Research Article
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Abstract
Many refugees resettled in Western countries suffer from an accumulation of traumatic and current stressors that contribute to mental health problems and may complicate trauma-focused treatment. Consequently, the acceptability, safety, and efficacy of trauma-focused treatment with refugees have been a matter of clinical and scientific interest. In recent years, the evidence has accumulated for narrative exposure therapy and culturally adapted cognitive behavioral therapy. Although eye movement desensitization and reprocessing (EMDR) is practiced with resettled refugees, only five small studies of limited quality have been conducted on EMDR with this population. In the absence of strong evidence, therapists practising EMDR with refugees may be aided by transcultural psychiatric principles, especially matching of explanatory models. In addition, high-quality research is needed to reliably determine acceptability, safety, and efficacy of EMDR with traumatized refugees.
Armed conflict, war, disaster, and persecution are forces that worldwide cause survivors to leave their homes and seek refuge elsewhere. Although psychological treatment of those who are left traumatized by these experiences may be imperative for successful repatriation or resettlement, it is a great clinical challenge. Eye movement desensitization and reprocessing (EMDR) has been found efficacious in treating chronic posttraumatic stress disorder (PTSD; American Psychiatric Association, 2013) in both adults (Bisson et al., 2007) and children (Rodenburg, Benjamin, De Roos, Meijer, & Stams, 2009). Consequently, EMDR is recommended as a treatment of choice in treatment guidelines for PTSD (e.g., National Institute for Clinical Excellence [NICE], 2005; Tol, Barbui, & Van Ommeren, 2013).
Following treatment guidelines, Western centers for refugee mental health are increasingly using EMDR with their refugee patients (e.g., Lab, Santos, & De Zulueta, 2008; Robertson, Blumberg, Gratton, Walsh, & Kayal, 2013; Sjölund, Kastrup, Montgomery, & Persson, 2009). EMDR may be a suitable approach for refugees because it does not include homework assignments, may minimalize language issues because speech is not always necessary, and has been found efficacious with patients from non-Western cultural backgrounds (Jaberghaderi, Greenwald, Rubin, Zand, & Dolatabadi, 2004). However, conclusions drawn on the basis of research with general populations, even when cross-cultural, may not necessarily generalize to refugees. Refugees suffering from chronic PTSD are generally considered complex populations with whom the efficacy of psychotherapy should be separately studied. Unfortunately, so far evidence on EMDR with refugees has been scarce. The aim of this article is to increase awareness of possible challenges involved in EMDR treatment with refugees and stimulate outcome research of EMDR with this population. To that end, this article outlines the psychosocial and transcultural complexities of treating traumatized refugees with EMDR, evaluates the research to date, and proposes a research agenda.
Refugee Trauma and Treatment
Who Is a Refugee?
Who is defined as refugee is primarily a legal matter. Refugees are those who, because of well-founded fears of persecution for reasons of race, religion, nationality, membership of a particular social group, or political opinion, are outside their countries of nationality and are unable or unwilling to avail themselves of the protection of those countries. Those who are legally acknowledged to meet this definition are granted the right not to be sent back to their countries of origin. Asylum seekers are those whose claim to that right is still under examination. In 2013, 11.1 million refugees and 987,000 asylum seekers were of concern to the United Nations High Commissioner for Refugees (UNHCR) worldwide (see www.unhcr.org). Most refugees are originally from Asia and Africa and find shelter in their regions of origin, but a fifth of refugees resettle in the West (Europe, North America, and Australia). This article is concerned with the subgroup of resettled refugees who seek treatment in Western mental health settings for trauma-related disorders.
Refugee Stressors and Mental Health
Mental health of refugees is generally acknowledged to be influenced both by traumatic and current stressors (e.g., Miller & Rasmussen, 2010). Refugees are at high risk of experiencing traumatic events before, during, and after their flight (Silove, Tarn, Bowles, & Reid, 1991). Before fleeing, traumatic events may vary from imprisonment and torture in political refugees, forced witnessing and committing of atrocities in former child soldiers, and bombings and rape in civilian war survivors, to injury and witnessing the death of others in refugee military veterans. The flight itself may be traumatizing because refugees often employ the use of smugglers to cross international borders and in the process may face serious threats including injury or death or human trafficking (e.g., Arbel & Brenner, 2013). After the flight, refugees are at risk of being imprisoned or deported (e.g., Robjant, Hassan, & Katona, 2009), whereas women and children are at special risk of sexual abuse or exploitation (see www.unhcr.org). Meta-analytically, torture and a cumulative number of traumatic experiences form risk factors for development of PTSD and depression in adult refugees, with torture explaining almost a quarter of the variance in PTSD (Steel et al., 2009). In refugee children also, the key risk factor for PTSD is exposure to violence (Fazel, Reed, Panter-Brick, & Stein, 2011).
