furthermore, 28 (66%) patients reported suffering from four to five different PTSD symptoms. Additionally, 30 patients (71%) fulfilled the criteria of major depression, and 32 patients (76%) displayed symptoms of a generalized anxiety disorder. Furthermore, 38 patients (90%) scored positive on emotional distress assessed by the RHS-15 distress thermometer.

Table 2 depicts the results of the practice behavior reported at T2 and follow-up.

We identified and coded 344 single statements from the T2 interviews and 334 single statements from the follow-up interviews. From these codes, we created twelve categories, which were then summarized into four main themes. Examples of each category are shown in Multimedia Appendix 2.

This study aimed to investigate the self-practice of stabilizing and guided imagery techniques via digital audio files in newly arrived refugees living in a state registration and reception center. The qualitative results show that the self-practice of audio-based stabilizing and guided imagery techniques can help traumatized individuals experience symptom relief in the early stages of arrival in their host country. Although some difficulties in practicing the exercise were reported, “The Inner Safe Place” was perceived as the most helpful technique in delivering positive inner images and feelings. However, self-practice of audio-based stabilizing and guided imagery techniques require a high degree of self-motivation and commitment from affected refugees. Finding such motivation and commitment may sometimes be overtaxing in light of impeding internal factors, such as lack of concentration, or postmigratory stressors, like lacking privacy in the accommodations.

Concerning aspects of the user application, the patients’ statements indicate that using audio files is feasible and practicable. Issues only arose because of device problems. Various studies have described that the majority of refugees own a smartphone, yet not everyone in this group has access to the internet [60]. In the current study, the audio file was transferred to the patient’s smartphone via USB cable or Bluetooth. The MP3 format appears to be a robust and simple format available offline for everyone. In a study by Zehetmair et al [14] assessing stabilizing and guided imagery techniques in a group setting, participating refugees voiced a desire for instructions to facilitate practicing the techniques between the face-to-face group sessions. By developing an audio-based approach in this study, every participant always had the technique instructions with them. The files are available for download [40].

Examining the participants’ practicing behavior, we found that 52% of the patients described the daily (to several times daily) self-practice of the stabilizing and guided imagery techniques at T2. However, the statements indicated a decreasing tendency of self-practice and more flexible use of the audio files at follow-up. On the one hand, this may be explained by the high degree of self-motivation and commitment the self-practice of the techniques requires of the highly burdened patients causing them to abate over time. Furthermore, the booster session could also have been perceived as a monitoring element, so they may have practiced more before T2 than after when they practiced at their own accord without an anchoring/monitoring session. Nevertheless, at follow-up, still 52% of the patients practiced the stabilizing and guided imagery techniques frequently, with statements ranging from daily to several times a week.

The qualitative results of the T2 and follow-up interviews showed that audio-based stabilizing and guided imagery techniques were able to alleviate the symptoms associated with mental stress. The participating refugees described changes in arousal levels, mood and empowerment, thoughts and concentration, as well as sleep and tension. Perceived symptom changes through the practice of stabilizing and guided imagery techniques immediately after practice or over time are consistent with other outcomes [13]. Several studies encourage the use of stabilizing and guided imagery techniques in traumatized patients: for example, increases in conscious action (eg, consciously change the attention focus) and decreases in hyperarousal, emotional numbness, and perceived stress have been shown [61,62]. These changes lead to an experience of improved situation control and self-efficacy [10,61,63]. According to Reddemann [63], the combination of self-calming elements and elements of internal process recognition increases internal stabilization.

Nevertheless, the participants described external and internal impeding factors for the self-practice of stabilizing and guided imagery techniques via audio file. Newly arrived refugees are faced with problems such as frequent reallocation, uncertainties regarding their asylum application, as well as uncertainties about social, cultural, or future-related aspects. Moreover, refugees in refugee camps report inhuman living conditions, forced passivity, and waiting, all of which exacerbate their feelings of a lack of control regarding their current situation [64-66]. Accordingly, the patients in our study reported that the stabilizing and guided imagery techniques provided them with short term symptom relief but were unable to offer any solutions for their overwhelming and stressful everyday life’s problems. Furthermore, our participants were not only preoccupied with worries about the present and future but also described experiencing trauma-related symptoms, which often made it difficult for them to stay focused or engage in the techniques. Although the audio files were designed to promote stabilization and distressing memory distancing, we cannot rule out that participants may be triggered by hearing the language of their home country, which is often strongly associated with trauma. Despite the high burden of traumatic symptoms, patients reported they were able to consciously shift the focus of their thoughts to the techniques.

