Skip to main content An official website of the United States government Here's how you know Here's how you know Official websites use .gov A .gov website belongs to an official government organization in the United States. Secure .gov websites use HTTPS A lock ( Lock Locked padlock icon ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites. Search Log in Dashboard Publications Account settings Log out Search… Search NCBI Primary site navigation Search Logged in as: Dashboard Publications Account settings Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide PERMALINK Copy As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice Eur J Psychotraumatol . 2026 Mar 24;17(1):2643046. doi: 10.1080/20008066.2026.2643046 Search in PMC Search in PubMed View in NLM Catalog Add to search Show available content in en es Assessing trauma in refugees using ITEM and ITI: clinician’s reported challenges and ethical-professional considerations Evaluación del trauma en refugiados mediante la ITI y la ITEM: desafíos y consideraciones ético-profesionales reportados por los profesionales clínicos Frederik Bernt Scharff Frederik Bernt Scharff a DIGNITY: Danish Institute Against Torture, Copenhagen, Denmark Find articles by Frederik Bernt Scharff a , Sofie Grimshave Bangsgaard Sofie Grimshave Bangsgaard a DIGNITY: Danish Institute Against Torture, Copenhagen, Denmark Find articles by Sofie Grimshave Bangsgaard a , Thomas Brudholm Thomas Brudholm b Department for Cross-Cultural and Regional Studies, University of Copenhagen, Copenhagen, Denmark Find articles by Thomas Brudholm b , Lotte Segal Lotte Segal c Social Anthropology, School of Social and Political Sciences, University of Edinburgh, Edinburgh, UK Find articles by Lotte Segal c , Linda Nordin Linda Nordin a DIGNITY: Danish Institute Against Torture, Copenhagen, Denmark d Department of Psychology, Lund University, Lund, Sweden Find articles by Linda Nordin a, d , Sabina Palic Sabina Palic a DIGNITY: Danish Institute Against Torture, Copenhagen, Denmark e Department for Treatment of Borderline Personality Disorder and Self-Harm, Mental Health Centre Glostrup, Copenhagen University Hospital – Amager and Hvidovre, Copenhagen, Denmark Find articles by Sabina Palic a, e , Marie Høgh Thøgersen Marie Høgh Thøgersen a DIGNITY: Danish Institute Against Torture, Copenhagen, Denmark f Department of Psychology, University of Copenhagen, Copenhagen, Denmark g Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark Find articles by Marie Høgh Thøgersen a, f, g, CONTACT, ✉ Author information Article notes Copyright and License information a DIGNITY: Danish Institute Against Torture, Copenhagen, Denmark b Department for Cross-Cultural and Regional Studies, University of Copenhagen, Copenhagen, Denmark c Social Anthropology, School of Social and Political Sciences, University of Edinburgh, Edinburgh, UK d Department of Psychology, Lund University, Lund, Sweden e Department for Treatment of Borderline Personality Disorder and Self-Harm, Mental Health Centre Glostrup, Copenhagen University Hospital – Amager and Hvidovre, Copenhagen, Denmark f Department of Psychology, University of Copenhagen, Copenhagen, Denmark g Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark CONTACT Marie Høgh Thøgersen [email protected] Pindosvej 18, 2300 kbh S. Copenhagen, Denmark ✉ Email: [email protected] Received 2025 Sep 11; Accepted 2026 Mar 2; Collection date 2026. © 2026 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License ( http://creativecommons.org/licenses/by-nc/4.0/ ), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent. PMC Copyright notice PMCID: PMC13015056 PMID: 41873514 ABSTRACT Introduction: This study investigates clinical reported challenges and ethical-professional considerations related to the use of the International Trauma Interview (ITI) and International Trauma Exposure Measure (ITEM) with trauma-affected refugees in Denmark. These instruments were implemented in 2023 across several Danish refugee rehabilitation clinics to screen for trauma and assess ICD-11 PTSD and Complex PTSD diagnoses. Methods: Data collection included individual and focus group interviews with 12 clinical psychologists administering ITEM and ITI across three refugee treatment clinics. Interviews were analyzed and coded to identify key issues experienced by clinicians regarding their use of ITEM and ITI with refugee patients. Results: All clinicians reported challenges using ITEM and/or ITI, with the majority expressing ethical-professional considerations. Main themes included: When and how to administer the measures, to whom, and the perceived appropriateness of the content for refugees. Simultaneously, all clinicians found the measures clinically useful to some extent. Conclusions: Clinicians’ ethical and professional considerations on the use of ITI and ITEM with refugees indicated multiple ways to improve the measures’ clinical utility and reduce patient distress. Key recommendations included introducing more flexible timing of assessments, implementing training on integrating and communicating assessment findings to patients and revising the language to be clearer and more culturally sensitive. Further regular supervision and dedicated spaces for discussing challenges may be needed to support the use of the measures in a refugee setting. KEYWORDS: International Trauma Interview (ITI) complex PTSD, refugee mental health, cross cultural asessment, implementation in clinical practice, clinician perspectives HIGHLIGHTS Use of the International Trauma Interview and International Trauma Exposure Measure with refugees helps target treatment, while it also causes patient distress. Routine use of ITI and ITEM with refugees requires more flexible assessment timing, more training on integrating results in treatment plans, and more clinical supervision. Revising the language of the ITI and ITEM to better reflect cultural and educational diversity may improve the clinical utility in refugee settings. Abstract Introducción: Este estudio investiga los desafíos y consideraciones ético-profesionales reportados por los profesionales clínicos en relación con el uso de la Entrevista Internacional de Trauma (ITI por sus siglas en ingles) y la Medida Internacional de Exposición al Trauma (ITEM por sus siglas en ingles) en refugiados afectados por trauma en Dinamarca. Estos instrumentos se implementaron en 2023 en varias clínicas de rehabilitación para refugiados daneses para detectar traumas y evaluar los diagnósticos de TEPT y TEPT complejo según la CIE-11. Métodos: La recopilación de datos incluyó entrevistas individuales y grupales con 12 psicólogos clínicos que administraban la ITEM y la ITI en tres clínicas de tratamiento para refugiados. Las entrevistas se analizaron y codificaron para identificar los problemas clave que experimentaban los profesionales clínicos en relación con el uso de la ITEM e ITI en pacientes refugiados. Resultados: Todos los profesionales clínicos reportaron