The emerging evidence for Narrative Exposure Therapy: A review

Randomized controlled trial of two internet-based written therapies for world trade center workers and survivors with persistent PTSD symptoms

Posttraumatic stress disorder (PTSD) remains prevalent among individuals exposed to the 9/11 World Trade Center (WTC) terrorist attacks. The present study compared an Internet-based, therapist-assisted psychotherapy for PTSD to an active control intervention in WTC survivors and recovery workers with WTC-related PTSD symptoms (n = 105; 75% syndromal PTSD). Participants were randomized to integrative testimonial therapy (ITT), focused on WTC-related trauma, or modified present-centered therapy (I-MPCT), each comprising 11 assigned written narratives. The primary outcome was baseline-to-post-treatment change in PTSD symptoms on the PTSD Checklist for DSM-5 (PCL-5). Secondary measures included PTSD symptom clusters, depressive/anxiety symptoms, functioning, and quality of life. A significant main effect of time was observed for the primary outcome (average "large" effect size improvement, d = 1.49). Significant and "moderate-to-large" main effects of time were also observed for all PTSD symptom clusters, depressive symptoms, quality of life, and mental health-related functioning (d range=0.62-1.33). Treatment and treatment-by-time interactions were not significant. In planned secondary analyses incorporating 3-month follow-up measures, ITT was associated with significantly greater reductions than I-MPCT in PTSD avoidance and negative alterations in cognitions and mood, anxiety, and mental health-related functioning. Both therapies significantly lowered PTSD symptoms, suggesting they may benefit hard-to-reach individuals with chronic WTC-related PTSD symptoms.

The memory trace of an intrusive trauma-analog episode

Intrusive memories are a core symptom of posttraumatic stress disorder. Compared with memories of everyday events, they are characterized by several seemingly contradictory features: intrusive memories contain distinct sensory and emotional details of the traumatic event and can be triggered by various perceptually similar cues, but they are poorly integrated into conceptual memory. Here, we conduct exploratory whole-brain analyses to investigate the neural representations of trauma-analog experiences and how they are reactivated during memory intrusions. We show that trauma-analog movies induce excessive processing and generalized representations in sensory areas but decreased blood-oxygen-level-dependent (BOLD) responses and highly distinct representations in conceptual/semantic areas. Intrusive memories activate generalized representations in sensory areas and reactivate memory traces specific to trauma-analog events in the anterior cingulate cortex. These findings provide the first evidence of how traumatic events could distort memory representations in the human brain, which may form the basis for future confirmatory research on the neural representations of traumatic experiences.

Effects of Narrative Exposure Therapy for Treating Depressive and Anxious Disorders: A Systematic Review and Meta-Analysis

OBJECTIVE

Narrative exposure therapy (NET) has been used in various contexts for the treatment of the effects of trauma, with promising results in clinical trials. However, its effects on anxiety and depression are still unclear. The present study is a systematic review and meta-analysis of the effects of NET on depression and anxiety.

METHODS

The Embase, Cumulative Index of Nursing and Allied Health Literature, PubMed, Web of Science core collection, Cochrane Library, Chinese National Knowledge Infrastructure, Chinese Biomedical Database, and Wangfang databases were searched from the earliest records to March 2023. Two researchers independently screened the literature, extracted data, evaluated the risk of bias, and cross-checked the data. Meta-analysis was performed using the program RevMan 5.3.

RESULTS

Eleven randomized controlled trials with a total of 754 participants were included in the study. The results showed that NET reduced both the depression (standard mean difference [SMD]=-0.51, 95% confidence interval [CI] -0.73--0.29, p<0.00001) and anxiety (SMD=-0.65, 95% CI -1.13--0.18, p=0.007) scores of the patients. Furthermore, NET was found to alleviate negative emotions associated with guilt (mean difference [MD]=-3.60, 95% CI -5.52--1.68, p=0.0005) and negative change (MD=-5.80, 95% CI -9.76--1.83, p=0.004).

CONCLUSION

This analysis showed that NET can alleviate depression and anxiety. It may thus be used in clinical settings to alleviate patients' negative feelings and aid their overall recovery.

