The Role of Context in the Implementation of Trauma-Focused Treatments: Effectiveness Research and Implementation in Higher and Lower Income Settings

Building Resilience Against ViolencE (BRAVE): protocol of a parenting intervention for mothers and fathers with post-traumatic stress disorder in Pakistan

BACKGROUND

Prevalence of post-traumatic stress disorder (PTSD) is high in Pakistan both due to natural disasters and ongoing conflicts. Offspring of trauma survivors are at increased risk for mental and physical illnesses. Parental PTSD has been linked to troubled parent-child relationships, behaviour problems, trauma symptoms, and depression in children. This study aims to explore the acceptability, feasibility and indications of the effectiveness of group learning through play plus trauma-focused cognitive behaviour therapy (LTP Plus TF-CBT) for parents experiencing PTSD.

METHODS/DESIGN

This is a two-arm pilot cluster randomised controlled trial (RCT). We aim to recruit 300 parents with a diagnosis of PTSD. The screening will be done using the Impact of Event Scale-Revised. Diagnosis of PTSD will be confirmed using the Clinician-Administered PTSD Scale-5 (CAPS-5). Union Councils from Peshawar and Karachi will be randomised into either group LTP Plus TF CBT arm or treatment as usual (TAU). The intervention includes 12 sessions of LTP Plus TF-CBT delivered weekly in the first 2 months and then fortnightly in a group setting by trained psychologists. The groups will be co-facilitated by the community health workers (CHWs). Parents will be assessed at baseline and 4th month (end of the intervention), using the Patient Health Questionnaire (PHQ-9), Generalised Anxiety Disorder (GAD-7) Scale, Client Service Receipt Inventory (CSRI), and Ages and Stages Questionnaire (ASQ-3).

DISCUSSION

This trial would help build an understanding of the acceptability, feasibility and indications of the effectiveness of a low-cost parenting intervention.

The double burden of treating traumatic stress in low-resource communities: experiences and perspectives of non-specialist health workers in South Africa

Considering the global trend towards the dissemination and implementation of trauma-focused treatments in the majority of the world, it is imperative to ascertain the contextual factors which affect the treatment of traumatic stress, especially in low- and middle-income countries characterised by ongoing adversity such as poverty and increased levels of trauma exposure. We explored the experiences of non-specialist health workers whose work involved providing trauma-focused services in low-resource communities in South Africa. Participants ( n = 18) worked at four non-governmental organisations in the Eastern Cape and Western Cape of South Africa. Semi-structured individual interviews were conducted and analysed using a phenomenologically informed thematic analysis. Two superordinate themes were identified, namely, adjusting to trauma-focused work and trauma in the social context. Five themes that made up the superordinate themes were Encountering Trauma Narratives, Support and Resilience, Going the Extra Mile, Helplessness, and Social Factors. The findings are not only in keeping with the psychological risks of trauma-focused work (e.g., vicarious traumatisation) but also highlighting the impact of the social context on the provision of trauma-focused work. Participants reported experiencing an added burden of helplessness due to social factors, such as poverty and high levels of trauma exposure, which affect the process of treating traumatic stress in low-resource settings. We discuss how these findings can contribute to efforts to implement trauma-focused services in low- and middle-income countries.

Training During a Pandemic: Successes, Challenges, and Practical Guidance From a Virtual Facilitated Learning Collaborative Training Program for Written Exposure Therapy

In response to COVID-19, continued workforce training is essential to ensure that evidence-based treatments are available on the frontline to meet communities' ongoing and emerging mental health needs. However, training during a pandemic imposes many new challenges. This paper describes a multisite training and implementation pilot program, facets of which allowed for continued training despite the onset of the COVID-19 pandemic and subsequent social distancing guidelines. This virtual facilitated learning collaborative in Written Exposure Therapy, an evidence-based treatment for posttraumatic stress disorder, included virtual workshop training, phone-based clinical consultation, implementation-focused video calls for program leadership, and program evaluation. Data are presented about program enrollees and patient impact following the onset of COVID-19-related social distancing restrictions. Challenges, successes, and practical guidance are discussed to inform the field regarding training strategies likely to be durable in an uncertain, dynamic healthcare landscape.

Service providers' perceptions of barriers to the implementation of trauma-focused substance use services for women in Cape Town, South Africa

BACKGROUND

A substantial number of South African women with substance use disorders also report psychological trauma related to experiences of physical and sexual abuse. Trauma-focused substance use programmes may support recovery from co-occurring substance use disorders and psychological trauma, yet integrated programmes are not widely available in South Africa. As part of the process of developing a trauma-focused substance use programme for South African women, we explored service providers' views of the feasibility of implementing trauma-focused substance use interventions within usual care settings in Cape Town, including potential barriers that need to be considered when planning for implementation.

METHODS

We conducted 16 in-depth interviews with key informants responsible for planning or delivering substance use, psychological trauma or gender-based violence services to women in Cape Town. Guided by Extended Normalisation Process Theory, interviews explored participants' perceptions of the potential value of trauma-focused substance use programmes, the feasibility of their implementation, and factors that may facilitate or hinder the implementation of trauma-focused substance use programmes. Qualitative data were analysed using the framework approach.

RESULTS

Three themes emerged: (1) Potential for the implementation of trauma-focused substance use programmes, describing participants' views of the acceptability of these programmes; (2) Capacity for intersectoral collaboration, which participants considered necessary for limiting barriers to implementation; and (3) Co-operation with community structures to enhance capability for implementation.

CONCLUSION

Findings show potential for implementing trauma-focused substance use interventions in South Africa, however context-specific capacity and capability barriers need to be considered and addressed for implementation to be successful.

From Posttraumatic Stress Disorder to Posttraumatic Growth: A Paradigm Shift or Paradox?

Trauma, unfortunately, is an all too common part of today's world. The construct posttraumatic stress disorder (PTSD) has been the dominant paradigm to guide researchers and clinicians in the United States and around the world in their efforts to understand and help persons who have experienced trauma. However, PTSD as a diagnosis and this theoretical construct has some problems and limitations, particularly when considered from a global perspective. The author explores the less widely studied construct of posttraumatic growth (PTG) as a phenomenon that avoids some of the problems of PTSD and asks the question: Does it represent a paradigm shift or a paradox? The author seeks to consider this issue from a global perspective and discusses Syrian refugees as a case study.

Empirical Examinations of Modifications and Adaptations to Evidence-Based Psychotherapies: Methodologies, Impact, and Future Directions

This review describes methods used to examine the modifications and adaptations to evidence-based psychological treatments (EBPTs), assesses what is known about the impact of modifications and adaptations to EBPTs, and makes recommendations for future research and clinical care. One hundred eight primary studies and three meta-analyses were identified. All studies examined planned adaptations, and many simultaneously investigated multiple types of adaptations. With the exception of studies on adding or removing specific EBPT elements, few studies compared adapted EBPTs to the original protocols. There was little evidence that adaptations in the studies were detrimental, but there was also limited consistent evidence that adapted protocols outperformed the original protocols, with the exception of adding components to EBPTs. Implications for EBPT delivery and future research are discussed.