dificultades al usar la ITEM y/o la ITI, y la mayoría expresó consideraciones ético-profesionales. Los temas principales incluyeron: Cuándo y cómo administrar las medidas, a quién y la pertinencia percibida del contenido para los refugiados. Simultáneamente, todos los profesionales clínicos encontraron las medidas clínicamente útiles en cierta medida. Conclusiones: Si bien reconocieron la importancia clínica del conocimiento generado, los profesionales clínicos expresaron diversas consideraciones ético-profesionales asociadas con el uso de ITEM e ITI en una población de refugiados traumatizados. Se requieren revisiones del contenido, los procedimientos de administración y la capacitación para abordar esto. PALABRAS CLAVE: Entrevista Internacional de Trauma, salud mental de refugiados, evaluación intercultural, implementación en la práctica clínica, perspectivas de los clínicos 1. Introduction Refugees experience high rates of trauma-related mental health disorders (Patanè et al., 2022 ), underscoring the need for reliable and clinically feasible trauma assessment tools to guide treatment decisions. The introduction of ICD-11 PTSD and C-PTSD diagnoses has necessitated the development of new measures, such as the International Trauma Interview (ITI) and the International Trauma Exposure Measure (ITEM), designed to support diagnostic assessment of these disorders (Hyland et al., 2021 ; Roberts et al., 2022 ). In 2023, routine diagnostic assessment using these two measures was implemented across four Danish mental health clinics that provide outpatient treatment for trauma-affected refugees, as part of the Danish Trauma Database (DTD) collaboration (Thøgersen et al., 2023 ). With 37 clinical psychologists across the four clinics (Thøgersen et al., 2023 ), it was decided that the ITI would be administered by clinical psychologists. To support its implementation, regular meetings were held, during which the majority of psychologists raised concerns about the assessment procedures. These concerns were related to the suitability, clinical value, and ethical implications of using these measures with trauma-affected refugees, including the potential for the instruments to cause high levels of patient distress. Given that clinicians’ engagement was key to successful implementation, it was considered imperative to address and explore their concerns. The clinicians' concerns align with a growing body of literature that highlights significant shortcomings in the cultural, conceptual, and linguistic sensitivity, and consequently the clinical utility, of Western-developed trauma and PTSD diagnostic measures for refugee populations (Heim et al., 2022 ; Magwood et al., 2023 ; Patel & Hall, 2021 ; Wells et al., 2015 ). Despite these potential issues, no studies have, to our knowledge, examined to what extent the ITI and ITEM are suitable for clinical use in refugee populations (Hyland et al., 2021 ; Roberts et al., 2025 ). Beyond the potential negative impact on patients, ethical dilemmas in clinical work may give rise to moral distress when clinicians are prevented by institutional constraints from acting in accordance with their professional judgement (Lamiani et al., 2017 ). Moral distress has been linked to a range of negative outcomes including compassion fatigue, burnout, posttraumatic stress, and low staff retention (Lamiani et al., 2017 ; Wilson et al., 2024 ) – issues that are particularly relevant in refugee care, where such risks are well-documented (Kramer et al., 2018 ; Schouler-Ocak & Iris, 2023 ). However, Austin et al. ( 2005 ) suggest that beyond these adverse outcomes, clinicians’ moral distress may offer valuable insights into clinical practice and help identify areas for improvement. In light of this, clinicians’ concerns at the DTD clinics regarding the ITI–ITEM assessment procedures may serve as important indicators of how these diagnostic tools perform in real-world clinical settings. Exploring these concerns can help clarify practical and procedural barriers to successful implementation and point towards strategies to address them. Contrary to Austin et al. ( 2005 ), this study examines a broader range of ethical-professional reflections beyond moral distress, focusing on how clinicians’ practice-related concerns can inform the ITI–ITEM assessment procedure. Our aim is to identify the key issues clinicians experience when using ITEM and ITI with refugee patients and to translate these insights into recommendations for improving the assessment procedures, reducing organizational constraints, and potentially revising the content of the measures. 2. Methods To explore clinicians’ experiences and perceptions related to the use of ITI and ITEM with trauma-affected refugees, we employed a staggered qualitative design informed by grounded theory. The design comprised: (1) Explorative ethnographic participant observation within a Danish rehabilitation clinic for trauma-affected refugees; (2) a focus group interview with clinical staff working at this clinic; and (3) individual semi-structured interviews with clinical staff at three refugee rehabilitation clinics (see Figure 1 for an overview of the design). This approach was applied to ensure that interview questions and thematic focus were anchored in immediate clinical and practice-based concerns. Figure 1. Open in a new tab Flow chart of study design. Note: PHIL: Philosopher, ANTH: Anthropologist, PSYCH: Psychologist, SOC: Sociologist, IDI: Individual interview, FGI: Focus group interview, Clinic 1: Clinic hosting research project, Clinic 2 & 3: Clinics participating in the DTD. The study was conducted by an Interdisciplinary Research Team consisting of a philosopher (PhD), an anthropologist (PhD), a sociologist (MSc), and two psychologists (PhD). The philosopher and anthropologist both work with applied ethics and have experience interviewing vulnerable populations. The two psychologists and the sociologist were employed at the clinic where the study originated (Clinic 1) and possessed extensive familiarity with the clinical context. The study formed part of an interdisciplinary research project on ethical responses to serious harm ( Afterthoughts , Velux Foundation grant no. 40436). All participating clinics are specialized outpatient clinics providing multidisciplinary treatment for trauma-affected refugees through teams that included psychiatrists, psychologists, social workers, and physiotherapists (for additional information on the clinics see Thøgersen et al., 2023 ). The ITI and ITEM were administered exclusively by psychologists. All trauma-affected refugees referred to the clinics held residence permits and had been diagnosed with mental disorders associated with traumatic experience related to their refugee backgrounds. 