In addition to traumatic stressors, current stressors both in the country of refuge and the country of origin impact the mental health of both adults and children (Fazel et al., 2011; Steel et al., 2009). Obtaining the legal label of refugee in a Western country often requires a lengthy asylum process which carries a tremendous amount of stress (e.g., Laban, Gernaat, Komproe, Schreuders, & De Jong, 2004; Robjant et al., 2009). Also after obtaining a residency status, refugees have to cope with stressors such as loss of country, cultural resources, family, friends, and social status (e.g., Summerfield, 2001). At the same time, family and friends in the country of origin may continue to suffer from ongoing conflict, causing great anxiety to those living in relative safety.
Consequently, for adult refugees resettled in Western countries, prevalence of PTSD is around 9% and prevalence of depression around 5% (Fazel, Wheeler, & Danesh, 2005). Upon inclusion of those who have fled to another region in their own countries (internally displaced persons) and of refugees and asylum seekers in developing countries, prevalence rates rise to 31% for both PTSD and depression (Steel et al., 2009). For refugee children and adolescents living in Western countries, PTSD prevalence ranges from 7% to 17% (Fazel et al., 2005), depression from 3% to 30% (Bronstein & Montgomery, 2011). The accumulation of stressors not only leaves refugees at higher risk of developing mental health problems than general populations (Bronstein & Montgomery, 2011; Fazel et al., 2005), economic migrants (Lindert, Von Ehrenstein, Priebe, Mielck, & Brähler, 2009), and compatriots who have stayed in their countries of origin (Porter & Haslam, 2001), but may also complicate their psychosocial recovery.
Trauma-Focused Therapy With Refugees: Clinical Challenges
Because of the accumulation of traumatic and current stress faced by refugees, treatment for traumatized refugees has long consisted of supportive, unstructured, multimodal interventions, with no central focus on processing of traumatic memories and with limited effectiveness (e.g., Boehnlein et al., 2004; Carlsson, Mortensen, & Kastrup, 2005). However, in response to the evidence base for trauma-focused cognitive behavioral therapy and EMDR (e.g., Bisson et al., 2007), trauma-focused treatment has increasingly been incorporated in care as usual with refugees. To fine-tune care provision, several authors have drawn attention to the clinical challenges faced when providing trauma-focused treatment to refugees.
Acceptability
Authors such as Summerfield (1999) and Miller, Kulkarni, and Kushner (2006) have addressed the issue of acceptability of individual trauma-focused treatments to refugees. They argue that a predominant treatment focus on trauma and PTSD may not fully meet refugees’ needs for various reasons. First, contrary to single traumatic experiences such as traffic accidents, war and persecution primarily cause destruction at a societal rather than an individual level. Interventions should therefore primarily be aimed at collectives rather than individuals. Second, although trauma-focused treatments have been designed to alleviate PTSD, the PTSD construct may not appropriately reflect refugees’ responses to experiences of war or persecution. These may consist of different symptom constellations for which tailored interventions may need to be designed. Third, the notion of “working through” of traumatic experiences is of Western origin and may not be applicable transculturally (see also Kleber, Figley, & Gersons, 1995), with some refugees preferring present-centered interventions over trauma-focused interventions (e.g., Morris et al., 1993). Fourth, survivors of war and persecution tend to prioritize practical concerns such as obtainment of work, education, and housing over mental health concerns, and trauma-focused therapy may therefore not appeal to them. Although these arguments have served to raise awareness of the need for holistic and tailored approaches, objections have also been made. Hinton and Lewis-Fernández (2011) have shown that although transcultural variation may exist in the prevalence of avoidance and somatic symptoms and in the interpretation of traumatic events and trauma-related symptoms, PTSD is found across cultures in response to traumatic events. Other authors (e.g., Hodes & Goldberg, 2002) argue that trauma-focused therapy may be imperative for a subgroup of refugees who do not recover from PTSD after having their practical needs met.