Improving Traumatic Stress with Justice-Impacted Women and Women Experiencing Homelessness: A Pilot Study of Narrative Exposure Therapy

OBJECTIVE

We sought to investigate the feasibility, acceptability, and impact of a brief, manualized trauma-focused intervention aimed at improving PTSD symptoms in persons with complex PTSD, Narrative Exposure Therapy (NET).

DESIGN

Using a mixed methods approach, we tested the feasibility, acceptability, and impact of NET in a sample of trauma-affected women in traumatogenic circumstances: justice-impacted women in prison and women experiencing homelessness in a shelter. We quantitatively assessed data using a single sample, pre-/post-intervention design. We qualitatively assessed self-described symptom change and opportunities for intervention adaptation using a content analysis approach.

METHODS

Sixteen trauma-affected participants completed the intervention protocol. NET interventionists included one nurse practitioner, one registered nurse, and one nursing student. All NET participants attended pre-/post-intervention visits and active NET sessions. In-depth interviews were conducted at pre- and post-intervention, alongside a diagnostic battery.

RESULTS

NET was both highly feasible and acceptable among participants. Participants significantly improved on the intervention-specific outcome of PTSD symptoms, as well as somatic symptom burden, with large effect sizes. Participants also improved on subjective self-described symptom change. Participants offered recommendations regarding opportunities to enhance population-specific intervention acceptability.

CONCLUSIONS

Results from this pilot study are consistent with previous evidence demonstrating that NET facilitates improvements in women with traumatic stress. Findings of high feasibility, acceptability, and impact supports the use of NET in JW and WEH. Integrating participant recommendations to optimize acceptability may further support scalability and reach of NET. Replication with a larger sample and within a randomized controlled design is required to definitively determine effectiveness.

Accelerated Fear Extinction by Regular Light-Intensity Exercise: A Possible Role of Hippocampal BDNF-TrkB Signaling

PURPOSE

Growing concern exists worldwide about stress-related mental disorders, such as posttraumatic stress disorder (PTSD), often linked to hippocampal dysfunctions. Recognizing this connection, regular light-intensity exercise (LIE)-such as yoga, walking, or slow jogging-may offer a solution. Easily accessible even to vulnerable individuals, LIE has been found to enhance hippocampus-based cognitive functions through the stimulation of neurotrophic factors like brain-derived neurotrophic factor (BDNF). A prior study that demonstrated BDNF's role in extinguishing original fear memory further leads us to propose that a consistent LIE training might drive fear extinction learning, offering potential therapeutic benefits through BDNF signaling.

METHODS

Eleven-week-old Wistar rats underwent 4 wk of training under conditions of sedentary, LIE, or moderate-intensity exercise (MOE) after contextual or auditory fear conditioning. Subsequently, fear extinction tests were performed. We then administered intraperitoneal (i.p.) ANA-12, a selective antagonist of tropomyosin receptor kinase B (TrkB), or a vehicle to explore the role of BDNF signaling in exercise-induced fear extinction among the LIE rats. Following the regular exercise training, further fear extinction tests were conducted, and hippocampal protein analysis was performed using Western blotting.

RESULTS

Both LIE and MOE over 4 wk accelerated hippocampus-associated contextual fear extinction compared with sedentary. In addition, 4 wk of LIE with i.p. administered vehicle increased hippocampal BDNF and TrkB protein levels. In contrast, i.p. ANA-12 administration fully blocked the LIE-enhanced protein levels and its effect on contextual fear extinction.

CONCLUSIONS

Our findings reveal that LIE regimen promotes fear extinction learning, at least partially tied to hippocampal BDNF-TrkB signaling. This suggests that even regular light exercise could alleviate the excessive fear response in anxiety disorders and PTSD, providing hope for those affected.