2.1. Data collection Data collection was conducted over three phases. The participant observation was led by the philosopher who attended staff meetings, therapeutic sessions, and informal workplace interactions at clinic 1. The philosopher and anthropologist also attended ITI supervision sessions every six weeks. As external collaborators, they provided an outside perspective and helped minimize insider bias. These exploratory methods revealed the presence of ethical-professional concerns among clinicians regarding the use of ITI and ITEM. To explore these concerns, we conducted a focus group interview designed to elicit shared reflections and co-develop questions for subsequent individual interviews. The focus group was conducted by the 1st, 3rd, 4th and last author and lasted 180 min. All clinicians working with ITI and ITEM in the clinic were invited for participation in the focus group. All six clinicians consented to participate, but two were unable to participate due to sickness and unforeseen clinical demands. Recognizing that focus group interviews tend to produce only information participants feel comfortable sharing collectively, leaving more sensitive or professionally challenging issues unspoken, we subsequently conducted ten individual interviews. These individual interviews offered a confidential space for participants to elaborate on concerns raised in the focus groups. To minimize selection bias and increase representability and sensitivity to different organizational structures, all four DTD clinics using ITI and ITEM were invited to participate and three clinics consented. All clinicians using the ITI and ITEM at the three clinics were invited to participate in the interviews. Participation was voluntary, and interviews were conducted on a rolling basis with clinicians who provided informed consent. Two clinicians who took part in the focus group also participated in individual interviews, allowing for further exploration of themes they had raised collectively. Recruitment continued until the primary interviewer judged that data saturation had been reached. The interviews were led by the anthropologist (4th author) who had extensive experience with qualitative interviewing. Toreduce potential peer-related bias, two secondary interviewers (1st and 3rd authors) alternated between interviews to ensure multiple perspectives were represented in the interview process. Individual interviews lasted 35–60 min. The interview guide included questions on the participants’ level of clinical experience followed by five questions on the use of ITEM and ITI respectively. Data collection was conducted between January 2023 and October 2024. All interviewees were trained clinical psychologists (MSc Psych) who had received the ITI training course recommended by the international ITI consortium. The interviewees’ clinical experience with refugees ranged from 0.5 to 20 years. All interviews were audio recorded, transcribed and then translated from Danish to English. Collected data were processed according to current EU General Data Protection Regulation (GDPR) standards. 2.2. Data analysis The interviews were analyzed using thematic analysis (Braun & Clarke, 2006 ). Coding was conducted by the two psychologists (1st and last author) and the sociologist (2nd author). The inclusion of the sociologist helped ensure that the coding process was not shaped solely by a clinical psychological perspective. The analysis was conducted in three phases (see Figure 1 ). First, the researchers familiarized themselves with the data by reading a subset of the interviews, including the focus group interview and four individual interviews, conducting open coding without a theoretical start list, to generate initial codes. Second, these preliminary codes were applied to the full dataset to refine the coding scheme and identify themes among the codes. Third, all interviews were re-analyzed to review, define and name the themes, resulting in the identification of three overarching themes. Each phase was conducted independently by all three researchers, after which the team compared and integrated their interpretations. 3. Results Refugees assessed with ITEM and ITI in the DTD collaboration originated from a wide range of countries with the largest categories being Syria (24.5%), Ukraine (15.3%), Iraq (9.4%), Afghanistan (7.8%), Bosnia–Herzegovina (7.0%), Lebanon (6.8%), Iran (6.1%), Somalia (4.6%) and Palestine (2.6%). The assessed refugees had experienced, on average, 10.6 (SD = 3.8) different trauma types as measured on ITEM, with the most frequently endorsed trauma types being: War exposure (87.2%), lost someone close in a terrible way (78.3%), were humiliated, oppressed, or violated (72.4%), were made to feel unloved, unwelcome, or worthless (71.1%), were physically assaulted by someone other than a parent or guardian (70.7%), someone threatened your life with a weapon (69.1%) and witnessed someone experiencing extreme suffering or dying (67.8%). 3.1. Qualitative results The analysis identified three central themes consistently reported by clinicians, reflecting recurring considerations and concerns regarding the timing, administration, and purpose of ITI and ITEM for trauma-affected refugees. The following sections provide an in-depth exploration of these three themes. 3.1.1. Theme I: When Across the clinics, ITEM and ITI are administered as part of the diagnostic assessment during the first or second meeting with a psychologist. The timing of the assessment raised concerns amongst several clinicians, despite their awareness that the avoidance of trauma reminders is a central coping mechanism for dealing with traumatic memories and trauma-related feelings of shame or guilt for patients with PTSD. Clinicians noted that some patients struggle with disclosing vulnerable information about traumatic experiences early in the treatment: There are some men for whom the sexual questions can be very difficult, because it is very shameful for them to talk about whether they've been victims of sexual abuse. Then there's the question about whether they've been perpetrators themselves. And I honestly think that if they had been, the first time they meet me, they would never ever admit it. All clinicians emphasized that a strong therapeutic alliance is key to encouraging patients to share sensitive details of their trauma histories. Supporting this observation, several clinicians reported instances where patients, despite initially denying certain experiences during ITEM, later revealed these events as treatment progressed. This suggests that administering ITEM before the trust of the therapeutic alliance has been established may lead to underreporting of certain trauma types and lower the validity of the ITEM. Not everyone who comes here knows exactly who we are, where we fit in the bigger picture, or how we relate to other authorities. […] So often, part of the process is just helping them feel that there are people here they can trust. We don’t start with them trusting us and being ready to open up about everything. It’s really about rebuilding that trust. Clinicians suggested that insufficient time to adequately explain the