Safety
There is a longstanding assumption within refugee care that exposure to traumatic memories may lead to unmanageable distress or adverse effects (e.g., Nickerson, Bryant, Silove, & Steel, 2011). This assumption is rooted within the conceptualization of refugees as suffering from complex PTSD (e.g., Palic & Elklit, 2011). Complex PTSD includes the core symptoms of PTSD in conjunction with emotion regulation difficulties, disturbances in relational capacities, alterations in attention and consciousness, adversely affected belief systems, and somatic distress or disorganization (Cloitre et al., 2012). The few studies that have been conducted on complex PTSD in refugees have shown that the majority of traumatized refugees do not suffer from complex PTSD (De Jong, Komproe, Spinazzola, Van der Kolk, & Van Ommeren, 2005; Palic & Elklit, 2014; Teodorescu, Heir, Hauff, Wentzel-Larsen, & Lien, 2012; Weine et al., 1998). Nevertheless, a phased treatment approach, fitting with the complex PTSD diagnosis, is often advised for traumatized refugees (e.g., NICE, 2005). According to this approach, to avoid symptom increase, trauma-focused work should not be undertaken until a secure treatment alliance has been formed and the patient is physically safe and emotionally and behaviorally stable. As many refugees are living in unsafe or unstable conditions, especially during the asylum process, their ability to undergo trauma-focused therapy is often clinically questioned. In recent years, the experience-based emphasis on physical safety has been challenged by research indicating that asylum seekers may benefit from unphased trauma-focused therapy even in the absence of a residency status (e.g., Neuner et al., 2010; Stenmark, Catani, Neuner, Elbert, & Holen, 2013). Although the evidence is still limited, these findings may result in a shortening of the stabilization phase and offering trauma-focused treatment to a broader range of refugees.
Efficacy
The efficacy of offering Western trauma-focused treatments to non-Western clients has been a matter of transcultural interest (Wilson & Drožđek, 2007). It has been argued that all clients suffering from PTSD, regardless of cultural background, should be offered trauma-focused treatment but that cultural adaptations to trauma-focused treatments may need to be made to increase efficacy (Zayfert, 2008). Meta-analytically, the main reason why culturally adapted psychotherapy is significantly more effective than nonadapted psychotherapy is because it offers a better match between therapy and client in explanatory models of mental illness and psychological distress (Benish, Quintana, & Wampold, 2011). Ethnic matching between client and therapist, although often preferred by clients, has not been shown to increase efficacy (Cabral & Smith, 2011). However, language matching (conducting psychotherapy in the client’s mother tongue) has (Griner & Smith, 2006). As refugee populations are usually culturally diverse, language matching may not always be possible. Consequently, interpreters may need to be used, which alters therapeutic alliance and process (e.g., Miller, Martell, Pazdirek, Caruth, & Lopez, 2005). Although in some clinical trials of trauma-focused therapy interpreters have been used (e.g., Neuner et al., 2010; Stenmark et al., 2013; Ter Heide, Mooren, Kleijn, De Jongh, & Kleber, 2011), it is too early to draw definite conclusions on the influence of interpreters on treatment effectiveness.
Although literature on the issues of acceptability, safety, and efficacy of trauma-focused treatment with refugees has served to alert clinicians to potential clinical challenges, transcultural data are providing increasing clarity on which arguments hold under scientific scrutiny. In recent years, the evidence has accumulated for two forms of trauma-focused therapy, which we will discuss in the following paragraph.