Family Function and Post-Traumatic Stress Disorder in Children and Adolescents: A Meta-Analysis

Family function reflects the operating status of the family system, which plays a vital role in children's mental health. The current meta-analysis examined the association between family function and post-traumatic stress disorder (PTSD) in children and adolescents for the first time. Studies published from 1980 to 2021 were identified via searching and screening. We identified 31 studies (91 unique effects) with 8,684 children. A three-level meta-analysis revealed that overall family function was negatively associated with PTSD (r = -0.205). Among elements of family function, family affect (r = -0.251), communication (r = -0.221), and cohesion (r = -0.184) were associated with less PTSD, whereas family conflict (r = 0.228) was associated with more PTSD in children. Family flexibility (r = -0.103) was not associated with PTSD. Moderator analyses revealed differences between various types of trauma events and family function scales. The findings highlight the differences in the roles of the elements of family function and suggest that interventions should be focused on targeting specific elements of family function.

Trauma treatment using Narrative Exposure Therapy adapted to persons with intellectual disabilities or severe chronic mental disorders - a randomised controlled pilot study with an embedded observational study

BACKGROUND

Despite an increased likelihood of experiencing traumatic events and increased vulnerability, there are only few publications on trauma therapy for persons with intellectual disabilities (IDs). This pilot study for the first time investigates the feasibility and effectiveness of Narrative Exposure Therapy (NET) within this target group modified by Plain Language.

METHODS

A group of n = 10 participants with ID dual diagnoses and another group of n = 5 participants with severe and chronic mental disorders were separately stratified and randomised, then forming together an intervention group (n = 7) and a waiting list control group (n = 8). All participants were treated with NET attuned to their communication abilities by using Plain Language. Primary outcome was the post-traumatic stress measured with the Post-Traumatic Symptom Scale-10 before and after the intervention. In addition, the Adverse Childhood Experience Index was used for diagnostic purposes. Data were analysed using t-test for repeated measures and analysis of covariance.

RESULTS

Narrative Exposure Therapy and the randomised controlled trial study proved to be successfully conductible with participants with IDs in a congregated residential service. Although the corresponding effect size was high (partial eta square = 0.188), the between-group difference was not significant (P = 0.12). Analysis of the observational study resulted in a highly significant improvement for participants with IDs (P < 0.001; Hedges' g = 2.36) and in a significant improvement in participants with severe and chronic mental disorders (P < 0.013; Hedges' g = 1.52). Additionally, the participants with IDs show a significantly better reduction of symptom burden (P = 0.03; partial eta square = 0.327).

CONCLUSIONS

The results provide a first evidence for a possible and successful implementation of NET modified in Plain Language for persons with IDs and complex mental health support needs. Completeness in responding to the items of Post-Traumatic Symptom Scale-10 and Adverse Childhood Experience Index indicates the suitability of these instruments for both groups of participants. Although the group difference in the randomised controlled trial failed to achieve statistical significance mainly due to the small sample size, the results of the embedded observational study are promising for the conduct of further studies with the modified NET.

The Implementation of Narrative Exposure Therapy (NET) for Transgender and Gender Diverse Adolescents and Young Adults

Purpose

There is limited information available regarding the use of trauma modalities within the transgender and gender diverse community (TGD) to address gender-based trauma, including discrimination and invalidation, particularly for adolescents and young adults (AYA). The purpose of this paper is to describe a novel treatment approach to addressing post-traumatic stress disorder (PTSD) symptoms within TGD AYA, inclusive of gender-based trauma.

Methods

Narrative Exposure Therapy (NET) was implemented as a brief intervention for TGD AYA who had a positive screening for PTSD symptomatology. Measures were used to assess PTSD symptoms, as well as changes in self-perceived resilience and positive well-being. Two case vignettes are provided to demonstrate the adaptations made to be responsive to the unique needs of TGD AYA for trauma processing.

Results

Preliminary outcomes from two case studies indicate the strength of NET when working with TGD AYA who face multiple traumatic events and continue to experience invalidation.

Conclusion

NET shows promise as an effective brief intervention to reduce PTSD symptomology and increase resiliency in TGD AYA.