purpose of treatment and clarify the confidentiality of their role prior to completing ITEM limits its validity. Further, for some patients, distrust of authorities may be exacerbated by difficulties distinguishing between clinicians and other representatives of the Danish welfare state. Especially for patients with traumatic experiences centred around interrogation, the introduction of ITEM before trust is established in the therapeutic process could function as a trauma reminder and potentially cause ITEM to feel like an interrogation. When this happens, the requirement to administer ITEM risks clashing with clinicians’ professional ethos and identity as caregivers and custodians of the clinic, as a safe therapeutic space. Hence, for several of our informants, the timing of the interviews emerged as an issue requiring ethical and professional consideration. Meanwhile, other clinicians expressed that being too cautious about evoking negative reactions could itself be counterproductive. I think, as clinicians, we sometimes tend to overprotect our clients. We forget how much they’ve already survived and that they’ve made it this far. They are actually ready for this. I know that some aren't, but most are […]. That's also why I’ve used this [ITEM] from the beginning. I think it makes sense to get a clear overview of what they have been dealing with. Supporting this view, one clinician suggested that when patients share their trauma experiences during ITEM, it can foster empathy and support from the clinician, thereby helping to establish the therapeutic alliance early in the treatment process. In our view, the overall ambiguity in the clinicians’ normative reflections regarding the timing of ITEM reflect an inescapable and recurrent challenge in trauma-focused treatment, namely of balancing the need to create a safe therapeutic space with the necessity of confronting the trauma history to facilitate meaningful treatment progress. [On what characterizes patients less ready for ITI or ITEM] Avoidance plays a big role—the degree of avoidance … the level of hypervigilance as well, and whether it starts to border on something paranoid. I mean, we do have some cases where it's on a continuum, and then eventually it’s almost a psychotic symptom, like a paranoid delusion even though that can, of course, be part of a PTSD diagnosis. Also, the therapeutic alliance - how quickly they bond with me and how guarded they are … cases where there are relational difficulties may also be more challenging, and many of them - especially those with complex PTSD - struggle to be with themselves and with others. Interpersonal difficulties and that kind of thing. Clinicians relied on their clinical judgement to assess whether patients were ‘ready’ or prepared for the assessment. A majority of clinicians conveyed that the lack of flexibility created by the fixed timing of both ITI and ITEM limited their ability to determine patients’ readiness to complete the assessment in a meaningful way. Furthermore, while most clinicians felt that the majority of patients were ready to talk about their trauma, they also agreed that in some cases the patient was not ready. In such cases, a requirement to proceed with the assessment produces an ethical dilemma, where following institutional procedure clashes with the clinician’s judgement of proper timing and the patient's best interest. Specifically, regarding ITI, clinicians noted that patients with elevated levels of symptom severity (e.g. C-PTSD with severe affective dysregulation) and severe psychiatric comorbidity often struggle to complete ITI. 3.1.2. Theme II: How The second major theme was how ITEM and ITI were administered to trauma-affected refugees and the contents of the measures. It’s about things that we psychologists are really knowledgeable about, but it’s pretty difficult concepts for the patient to understand - what on earth does this actually mean? Sometimes you have to repeat the same thing many times and provide a lot of examples for them to understand what you’re saying. A majority of clinicians raised concern about the suitability of ITEM and ITI for trauma-affected refugees with serious mental illness. Several clinicians noted that the likelihood of successful completion of the two assessments depends on the patients’ social, cultural, and cognitive resources. Specifically, clinicians reported that some patients experienced the language in ITI as overly complicated, had difficulty separating questions, and lacked familiarity with the psychologized language. These challenges were particularly pronounced in patients with lower levels of education and functional capacity. In such cases, clinicians reported the need for frequent repetition and reframing of questions and noted answers of questionable validity. This contributed to longer sessions and cognitive fatigue in patients. Clinicians also expressed that questions in both ITEM and ITI were emotionally challenging for some of the patients, leading to dissociative episodes, affective outbursts, and general distress. This emotional impact extended to clinicians themselves, leading to distress, and compensatory behaviours to maintain the therapeutic alliance, and was thus a cause of ethical-professional concern. I often catch myself being very apologetic when I have to do it because I find it hard, or because the questions are tough. I give a lot of disclaimers along the way […] and some of the feedback has been, that it sometimes feels a bit abusive because the questions are so direct […] it can also be exhausting for me on a personal level to have to be an excuse for myself in a work situation. Regarding ITI, some clinicians reported that the question ‘Do you feel like a failure?’ was particularly challenging, especially for patients with C-PTSD. In ITEM, the questions regarding sexual trauma were reported as shameful for subgroups of the population. Furthermore, the question regarding the worst trauma was deemed inappropriate for patients exposed to multiple, high severity traumas. According to several clinicians, some patients perceived the question as an indication that their traumatic experiences were not understood. This is especially pertinent for refugee patients with C-PTSD as they often experience prolonged exposure to adversity such as abuse, war, torture, or captivity. Assessing which traumas are the worst they've experienced is often really difficult. This is where I see most patients becoming irritable or sad. I think this point can be the most damaging for the alliance because they feel something is being neglected when asked to pinpoint the very worst, since everything has been terrible. A clinician summarized the difficulties regarding ITI and ITEM with a patient’s words: “This interview is definitely not made for people like us.” Interview duration was a recurring theme. Many clinicians reported that due to the complexity of the population and the interview, ITI was difficult to conduct