Psychological Treatment of Refugees: Current Evidence
As noted, treatment for refugees has long consisted of multimodal, supportive interventions, and sometimes care was taken “not to remind survivors of their past traumatic experiences” (McIvor & Turner, 1995, p. 707). Since the publication of the first trauma-focused trial comparing CBT and exposure therapy in refugees, which resulted in large effect sizes for both conditions (Paunovic & Öst, 2001), this stance has become increasingly untenable. Two forms of trauma-focused treatment that have since gathered most evidence also take a cognitive behavioral approach. In narrative exposure therapy (NET), refugees are exposed to traumatic memories and associated emotions by narrating their life story, of which a written report is made (Schauer, Neuner, & Elbert, 2005). In NET, transcultural acceptability has been taken into account by employing the cross-cultural form of narrative, whereas the provision of a written report that may be presented as statement in a legal or human rights context may also increase acceptability to refugees. NET has been shown to have high safety as well as result in very large effect sizes with refugees in stable and less stable settings (Nickerson et al., 2011; Palic & Elklit, 2011; Robjant & Fazel, 2010; Stenmark et al., 2013). A second treatment resulting in large effect sizes is a form of culturally adapted CBT (CACBT) developed by Hinton and colleagues (2004, 2005). CACBT pays special attention to treatment acceptability by focusing interventions on culture-specific symptoms and using interventions that may have culture-specific appeal. Treatment protocol consists of various interventions, including relaxation, mindfulness, visualizations, and exposure to culture-specific somatic sensations and traumatic memories. NET and CACBT are similar in that they are both highly structured treatments that are limited in length, but they differ greatly in how much time is spent on processing of traumatic memories: Although trauma processing is the main intervention in NET, it is only minimal in CACBT.
In conclusion, current evidence points to the safety and efficacy of trauma-focused treatment with resettled refugees when providing a culture-sensitive rationale and intervention. We now turn to the practice and research of EMDR with traumatized refugees.
EMDR with Traumatized Refugees: Practice and Research
EMDR in Western Mental Health Settings
The individual EMDR protocol for PTSD consists of the following steps: (a) taking of patient history and treatment planning; (b) preparation through psychoeducation and stabilizing interventions; (c) assessment of the target memory and its corresponding negative and positive cognitions, emotion, and level, and location of distress; (d) desensitization and reprocessing of traumatic material using an attention-demanding task such as tracking the therapist’s fingers with the eyes; (e) installation of positive cognition; (f) scanning of the body for remaining distress; (g) session closure; and (h) reevaluation (Shapiro, 2001). The children’s protocol has some age-appropriate adaptations (Rodenburg et al., 2009). With traumatized refugees, the EMDR protocol can be applied as the sole therapeutic intervention or as part of a phased or multimodal approach.
Several case reports have appeared describing the successful use of EMDR with refugees from diverse cultural backgrounds. Ross and Gonsalves (1993) present an early case of a Guatemalan refugee who was repeatedly imprisoned and tortured for political activities. The patient presented with a range of symptoms diagnosable as complex PTSD, which were treated with eclectic short-term psychotherapy. Two sessions of EMDR in the middle of treatment resulted in improved sleep and cessation of nightmares. Bower, Pahl, and Bernstein (2004) describe the multimodal treatment of a Bosnian female refugee who suffered from PTSD and depression following detainment and repeated rape in a concentration camp, during which the names of her abusers were tattooed on her body. Psychotropic medication and removal of tattoos led to great decrease of depressive symptoms. Subsequently, five EMDR sessions resulted in diminished nightmares, distressing memories, and anxiety. Therapy continued with counseling focused on psychosocial issues. Ilic (2004) illustrates his description of EMDR with former prisoners of war with a case report of a Croatian refugee military veteran who was tortured in a prisoner of war camp. The patient presented with chronic PTSD including nightmares and rumination. After a preparatory phase, three sessions of EMDR resulted in significant reduction of PTSD symptoms, and treatment was continued with psychosocial rehabilitation. Stöfsel (2005) describes a case series of EMDR within a phased approach. With six patients, EMDR was successful (meaning that all relevant traumatic memories had been processed and SUD had gone down from 8–10 to 0); however, two hospitalized patients were unable to manage emotions raised by EMDR and EMDR was terminated. No further details are provided in this case series. Regel and Berliner (2007) describe the case of a Kurdish Iraqi torture survivor who suffered from a multitude of symptoms including PTSD, depression, and social phobia. After stabilization and graded exposure in vivo, EMDR was implemented to process traumatic memories. After a total of 12 sessions, the patient was acceptant of occasional troubling memories, had a stable mood and sleeping pattern, was regularly employed, and was active in helping other refugees.
