Introduction:
A recent systematic review and meta-analysis on psychosocial interventions with traumaaffected refugees and asylum-seekers showed a rather small effect of interventions on PTSD. Thus, there is a need to explore alternative and adjunctive therapies to improve outcomes. In neurofeedback, the brainwave activity is fed back to the person as an auditory or visual signal, rewarding the person each time progress is made toward normalizing dysregulated neural activity. This may, as an example, imply movement from a state of hyperarousal towards calm alertness. The learning mechanism is at its base considered to be operant conditioning, where the behaviour of the participant—in this case, neurological activity—is gradually changed through repeated reinforcement. In neurofeedback, this simple learning mechanism is accelerated by continuous and instant feedback, with rewards occurring as often as every second.

Neurofeedback has been particularly applied and evaluated in the treatment of attention deficit hyperactivity disorder (ADHD). It has proven highly effective for reducing inattentiveness and impulsivity. Neurofeedback is also showing promising results in the treatment of depression, anxiety, insomnia, autism, addictions, and PTSD6 . A recent review of the effect of neurofeedback in the treatment of PTSD found that neurofeedback training appears effective in alleviating symptoms, and demonstrates changes in patients brainwave activity as well as their fMRI connectivity of core neurocognitive networks.
The study has three objectives:
To assess the recruitment and retention rate in a diverse sample of refugees offered neurofeedback as an adjunct therapy.
To assess patients' perceived satisfaction as well as potential discomfort related to the neurofeedback intervention.
To measure changes in symptoms during treatment in order to evaluate preliminary indications of treatment effects, and to inform a power calculation for a potential randomized controlled trial.

Methods:
40 participants will be included. Participants will be recruited among patients referred to treatment at the Competence Centre for Transcultural Psychiatry. The inclusion criteria are: being an adult (18 years or older) refugee or a person who has been family reunified with a refugee; having PTSD and psychological trauma experienced outside Denmark in the anamnesis. The exclusion criteria are current abuse of drugs or alcohol (F1x.24-F1x.26), severe psychotic disorder (defined as patients with an ICD-10 diagnosis F2x), or disorders involving mania (F30.1-F31.9). The participants will be offered neurofeedback after the first or second phase of treatment at CTP. As the primary outcome measure, we will use the Harvard Trauma Questionnaire (HTQ). As secondary outcome measures, we will use the Hopkins Symptom Checklist-25 (HSCL-25), the Sheehan Disability Scale (SDS), the WHO-Five Well-being Index (WHO-5), and the Hamilton interview-based rating scales for depression (Ham-D) and anxiety (Ham-A). Furthermore, at end of the intervention, all participants will be asked to complete a combined Satisfaction and Accept-ability Questionnaire (SAQ). The scales will be administered at baseline and again after 12 sessions.
Electroencephalography (EEG) will be recorded at the beginning and end of each session. Each recording will have a duration of three minutes. A cap with 21 electrodes is used for recording from 19 channels.

In-depth descriptions of the experience with neurofeedback will be collected in qualitative interviews with 5-6 patients. This will cover patients’ potential concerns about the intervention, particularly leading up to the first session, potential difficulties in understanding the procedure before eventually trying it, what attracted them to try the intervention, as well as whether—and if so how—it impacted their perceived stress and quality of life.

Expected results:
This pilot study evaluates a relatively new treatment for a severely distressed population. With this project we expect to have indications of the potential impact on several outcome measures that neurofeedback treatment might have, along with solid results on whether or not the treatment is both feasible and acceptable for refugees with PTSD. We expect to gain extensive knowledge on why treatment might be acceptable or not, what the participants are generally expecting from neurofeedback treatment and what apprehensions they might have.

Expected Impact:
The results generated in this project are expected to inform whether and how a full randomized controlled study of neurofeedback with refugees can be carried out. In addition, we expect the findings to inform how neurofeedback should initially be explained and presented to refugees with PTSD, before starting treatment. Knowing what to expect from neurofeedback treatment might be key to reducing treatment dropout.