in a timely manner. This led the interview to be conducted over multiple taxing sessions for the patients, leading to fatigue, distress, and frustration, with clinicians noting that it could result in task avoidance for both patients and clinicians: It’s a long interview […] And the target group is generally less capable. I think there’s a lot of it that they don’t fully understand. I have to repeat many things […] Many of them get triggered and come into contact with all these difficult traumas and stressors during the session […] But I think it’s a bit of a mix of them having to answer something so difficult and hard to handle, for such a long time […] Additionally, I sense that some psychologists may experience a degree of avoidance towards the task. (As clinicians,) we are also affected by our patients-many of whom display avoidance as a core symptom. The difficulty of conducting the interviews in a timely manner was contrasted with a sometimes conflicting wish to allow time for validating and engaging with the patients’ responses to the instruments. We had a patient who had talked extensively about episodes of anger as a reaction to his traumas. He began expressing feelings of guilt and shame related to that. And in relation to his family, and what it had caused. However, the interview was running long, and in that situation, there was definitely no opportunity to explore it further, because we had to proceed to the next (section) To manage the tension between time management and proper care, one of the more experienced clinicians suggested that a shorter version of the ITI could be created to address this issue. How to administer the measures in a meaningful way : A central theme across interviews was how to administer the measures. Some clinicians reported that strictly following the interview guide could provide false diagnostic negatives and that diverging from it could ease the administration considerably. For example, sometimes: None of what they’re saying points in the direction of PTSD, but my overall impression, or the things that have come up when we've talked in a less structured way, actually show that they have more symptoms and a lower level of functioning than what’s been indicated. Level of clinical experience influenced how flexibly clinicians administered the measures. However, across experience levels, many clinicians expressed a need for ongoing supervision in the use of ITI and ITEM For every ITI (interview I have completed), I can see (from my written assessments) That l I've written “needs supervision” across all of it. Regarding ITEM, a recurring theme was whether to administer the instrument as self-report or more like an interview. Some clinicians feared that self-reporting might trigger unregulated trauma-reexperiencing due to the direct trauma-related questions. Contrary, other clinicians were of the opinion that letting patients self-report tended to decrease activation of the patient’s trauma experiences and conveyed that it felt like a protective way to allow the patient to report their trauma. The thing about letting people self-report ITEM, I think it's quite responsible, actually, in terms of giving them the opportunity to share it in a relatively non-threatening way […] they don't have to look at me and tell me what they've been exposed to, but instead, they sit there and check things off themselves. Still, clinicians emphasized the importance of following up on the content of ITEM to avoid patients from feeling that their disclosure of important trauma was ignored. Sometimes I don’t (follow-up) and that's the problem, because then what does it do for them if they've said something, but no one reacts to it? In sum, clinicians described the administration of ITI and ITEM as requiring significant skill and attentiveness, particularly in terms of language, emotional responses, timing, and the establishment of a trusting therapeutic relationship. The complexity of the instruments intensified the already demanding nature of clinical work with trauma-affected refugee populations. 3.1.3. Theme III: Why The last recurring theme present across interviews concerned why clinicians found it relevant to use ITEM and ITI in treatment of refugee patients. Most of the clinicians were of the opinion that both instruments provided valuable clinical information for refugee patients. Two key reasons emerged for their perceived usefulness. 3.1.3.1. Treatment focus Most clinicians assessed the measures to be useful for guiding the focus in subsequent treatment. Especially the DSO section of ITI was seen to reveal a new dimension of the patient’s symptom complexity due to the focus on relationships, affect regulation, and self-image. In the complex PTSD part, the entire experience of the distance one feels towards other people, along with this negative self-image, becomes very apparent […] It is also here that I can generate ideas for a treatment plan regarding where we should intervene and how. Additionally, there are indeed instances where I can see that, yes, it has affected something in the relationship with others, but there is actually a reasonably well-preserved self-perception […] I might not have anticipated that upon first meeting this person. Furthermore, some clinicians argued that understanding the full pattern and intensity of the patients’ PTSD and C-PTSD symptoms and trauma load was helpful in targeting treatment: I think that ITI provides me with a lot of information. So, I also feel that I can understand some symptoms much more than previously. And the aspect of doing it systematically, so it’s not just what stands out the most when we talk about it, I mean, to ask about the entire symptom picture. A recurring consideration across interviews was clinicians’ ability to balance the benefits of conducting ITI versus the costs with regards to information gained, allocation of limited treatment time and potential patient distress. 