Systematic Review: Method
Although EMDR is being used in clinical practice with refugees, no systematic review yet exists informing therapists and researchers on the state of the evidence for EMDR with refugee populations. We conducted a systematic search for outcome studies of EMDR with asylum seekers and refugees of all ages treated in Western settings. Our aim was to answer the following questions: Which treatment outcome studies on EMDR with refugees in Western settings have been conducted? What are the main findings in terms of dropout and outcome measures? To what extent do those studies meet the gold standards for PTSD treatment outcome studies (i.e., clearly defined target symptoms; reliable and valid measures; use of blind evaluators; assessor training; manualized, replicable, specific treatment programs; unbiased assignment to treatment; and treatment adherence; Foa & Meadows, 1997)? Finally, which conclusions can be drawn on treatment outcome of EMDR with refugees?
In October 2013, we searched PsycINFO, PubMed, PILOTS, the Francine Shapiro Library, and the Journal of EMDR Practice and Research using the search strategy (EMDR OR “eye movement desensitis/zation”) AND (refugee* OR asylum OR displaced OR torture OR persecution). In addition, we sent e-mails to all national EMDR organizations and to authors of presentation abstracts retrieved in the searches, asking if they knew of or had conducted any studies on EMDR with refugees. This search yielded 110 records. Most records presented clinical reports, recommendations, or reflections rather than research. Five studies were found that described study design and method as well as presented statistical data on treatment outcome.
Systematic Review: Results
Groenenberg and Van Waning (2002) conducted a pilot study of EMDR with eight asylum seekers and refugees. As part of regular phased treatment, one to six sessions of EMDR were conducted. One patient dropped out after the second session because of increasing distress. The remaining seven patients showed some decrease in anxiety and depression. As far as the gold standards are concerned, only replicable treatment and reliable, valid outcome measures were used; target symptoms, although clearly defined, did not include PTSD.
Oras, Cancela de Ezpeleta, and Ahmad (2004) studied the effectiveness of EMDR in a psychodynamic context with 13 refugee children (aged 8–16 years) suffering from PTSD. EMDR sessions ranged from one to six. No participants ended treatment prematurely. Treatment resulted in significant improvement in PTSD and Global Assessment of Functioning (GAF) scores. This study adhered only to clear definition of target symptoms; replicable treatment; and reliable, valid outcome measures.
Elofsson, Von Schèele, Theorell, and Söndergaard (2008) conducted a study of the physiological correlates of EMDR with 13 male resettled refugees. Only changes in subjective units of distress (SUD) per session were included as indication of clinical improvement. No dropouts are reported. SUD scores decreased significantly during the 17 sessions. Treatment was replicable and the physiological outcome measures were clear, reliable, and valid. No other gold standards were reported to have been met in this study.
In a pilot study by Renner, Bänninger-Huber, and Peltzer (2011), 94 Chechen asylum seekers and refugees were randomly assigned to either 15 sessions of a Culture-Sensitive and Resource Oriented Peer group, 15 CBT group sessions, 3 sessions of EMDR, or waitlist. Of the 17 participants assigned to EMDR, 3 dropped out because of inability to visualize a specific traumatic event. EMDR participants did not improve in PTSD, anxiety, or depression. Most gold standards were met, but no clinician-rated assessment requiring blindness and training of evaluators took place and treatment adherence was not measured. In addition, this study suffered from limitations in design (PTSD symptomatology was not an inclusion criterion, treatment dose was not equal for all conditions, and the dose of EMDR that was actually administered was unclear).
Finally, in another randomized pilot study (Ter Heide et al., 2011) 11 sessions of EMDR were compared with 11 sessions of stabilization in 20 asylum seekers and refugees with chronic PTSD. Dropout was equal in both conditions, with five participants prematurely ending EMDR because of satisfaction with symptom reduction, not wanting to speak about the past, and withdrawal by their study therapist because of current stress and cultural factors. EMDR participants showed some improvement in PTSD, anxiety, and depression. This study met all gold standards of PTSD treatment outcome studies.
EMDR With Refugees: A Research Agenda
Although EMDR is recommended and offered in clinical practice with refugees, research evaluating its acceptability, safety, and efficacy has lagged behind. Our systematic review of studies on EMDR with refugees in Western settings yielded only five studies: two naturalistic designs of EMDR with adults and children within a phased format, one physiological study into the effectiveness of eye movements, and two pilot randomized trials of unphased EMDR. Full randomized studies providing the highest level of evidence were lacking. None but one of the studies met all gold standards of PTSD outcome research. Consequently, no conclusions on acceptability, safety, and efficacy of EMDR with refugees can currently be drawn. If EMDR with refugees is to become evidence-based, research needs to be conducted in all three domains.