“The Inner Safe Place” was considered the most helpful technique by the majority of patients. It helped patients experience positive feelings of security, hope, well-being, and freedom. These emotions are particularly meaningful and soothing for traumatized refugees who have been subjected to persecution, imprisonment, and torture [67,68]. Several of them were able to transfer the resulting positive feelings to their present situation. This ability can motivate the refugees to continue practicing the respective techniques. Guided imagery techniques aim at eliciting positive feelings that traumatized individuals often are unable to feel by creating an inner image that contrasts the traumatic re-experience imagery and is available in situations of overwhelming emotions and thoughts [10]. This further can facilitate self-distancing from the traumatic experiences and the associated symptoms of emotional overload and intrusions [69]. However, participants also reported encountering some difficulties with the technique as the positive inner images often clashed harshly with their realities in the present. On the one hand, this highlights that the patients were able to engage in the technique and felt comfortable at their imaginary inner place; on the other hand, it also underpins the effect of post migratory stressors by contrasting their current living situation in a state registration and reception center with the place they had imagined for themselves.

This study has several limitations. First, the study relies on self-reports regarding both the questionnaire assessment as well as the qualitative interviews. Therefore, a tendency towards compliant or socially desirable behavior or answers cannot be ruled out. Nevertheless, we conducted 38 interviews (19 at T2, 19 at follow-up) with n=27 of the total sample of 42 patients participating in the study, which is sufficient to achieve saturation for main themes in heterogeneous populations [70]. Second, the patients were of different ages, education, and country of origin. This heterogeneity limits the generalizability of our results but also reflects the realities of the sample group. Third, the PHV psychosocial walk-in clinic’s psychiatrists and psychotherapists recommended treatment with audio-based stabilizing and guided imagery techniques to N=83 refugees and asylum seekers. The study included 42 patients who took part in the study and attended the introductory session (T1), equivalent to a dropout rate of 50%. Unfortunately, we do not have any information about the reasons for non-attendance. However, among other reasons, logistical barriers, like reallocation to different accommodations, scheduling conflicts, missing the appointment, as well as treatment enrollment barriers, such as treatment-related insecurities and fears or symptom- and anticipated outcome-related motivational issues may be possible explanations Additionally, there was a high dropout rate of 55% between T1 and T2. As already experienced in previous studies [13,14,71], the registration and reception center presents a research setting that is inherently afflicted by frequent reallocation and high dropout rates. The high dropout rate limits the generalizability of our results and can further have facilitated the occurrence of the selection bias. Fourth, we cannot neglect that there might have been other circumstances that affected the patients’ symptom load. So, even though the patients attributed symptom changes to the self-practice of the techniques, psychopharmaceutic or other stabilizing effects cannot be ruled out. Nevertheless, the positive effect attribution leads to increased commitment and motivation to continue practicing the techniques. Fifth, the impact of the respective narrators’ voice characteristics (male, female, etc) was not further assessed in this study. However, none of the patients reported difficulties related to the narrator’s voice but rather gave positive feedback regarding the audio file narration during their interviews. However, we cannot rule out that some patients might have encountered problems with the specific voice narrating their audio file.

This study explored refugees’ perspectives on the self-practice of stabilizing and guided imagery techniques via digital audio files after they arrived in a state registration and reception center. The stabilizing and guided imagery techniques via audio files proved to be a practical and effective tool for self-help regardless of the patient’s country of origin or ethnic background. In sum, the participants reported more positive effects than difficulties with the audio-based stabilizing and guided imagery techniques. They described effects on cognitive, emotional, physical, and empowerment levels; difficulties encountered were associated with internal impeding factors, such as lack of commitment, concentration, and only experiencing short-term relief, or external hindering factors, such as lack of privacy in their accommodations. Particularly the use of “The Inner Safe Place” technique was reported to produce pleasant and self-calming feelings. However, the experience sometimes stood in stark contrast to the patients’ daily reality, making it difficult for some patients to cope with the difference. Overall, the qualitative data presented show promising results for the use of audio-based stabilizing and guided imagery techniques in this sample group.