Counseling pregnant people after previous termination of pregnancy for fetal anomaly (TOPFA): the double RAINBOW approach

BACKGROUND AND OBJECTIVES

Pregnancy loss is exceptionally common, yet there exist few interventions for clinical providers to assist parents who are expecting again. Perhaps even less prevalent are practice models for parents who have terminated a pregnancy due to fetal anomaly (TOPFA). In this article, we present the "Double Rainbow" acronym, which provides evidence-supported guidance for counseling people experiencing a subsequent pregnancy after TOPFA.

DESIGN AND METHODS

Using prompts of: Remember; Rehearse & Anticipate; Attach & Internalize; Interrogate decision; Neutralize; Normalize; Bond; Breathe & Observe; Optimize health; Weave and Whole story, we tie intervention techniques to evidence-based treatments and clinical practice examples.

RESULTS

Filling a gap for guidance for effective intervention with people during subsequent pregnancies after termination of pregnancy due to fetal anomaly, we aim to improve such treatment while also encouraging evaluation of the approach, encouraging evaluation of its use with broader populations.

CONCLUSIONS

The double RAINBOW approach weaves together evidence-based therapies while also attending to the work of distinguishing past losses and promoting parental attachment and caregiving systems in clients who have terminated a pregnancy due to fetal anomaly.

Therapists' experience of the lifeline in narrative exposure therapy

This study aimed to explore the therapist experience of delivering the lifeline component of narrative exposure therapy (NET), an intervention for individuals with posttraumatic stress disorder resulting from exposure to multiple traumatic events. The lifeline in NET involves constructing a chronological representation of the client's life using physical symbols to depict traumatic events as well as positive experiences. A semistructured interview was conducted with 16 therapists experienced in delivering the lifeline component of NET to adult clients. The data from these interviews were analyzed using thematic analysis. Five overarching domains were identified, each encapsulating three themes. The first domain pertains to the overlapping purposes of the lifeline, united by the vital function of developing the therapeutic relationship. The second domain describes the value and potential therapeutic mechanisms of the lifeline's "whole life" perspective. The third domain speaks to the intensely emotional nature of the lifeline process and some of the challenges this presents. The fourth domain relates to the physicality of the lifeline and the value this adds beyond a purely verbal method. The final domain encompasses several challenges described by therapists as well as potential areas for further development. This study provides a rich account of the novel lifeline component in NET. The findings provide direction for refinement of clinical practice and avenues for future research.

Epigenetics of traumatic stress: The association of NR3C1 methylation and posttraumatic stress disorder symptom changes in response to narrative exposure therapy

Epigenetic processes allow plasticity in gene regulation in response to significant environmental events. Accumulating evidence suggests that effective psychotherapy is accompanied by epigenetic changes, rendering DNA methylation a potential biomarker of therapy success. Due to the central role of glucocorticoid dynamics in stress regulation and the alteration of aversive memories, glucocorticoid receptors are likely involved in the molecular processes that are required to successfully treat Posttraumatic Stress Disorder (PTSD). This study aimed to investigate the relationship between methylation at the glucocorticoid receptor gene (NR3C1) and PTSD treatment success of evidence-based psychotherapy. A sample of N = 153 conflict survivors from Northern Uganda (98 females and 55 males) with PTSD were treated with Narrative Exposure Therapy (NET). Diagnostic interviews and saliva sampling took place at pretreatment and 4 and 10 months after treatment completion. We investigated potential associations between PTSD symptom development and methylation changes at 38 CpG sites spanning NR3C1 over the three times of measurement using the repeated measures correlation. After accounting for multiple comparisons, DNA methylation at CpG site cg25535999 remained negatively associated with PTSD symptoms. These results were followed up by mixed models as well as structural equation modelling. These analyses revealed that treatment responders had a significant cg25535999 methylation increase after treatment with NET. Furthermore, lower methylation at cg25535999 pretreatment predicted a higher symptom improvement. Our results suggest different epigenetic profile dynamics at NR3C1 cg25535999 in therapy responders compared to non-responders and underscore the central role of glucocorticoid signaling in trauma-focused therapy.

Life and mental health in limbo of the Ukraine war: How can helpers assist civilians, asylum seekers and refugees affected by the war?