3.1.3.2. Trauma anamnesis Most clinicians reported that, despite the challenges associated with ITEM, the detailed trauma anamnesis it provided was clinically valuable. Several clinicians emphasized that ITEM helped ensure that significant traumatic events-the ones patients may not have disclosed spontaneously-were identified and could be integrated into treatment planning. I have previously encountered situations where central traumas only emerged later in the (therapeutic) process, raising concerns about whether timely intervention was still possible, and whether we have been focusing on something completely wrong until now? Some clinicians even highlighted that ITEM was useful in identifying trauma among patients who initially were not included in the target group for treatment. Identifying their trauma allowed these patients to receive treatment. It has helped uncover the extent of traumatization that otherwise wouldn’t have been possible. There are many patients, (..) who come in and you think, okay, they don’t belong to the target group at all and maybe haven’t been exposed to anything, and then when you ask them the right questions, you actually find out that it’s not war-related trauma, but there are other types of trauma. Several clinicians nonetheless expressed that although they found the instruments useful, they struggled with effectively communicating the purpose and value of the assessments to the patients. In some cases, the inability to explain the rationale behind the measures was a source of professional discomfort. This led some to emphasize that adequate preparation of clinicians should include an explanation of the rationale for using the measures in a language and style appropriate for the patient group. There is something counterintuitive about being a therapist and doing a trauma anamnesis […] it reactivates a trauma […] so you really need to be clear on why you’re doing this. I have referred to it as a necessary form of torment because we need to understand what they are struggling with to help them and to determine whether we can help them. In sum, clinicians acknowledged the clinical value of ITEM and ITI but emphasized the need for additional guidance on how to integrate the information gathered from the assessment in subsequent clinical practice. Clinicians highlighted a need for support in facilitating conversations with patients about the measures in the follow-up sessions, thus alerting us to the need for management of the measures beyond the individual clinician, involving supervision and discussion in how to balance competing objectives of routine assessment and a duty of care. 4. Discussion & conclusion This study identified three central themes, reflecting recurring considerations raised by clinicians concerning the use of ITEM and ITI with trauma-affected refugees. The first theme relates to the timing of assessments. In line with the trauma-informed guidelines for assessment (Sweeney et al., 2022 ), clinicians described issues with early administration of measures, especially for patients with severe symptoms, including psychiatric comorbidity or low levels of functioning. This may reflect a fundamental clinical dilemma in PTSD treatment: Balancing the creation of a compassionate and secure therapeutic environment that promotes trust and rapport while guiding patients through distressing yet essential processes to address trauma-related symptoms (Gjerstad et al., 2024 ; Olff et al., 2020 ; Sweeney et al., 2022 ). An issue in the treatment of PTSD is the patient’s avoidance behaviours, which makes initial engagement in trauma-focused therapy challenging. Clinicians must navigate between validating patients’ emotional needs and motivating them to actively participate in the treatment process (Gjerstad et al., 2024 ; Zoellner et al., 2011 ). Our analysis indicated that clinicians found that the routine use of ITEM and/or ITI at the start of treatment could complicate this balance. This is pertinent with trauma-affected refugees, who present with considerable cultural heterogeneity and variation in symptom severity, levels of functioning, social trust, post-migratory stressors, and comorbidity (Byrow et al., 2022 ; Lenferink et al., 2022 ). Such variation means achieving this balance varies more between patients compared to other populations. Therefore, in line with the guidelines for trauma-informed assessment (Sweeney et al., 2022 ), organizations treating refugees may benefit from a stronger focus on a flexible time framework for assessment, with possibilities for including trust and relationship-building sessions prior to assessment. For patients with comorbidity or symptom severity where PTSD treatment would not be the first intervention, early use of the instruments may be problematic as the burden incurred by the assessment for patients can outweigh its clinical value. However, for patients scheduled for PTSD treatment, the early use of the instruments may help clinicians and patients challenge avoidance behaviours. This was underscored by interviewees who expressed that they felt some clinicians tended to be overprotective of their patients to minimize their distress. This is problematic as studies indicate that despite experiencing distress, patients tolerate and benefit from trauma work and that some level of emotional activation may be necessary for the treatment to be effective (Gjerstad et al., 2024 ; Olff et al., 2020 ; Zoellner et al., 2011 ). The second theme that led to professional-ethical considerations amongst clinicians was how ITEM and ITI are constructed and administered. Clinicians expressed concerns about the content of ITI for use with low-functioning trauma-affected refugees. This was primarily centred around the language in the interview, which was deemed overly complicated, psychologized and somewhat lacking in cultural sensitivity. This made questions difficult for patients to understand and could make answers difficult to interpret for clinicians, reducing the validity of diagnosis. Consequently, assessments were often split into multiple appointments, placing an extra burden on patients and delaying the start of psychotherapy. Multiple clinicians reported frustration with the limited options for addressing this beyond reformulating all questions, causing us to propose that these issues may have implications beyond causing distress for clients and clinicians: In our interviews, several clinicians reported that following the ITI interview guide closely could, in some cases, lead to no diagnosis for patients who, on further examination, did suffer from PTSD. Adjusting the language in ITI to be more culturally and educationally sensitive may help create a more valid and easier-to-administer interview. Providing guidelines for how to follow-up on interview questions that provide inadequate answers with different patient groups could ease administration. For ITEM, our results suggest the measure should be administered as a questionnaire, but with a clinician present to safeguard against strong reactions. The clinicians’ concern related to identifying the ‘worst’ trauma in ITEM may be mitigated by aligning ITEM with the newest version of ITI, which has been adjusted to allow for multiple traumas to be categorized as index trauma for PTSD diagnosis, to acknowledge the issue of multi-traumatization (Roberts et al., 2022 ). The clinical value of ITEM and ITI was further explored in the third theme of our analysis, which centred on the value of using ITEM and ITI. Clinicians reported that both ITEM and ITI could inform their treatment plans and nuance their understanding of the patient’s trauma exposure and symptom complexity. However, they underlined that the clinical value should be weighed against the burden for patients, clinicians, and the therapeutic alliance. A large part of these costs seemed amplified by the timing, content and administration issues described above. An important point that emerged from our study was the critical need for training