Acceptability
It is recommended to study acceptability when examining a new treatment or an existing treatment with a new population (e.g., Lancaster, Dodd, & Williamson, 2004). Acceptability may be defined as refusing treatment or dropping out of treatment because of an insufficient match in treatment rationale between patient and treatment. Three studies (Groenenberg & Van Waning, 2002; Renner et al., 2011; Ter Heide et al., 2011) reported occasional refusals or dropout of EMDR because patients did not want to speak about the past. Although this may be related to treatment quality (such as providing insufficient information about treatment rationale) or study design (directly starting with EMDR without a prior stabilization phase), findings may also be in line with the argument that processing of traumatic memories may not appeal to some refugees. Questions on the ratio of acceptability versus nonacceptability may be answered by studies using unbiased assignment which keep track of refusals and dropout. Should EMDR have low acceptability to a subgroup of refugee patients, reasons for refusal may be explored as well as ways to increase acceptability, for example by using culturally specific metaphors to explain the mechanism of EMDR (e.g., Silver & Rogers, 2002).
Safety
Reporting of safety (also called “harm”) of treatments has been encouraged to increase quality of clinical trial reports (Ioannidis et al., 2004). Safety may be specified as an extent of symptom increase or the occurrence of specific adverse effects, such as suicide attempts. Although none of the five studies that came up in our review pointed to unsafety of EMDR, sample sizes were small and full randomized trials are needed to examine if EMDR may lead to adverse effects in a subgroup of patients. Subsequently, treatment predictors may be explored. Are refugees who experience high current stress, such as asylum seekers or illegals, more likely to experience adverse effects than those with relatively low current stress? Is severity of depression or psychotic symptoms a risk factor for adverse effects? Are adverse effects more likely to occur in refugee patients who immediately start with EMDR than in those who receive prior skills training? Data on these issues may aid practitioners in fine-tuning the timing of EMDR.
Efficacy
When studying the efficacy of an intervention, two questions are of interest: Is the intervention efficacious, and is it more efficacious than existing treatments. Although all but one study reported EMDR to have some degree of effectiveness or efficacy, high-quality randomized trials are needed to reliably determine the efficacy of EMDR with refugees. Because efficacy depends greatly on treatment design, different designs may be used. To determine optimal efficacy of EMDR, EMDR may be studied as sole therapeutic intervention compared to waitlist, within a phased format compared to direct EMDR or within a multimodal format compared to only EMDR. Number of treatment sessions may be standardized or may be made dependent on treatment efficacy. To determine the size of differences in efficacy between treatments, EMDR may be compared to care as usual or to evidence-based treatments such as NET. The efficacy of EMDR with interpreters also deserves specific attention. Information on efficacy of EMDR in different study designs is essential in helping practitioners choose the intervention as well as outline an order or combination of interventions.
Conclusion
Asylum seekers and refugees form diverse and complex populations, coming from multiple cultural backgrounds, having survived a diversity of life-threatening experiences, and living in more or less safe and stable environments. Although EMDR has been found efficacious in adults suffering from PTSD, research findings may not automatically generalize to traumatized refugees. In fine-tuning EMDR to resettled refugees, clinicians may be aided by principles derived from transcultural psychiatry, such as mapping multiple stressors, reaching agreement on treatment focus and rationale, and developing cultural adaptations to the EMDR treatment protocol. In addition, high-quality studies yielding reliable data on the acceptability, safety, and efficacy of EMDR with refugees are needed to move EMDR from experience-based practice to evidence-based practice with this population.
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Acknowledgments
The authors would like to thank the following persons for their contributions to this article: the Cogis librarians, Marthe Hoofwijk, Ad de Jongh, Anke van Nijnatten, and those authors and members of national EMDR organizations who replied to our requests for information. Research for this article was financially supported by ZonMW, the Netherlands organization for health research and development, and by Foundation Centrum ‘45. Foundation Centrum ‘45 is partner in Arq Psychotrauma Expert Group.