The terror spread by the war disrupts lives and severs families, leaving individuals and communities devastated. People are left to fend for themselves on multiple levels, especially psychologically. It is well documented that war adversely affects non-combatant civilians, both physically and psychologically. However, how the war puts civilians' lives in a limbo is an under-researched area. This paper focuses on three aspects: (1) how the mental health and well-being of Ukrainian civilians, asylum seekers, and refugees are affected by the war caused limbo; (2) what factors affect this process of being stuck in the limbo of war; and (3) how psychologists and helpers in the war-ridden and host countries can provide meaningful support. Based on the authors' own practical work with Ukrainian civilians, refugees, and professional helpers during the war, this paper provides an overview of multi-level factors that impact human psyches in a war, and possible ways to help those who are living in the war limbo. In this research and experiential learning-based review, we offer some helpful strategies, action plans, and resources for the helpers including psychologists, counselors, volunteers, and relief workers. We emphasize that the effects of war are neither linear nor equal for all civilians and refugees. Some will recover and return to a routine life while others will experience panic attacks, trauma, depression, and even PTSD, which can also surface much later and can prolong over the years. Hence, we provide experience-based ways of dealing with short-term and prolonged trauma of living with war and post-traumatic stress disorder (PTSD). Mental health professionals and other helpers in Ukraine and in host countries can use these helping strategies and resources to provide effective support for Ukrainians and for war refugees in general.

Treating trauma-driven OCD with narrative exposure therapy alongside cognitive behavioural therapy

When post-traumatic stress disorder (PTSD) co-occurs with obsessive compulsive disorder (OCD), symptoms of the former can interfere with evidence-based treatment of the latter. As a result, exposure-based treatments are recommended for both OCD and PTSD, potentially facilitating a concurrent treatment approach. This case study describes the application of concurrent cognitive behaviour therapy (CBT including exposure and response prevention; ERP) for OCD and narrative exposure therapy to treat a patient whose PTSD symptoms of intrusive images of memories and hyperarousal were interfering with standard CBT (including ERP) treatment for OCD. Following this concurrent approach, the patient’s symptoms of OCD reduced to non-clinical levels and showed reliable improvement in PTSD symptoms. Whilst further methodologically robust research is required, this case study highlights that this approach may be beneficial to the treatment of OCD where PTSD symptoms are impacting on treatment.

Key learning aims

(1)

Adapting narrative exposure therapy with a tribal community: A community-based approach

OBJECTIVE

American Indian (AI) individuals are at increased risk for present-day trauma exposure and associated negative outcomes, as well as ongoing effects of intergenerational trauma exposure and adversity. However, few empirically supported treatments exist that are specifically tailored and/or tested with AI communities. This study describes the process of selecting, adapting, and implementing narrative exposure therapy (NET) with an AI community.

METHODS

A community and academic partnership was formed and worked together to make culturally mindful changes to NET to best fit the needs of the community. The partnership incorporated community leaders/Elders (n = 7), providers (n = 11), and participants seeking treatment (n = 50) to implement an iterative process of adapting and implementing the adapted form of NET.

RESULTS

Key adaptions included addressing historical and intergenerational trauma, greater protections for confidentiality in a small community, and incorporation of cultural customs and traditions. Overall, the adapted form of NET was favorably received by the participants, and the implementation appeared to be feasible, with improved retention over past trials of adapted trauma-focused treatments with this community and with highly positive satisfaction ratings and feedback.

CONCLUSIONS

NET was shown to be an appropriate approach for this AI community and should be considered as a treatment option for other AI communities. Future work should consider strategies outlined in this adaption as well as following a similar process for working with AI communities to implement culturally appropriate interventions for trauma-related symptoms.