and ongoing supervision in fully realizing the clinical potential of ITEM and ITI. While more experienced clinicians generally reported fewer challenges and more clinical benefits in using the instruments, they emphasized the need for systematic clinical supervision during the implementation phase. Systematic clinical supervision is likely to alleviate the distress clinicians may experience when using the instruments in patient interactions and enhance the clinical usability of the assessments. To further improve implementation and reduce clinician concern beyond conventional supervision, and in accordance with philosopher and ethicist Margaret Walker’s approach to practice-based clinical ethics (Walker, 1993 ), we suggest institutionalizing ‘open moral-reflective spaces’ (Walker, 1993 , p. 38). That is, times and places for reflection on dilemmas and concerns that emerge in clinical practice, especially when new practices and procedures are implemented. Such spaces cannot be taken for granted in the tightly scheduled, goal-oriented everyday life of a modern clinic. A vital objective hereof is to make common discussion of given procedures and ethical concerns ‘professionally acceptable’ and to encourage ‘clinicians to think of moral questions about therapeutic decisions as a matter of public analysis, rather than a matter of intuition or private conscience’ (Walker, 1993 ). Although the clinicians generally recognized the assessments as clinically valuable, they almost unanimously reported that the routine use of ITEM and ITI led to situations they experienced as ethically and professionally distressing. It may be impossible to avoid distress in the work with trauma-affected refugees due to the traumatic experiences and emotional pain of the patients, and the exposure-based focus of trauma treatment. However, the inevitability of distress serves to underline the importance of working to mitigate it through the optimization of clinical procedures. Guidelines for trauma-informed assessment underline eight evidence-based principles on the organizational, patient, and therapist levels, which can assist treatment-providers in balancing this complex assessment task (Sweeney et al., 2022 ). The clinicians’ reflections presented in this article indicate that they are aware of these practices. However, the ethical and professional dilemmas presented might indicate a need for higher awareness and better implementation of the principles on the organizational level. 4.1. Limitations Engaging an interdisciplinary research team likely enhanced the analytic perspective and reduced discipline-specific bias. Nevertheless, this study has several limitations. It relies exclusively on clinicians’ perspectives, and patients’ experiences of ITEM and ITI were not explored. Consequently, the reported impact on patients reflects clinicians’ interpretations rather than patients’ accounts. Further, the ethnographic observations were conducted at one site, and the number of interviews was limited (n = 12), which may restrict the range of perspectives represented. In addition, the voluntary sampling approach may have introduced self-selection bias as clinicians’ existing views or workload may have influenced participation, potentially limiting the generalizability of the findings. This was partly mitigated by including clinicians from three different clinics, ensuring representation from varied organizational contexts. Three of the researchers were employed within one clinic, which may have influenced both data collection and interpretation. The involvement of two external researchers helped mitigate this risk, particularly in the initial stages where ethical-professional concerns emerged, but insider-outsider dynamics may still have influenced the analytic process. The decision to conduct ethnographic work at only one clinic reflects the substantial time required to build trust and obtain access to meetings and therapeutic sessions; conducting comparable work across all clinics was not feasible within project constraints. 4.2. Conclusion Investigating clinicians’ perspectives on the ethical-professional challenges and clinical value of the two assessments provides critical insight into the tension between clinical usefulness and potential patient distress in administering ITI and ITEM with refugee populations. Based on our analysis, we recommend that early assessment with ITEM and ITI in refugee populations takes place in a temporally flexible manner, based on patient severity, functioning, and the clinical utility of the assessments for the patient’s future treatment. Especially ITI may benefit from an adjusted version with careful attention to language to minimize detrimental effects for refugee patients. Training in ITEM and ITI should prepare clinicians on how to implement information gained in clinical practice, and how to explain the reasoning behind the assessments to patients and facilitate conversations with patients about the measures in follow-up sessions. Moreover, the use of the assessments should be accompanied by continuous supervision. Overall, such adjustments could enhance the clinical utility of the measures, which seem to provide valuable clinical information for some patients and can enhance practice and support exposure-based treatment. In conclusion, this study has highlighted the clinical relevance of extending clinical assessment research, from a focus on validity, feasibility, and effectiveness, to include ethically informed examinations in order to reveal how, when, and why clinical assessment can be better managed. Funding Statement This project was funded by the Velux Foundation. The grant number is 00040436. Disclosure statement No potential conflict of interest was reported by the author(s). Acknowledgements We would like to acknowledge the contributions of the clinicians who consented to participate in this study. In addition, we would like to acknowledge the Velux foundation for providing funding for this study and the Danish Trauma Database collaboration for providing access to clinical expertise. Ethics statement The Research Ethics Committee at the Faculty of Humanities and the Faculty of Law, University of Copenhagen, has approved the project on 29th August 2023, with registration number SC005336 and with ID1864. Written informed consent was obtained from all participants prior to their inclusion. Data availability statement The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical concerns. References Austin, W., Rankel, M., Kagan, L., Bergum, V., & Lemermeyer, G. (2005). To stay or to go, to speak or stay silent, to act or not to act: Moral distress as experienced by Psychologists. Ethics & Behavior , 15(3), 197–212. 10.1207/s15327019eb1503_1 [ DOI ] [ PubMed ] [ Google Scholar ] Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology , 3(2), 77–101. 