Article usage
| Period | Abstract | Full | Total | |
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| Apr 2024 | 16 | 76 | 29 | 121 |
| Mar 2024 | 8 | 65 | 24 | 97 |
| Feb 2024 | 8 | 68 | 25 | 101 |
| Jan 2024 | 12 | 48 | 20 | 80 |
| Dec 2023 | 21 | 50 | 28 | 99 |
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| Sep 2023 | 12 | 43 | 14 | 69 |
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| Jul 2023 | 8 | 40 | 16 | 64 |
| Jun 2023 | 18 | 58 | 21 | 97 |
| May 2023 | 7 | 43 | 25 | 75 |
| Apr 2023 | 10 | 38 | 19 | 67 |
| Mar 2023 | 46 | 38 | 17 | 101 |
| Feb 2023 | 15 | 28 | 12 | 55 |
| Jan 2023 | 26 | 43 | 24 | 93 |
| Dec 2022 | 19 | 23 | 13 | 55 |
| Nov 2022 | 21 | 46 | 14 | 81 |
| Oct 2022 | 24 | 42 | 15 | 81 |
| Sep 2022 | 18 | 35 | 17 | 70 |
| Aug 2022 | 23 | 25 | 11 | 59 |
| Jul 2022 | 32 | 18 | 8 | 58 |
| Jun 2022 | 27 | 23 | 8 | 58 |
| May 2022 | 20 | 31 | 16 | 67 |
| Apr 2022 | 8 | 40 | 13 | 61 |
| Mar 2022 | 15 | 36 | 7 | 58 |
| Feb 2022 | 12 | 27 | 5 | 44 |
| Jan 2022 | 17 | 23 | 3 | 43 |
| Dec 2021 | 17 | 23 | 12 | 52 |
| Nov 2021 | 15 | 37 | 11 | 63 |
| Oct 2021 | 11 | 38 | 12 | 61 |
| Sep 2021 | 14 | 25 | 6 | 45 |
| Aug 2021 | 5 | 9 | 4 | 18 |
| Jul 2021 | 7 | 13 | 1 | 21 |
| Jun 2021 | 8 | 14 | 6 | 28 |
| May 2021 | 20 | 49 | 12 | 81 |
| Apr 2021 | 61 | 39 | 13 | 113 |
| Mar 2021 | 12 | 36 | 12 | 60 |
| Feb 2021 | 12 | 67 | 17 | 96 |
| Jan 2021 | 18 | 44 | 7 | 69 |
| Dec 2020 | 11 | 41 | 4 | 56 |
| Nov 2020 | 8 | 57 | 5 | 70 |
| Oct 2020 | 27 | 50 | 13 | 90 |
| Sep 2020 | 25 | 30 | 6 | 61 |
| Aug 2020 | 20 | 42 | 5 | 67 |
| Jul 2020 | 13 | 45 | 8 | 66 |
| Jun 2020 | 10 | 60 | 12 | 82 |
| May 2020 | 26 | 58 | 15 | 99 |
| Apr 2020 | 10 | 71 | 7 | 88 |
| Mar 2020 | 27 | 66 | 14 | 107 |
| Feb 2020 | 17 | 78 | 9 | 104 |
| Jan 2020 | 15 | 64 | 17 | 96 |
| Dec 2019 | 104 | 45 | 5 | 154 |
| Nov 2019 | 37 | 123 | 17 | 177 |
| Oct 2019 | 15 | 63 | 12 | 90 |
| Sep 2019 | 8 | 24 | 5 | 37 |
| Aug 2019 | 7 | 37 | 16 | 60 |
| Jul 2019 | 5 | 53 | 18 | 76 |
| Jun 2019 | 17 | 41 | 16 | 74 |
| May 2019 | 8 | 43 | 20 | 71 |
| Apr 2019 | 13 | 52 | 21 | 86 |
| Mar 2019 | 6 | 35 | 18 | 59 |
| Feb 2019 | 9 | 25 | 8 | 42 |
| Jan 2019 | 8 | 44 | 9 | 61 |
| Dec 2018 | 6 | 1 | 0 | 7 |
| Nov 2018 | 6 | 0 | 0 | 6 |
| Oct 2018 | 10 | 1 | 2 | 13 |
| Sep 2018 | 3 | 2 | 0 | 5 |
| Aug 2018 | 7 | 0 | 1 | 8 |
| Jul 2018 | 5 | 0 | 0 | 5 |
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