Skills Training in Affective and Interpersonal Regulation for Refugees Integrated With Narrative Exposure Therapy: A Case Study on the Treatment of PTSD and Emotion Dysregulation for Refugees and Asylum-Seekers

The prevalence of post-traumatic stress disorder (PTSD) in individuals affected by war and conflict is high, with approximately 1 in 3 refugees and asylum-seekers meeting diagnostic criteria for PTSD. PTSD in refugees and asylum-seekers is associated with significant emotion dysregulation which may arise from chronic trauma exposure and post-migration stressors and lead to impaired day-to-day functioning. There is evidence that treatments that target emotion regulation skills prior to implementing exposure-based therapies lead to improved treatment response and reduced attrition in survivors of interpersonal traumas such as sexual abuse. The current case study details the use of a novel adaptation of one such treatment – Skills Training in Affective and Interpersonal Regulation for refugees and asylum-seekers (STAIR-R). In this case study, we report on the implementation of STAIR-R in combination with Narrative Exposure Therapy (NET) with Sara, a 60-year-old Iraqi woman who presented with high levels of nightmares, avoidance and emotion dysregulation following exposure to war- and conflict-related trauma and post-migration stressors. In this case study, we explore the intersection of emotion regulation skills training (in STAIR-R) and exposure therapy (in NET), and the potential for this combined intervention to improve emotion regulation skills, enhance coping with post-migration stressors and facilitate engagement with exposure-based treatment for PTSD.

The patient-authored medical record: A narrative path to a new tool in psychiatric nursing

This paper describes preliminary research from Japan on developing a new tool for psychiatric nurses, the patient-authored medical record, a "prescription" written in ordinary language by the patient with the assistance of a nurse. The nurse asks the patient how to improve their illness and she types up the patient's story on site in the form of a first-person narrative. The patient checks it for accuracy before taking a copy home. Ten Japanese patients participated in this field-oriented ethnographic study, and the analysis of the qualitative data strongly suggested that the approach had therapeutic effects on each patient. This narrative-based prescription could be used as a tool, specifically by psychiatric nurses, in many cultures, and it is our hope that it contributes to their professional identity.

Refugee Children and Interventions for Depression: A Review of Current Interventions and Implications of the Ecological Context

As of 2018, over 25.4 million people worldwide meet the criteria to be considered refugees, the highest number on record. Over half of these individuals are under 18 years old, leaving approximately 12 million children to cope with the trauma and stress typically encountered by refugees. Increased rates of depression in this population are well-documented in the literature. This article reviews the ecological determinants of depression for displaced children and current empirical methods for alleviating depression across contexts. PubMed and PsycINFO databases were reviewed for articles that met the following criteria for inclusion: published between January 1, 2000, and April 16, 2020; peer-reviewed empirical article; in English; reviewed an intervention targeting depression; and included a sample of refugees 18 years of age or younger. Sixteen interventions met inclusion criteria and were assessed using an ecological framework. The programs were analyzed for several methodological and outcome factors including intervention type, retention rate, participant demographics, participant country of origin and host country, ecological framework, and effectiveness. Major findings suggest that interventions including caregivers, involving the child's community, addressing multiple contexts, and that are culturally informed may improve outcomes. This article presents research surrounding risk and protective factors for depression within each context to inform existing interventions and presents additional avenues for services to meet the needs of refugee youth across contexts.

Psychological Interventions for Survivors of Intimate Partner Violence in Humanitarian Settings: An Overview of the Evidence and Implementation Considerations

This paper provides an analytical overview of different types of psychological interventions that have demonstrated efficacy in low-income and/or humanitarian settings and points to special considerations that may be needed if used with women who have been subjected to gender-based violence (GBV). This paper reviews diverse therapeutic modalities and contrasts them across several domains, including their conventional use and principles; their documented use and efficacy in humanitarian settings; any special considerations or modifications necessary for GBV-affected clients; and any additional resources or implementation concerns when working in low-income contexts. By examining the evidence base of multiple interventions, we hope to provide clinicians and GBV-prevention advocates with an overview of tools/approaches to provide survivor-centered, trauma-informed responses to GBV survivors. This analysis responds to the growing recognition that gender-based violence, in particular intimate partner violence and sexual violence, is strongly associated with mental health problems, including anxiety, depression, and post-traumatic stress. This is likely to be exacerbated in humanitarian contexts, where people often experience multiple and intersecting traumatic experiences. The need for mental health services in these settings is increasingly recognized, and a growing number of psychological interventions have been shown to be effective when delivered by lay providers and in humanitarian settings.