10.1191/1478088706qp063oa [ DOI ] [ Google Scholar ] Byrow, Y., Liddell, B., O’Donnell, M., Mau, V., McMahon, T., Bryant, R., Benson, G., & Nickerson, A. (2022). Profiles of post-migration stressors and mental health in refugees: A latent class analysis. Psychiatry Research , 311, 114494. 10.1016/j.psychres.2022.114494 [ DOI ] [ PubMed ] [ Google Scholar ] Gjerstad, S. F., Nordin, L., Poulsen, S., Spadaro, E. F. A., & Palic, S. (2024). How is trauma-focused therapy experienced by adults with PTSD? A systematic review of qualitative studies. BMC Psychology , 12(1), 135. 10.1186/s40359-024-01588-x [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Heim, E., Karatzias, T., & Maercker, A. (2022). Cultural concepts of distress and complex PTSD: Future directions for research and treatment. Clinical Psychology Review , 93, 102143. 10.1016/j.cpr.2022.102143 [ DOI ] [ PubMed ] [ Google Scholar ] Hyland, P., Karatzias, T., Shevlin, M., McElroy, E., Ben-Ezra, M., Cloitre, M., & Brewin, C. R. (2021). Does requiring trauma exposure affect rates of ICD-11 PTSD and complex PTSD? Implications for DSM-5. Psychological Trauma: Theory, Research, Practice, and Policy , 13(2), 133–141. 10.1037/tra0000908 [ DOI ] [ PubMed ] [ Google Scholar ] Kramer, S. A., Olsman, E., Hoogsteder, M. H. H., & Van Willigen, L. H. M. (2018). Sleepless nights because of ethical dilemmas in mental health care for asylum seekers. Journal of Refugee Studies , 31(4), 466–487. 10.1093/jrs/fex039 [ DOI ] [ Google Scholar ] Lamiani, G., Borghi, L., & Argentero, P. (2017). When healthcare professionals cannot do the right thing: A systematic review of moral distress and its correlates. Journal of Health Psychology , 22(1), 51–67. 10.1177/1359105315595120 [ DOI ] [ PubMed ] [ Google Scholar ] Lenferink, L. I. M., Liddell, B. J., Byrow, Y., O’Donnell, M., Bryant, R. A., Mau, V., McMahon, T., Benson, G., & Nickerson, A. (2022). Course and predictors of posttraumatic stress and depression longitudinal symptom profiles in refugees: A latent transition model. Journal of Psychiatric Research , 146, 1–10. 10.1016/j.jpsychires.2021.12.009 [ DOI ] [ PubMed ] [ Google Scholar ] Magwood, O., Bellai-Dussault, K., Fox, G., McCutcheon, C., Adams, O., Saad, A., & Kassam, A. (2023). Diagnostic test accuracy of screening tools for post-traumatic stress disorder among refugees and asylum seekers: A systematic review and meta-analysis. Journal of Migration and Health , 7, 100144. 10.1016/j.jmh.2022.100144 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Olff, M., Monson, C. M., Riggs, D. S., Lee, C., Ehlers, A., & Forbes, D. (2020). Psychological treatments: Core and common elements of effectiveness. In Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies (3rd ed., pp. 169–187). The Guilford Press. [ Google Scholar ] Patanè, M., Ghane, S., Karyotaki, E., Cuijpers, P., Schoonmade, L., Tarsitani, L., & Sijbrandij, M. (2022). Prevalence of mental disorders in refugees and asylum seekers: A systematic review and meta-analysis. Global Mental Health , 9, 250–263. 10.1017/gmh.2022.29 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Patel, A. R., & Hall, B. J. (2021). Beyond the DSM-5 diagnoses: A cross-cultural approach to assessing trauma reactions. Focus , 19(2), 197–203. 10.1176/appi.focus.20200049 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Roberts, N. P., Cloitre, M., Bisson, J., & Brewin, C. R. (2022). International Trauma Interview (ITI) for ICD-11 PTSD and Complex PTSD (Release Version 1.0) . Roberts, N. P., Hyland, P., Fox, R., Roberts, A., Lewis, C., Cloitre, M., Brewin, C. R., Karatzias, T., Shevlin, M., Gelezelyte, O., Bondjers, K., Fresno, A., Souch, A., & Bisson, J. I. (2025). The international trauma interview (ITI): Development of a semi-structured diagnostic interview and evaluation in a UK sample. European Journal of Psychotraumatology , 16(1), 2494361. 10.1080/20008066.2025.2494361 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Schouler-Ocak, M., & Iris, G.-C. T. (2023). Ethical dilemmas of mental healthcare for migrants and refugees. Current Opinion in Psychiatry , 36(5), 366–370. 10.1097/YCO.0000000000000886 [ DOI ] [ PubMed ] [ Google Scholar ] Sweeney, A., White, S., Kelly, K., Faulkner, A., Papoulias, S., & Gillard, S. (2022). Survivor-led guidelines for conducting trauma-informed psychological therapy assessments: Development and modified Delphi study. Health Expectations , 25(6), 2818–2827. 10.1111/hex.13585 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Thøgersen, M. H., Bager, L., Bangsgaard, S. G., Palic, S., Auning-Hansen, M., Møller, S. B., Larsen, K. B., Tækker, L., Jensen, B. S., Bothe, S., & Nordin, L. (2023). The Danish Trauma Database for refugees (DTD): A multicenter database collaboration – Overcoming the challenges and enhancing mental health treatment and research for refugees. International Journal of Environmental Research and Public Health , 20(16), 6611. 10.3390/ijerph20166611 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Walker, M. U. (1993). Keeping moral space open. New images of ethics consulting. The Hastings Center Report , 23(2), 33–40. 10.2307/3562818 [ DOI ] [ PubMed ] [ Google Scholar ] Wells, R., Wells, D., & Lawsin, C. (2015). Understanding psychological responses to trauma among refugees: The importance of measurement validity in cross-cultural settings. Journal and Proceedings of the Royal Society of New South Wales , 148(1), 60–69. 10.5962/p.361729 [ DOI ] [ Google Scholar ] Wilson, M. A., Shay, A., Harris, J. I., Faller, N., Usset, T. J., & Simmons, A. (2024). Moral distress and moral injury in military healthcare clinicians: A scoping review. AJPM Focus , 3(2), 100173. 10.1016/j.focus.2023.100173 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Zoellner, L. A., Feeny, N. C., Bittinger, J. N., Bedard-Gilligan, M. A., Slagle, D. M., Post, L. M., & Chen, J. A. (2011). Teaching trauma-focused exposure therapy for PTSD: Critical clinical lessons for novice exposure therapists. Psychological Trauma: Theory, Research, Practice, and Policy , 3(3), 300–308. 10.1037/a0024642 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Data Availability Statement The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical concerns. Articles from European Journal of Psychotraumatology are provided here courtesy of Taylor & Francis ACTIONS View on publisher site PDF (587.1 KB) Cite Collections Permalink PERMALINK Copy RESOURCES Similar articles Cited by other articles Links to NCBI Databases Cite Copy Download .nbib .nbib Format: AMA APA MLA NLM Add to Collections Create a new collection Add to an existing collection Name your collection * Choose a collection Unable to load your collection due to an error Please try again Add Cancel Follow NCBI NCBI on X (formerly known as Twitter) NCBI on Facebook NCBI on LinkedIn NCBI on GitHub NCBI RSS feed Connect with NLM NLM on X (formerly known as Twitter) NLM on Facebook NLM on YouTube National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894 Web Policies FOIA HHS Vulnerability Disclosure Help Accessibility Careers NLM NIH HHS USA.gov Back to Top