Evidence-based individual psychotherapy for complex posttraumatic stress disorder and at-risk groups for complex traumatization: A meta-review

BACKGROUND

The current meta-review of meta-analyses on psychotherapy research for complex post-traumatic stress disorder (CPTSD) and samples at risk of complex traumatization has three aims: first, to provide an overview of efficacy of individual psychotherapies; second, to compare the quality of the meta-analyses; and third, to assess statistical power.

METHODS

The literature search was conducted until August 2020. Meta-analyses providing individual treatment effect estimates focusing on CPTSD or samples at risk of complex traumatization (i.e., victims of childhood sexual abuse (CSA), war or torture, refugees, and veterans with PTSD) were eligible for inclusion. The effect sizes were classified according to Cohen as small, medium, or large. The "A MeaSurement Tool to Assess systematic Reviews" (AMSTAR) was applied to assess the quality of the meta-analyses, and power was assessed post-hoc.

RESULTS

Twenty-four meta-analyses were suitable for inclusion. The efficacy of the interventions varied (g = -0.04 (CI -0.39; 0.48), controlled, to d = 2.73 (1.69; 3.76), uncontrolled). Overall, 16 effect estimates were large. On average, the quality of the meta-analyses was good (average AMSTAR total score 7.71 points (range 3-11). Considering quality assessments and power together, nine meta-analyses were evaluated as high quality.

LIMITATIONS

No meta-analysis for CPTSD was eligible and the number of individuals with complex traumatization was not directly assessed in the at-risk groups.

CONCLUSIONS

For at-risk groups for complex traumatization, on average, good-quality empirical evidence exists. Given the limited research on CPTSD, future studies are needed to further investigate the efficacy of interventions.

A Refugee Rose of competencies and capabilities for mental healthcare of refugees

In this paper, I set out the challenges of care for refugees and suggest approaches to assessment and intervention. I discuss clinical interventions that can address the immediate concern of the clinician in a bio-psycho-social framework, and the value of considering eco-social and structural influences that can hinder recovery and perpetuate inequalities. Refugees face multiple adversities before, during and after escaping from life-threatening situations, political violence, torture and persecution. They present with complex health needs and encounter hostility from host countries and public services, which see their needs as an additional demand on the public purse. Regrettably, existing care practice and training of professionals do not often include skills for working across cultures, including cultural formulations and fair assessment, cultural adaptation of interventions, cultural competence and cultural consultation methods, including clinical ethnography and exploration of cultural identity and explanatory models. There are little data on effective and kind models of interpretation and translation. Care systems are rarely designed to fully address the needs of refugees. Health practitioners are not trained to address structural and institutional racism and discrimination, which leads to exclusion of the most marginalised, with little attention to social justice and fair processes as part of appropriate healthcare.

Advancing a Three-Tier Personality Framework for Posttraumatic Growth

Adversity has been assumed to foster positive personality change under certain conditions. In this article, we examine this assumption within the context of the three-tier personality framework integrating traits, characteristic adaptations, and narrative identity to provide a comprehensive understanding of personality growth. We first review findings on how adverse events affect personality on each of these three levels. Second, we summarize knowledge on event-based and person-based predictors of personality change in the face of adversity. Third, we specify affective, behavioral, and cognitive processes that explain personality change across levels of personality. Innovatively, our proposed process model addresses change at all three levels of personality, as well as similarities and differences in processes across the levels. We conclude by discussing unresolved issues, asking critical questions, and posing challenging hypotheses for testing this framework.

Efficacy of exposure in group settings for youth with posttraumatic stress symptoms

BACKGROUND

Exposure to traumatic experiences is a fundamental part of evidence-based trauma-focused cognitive behavioral treatment (CBT) but in group settings it is discussed controversially among researchers and practitioners. This study aims to examine the individual participants' stress level during group sessions with exposure and disclosure of traumatic events.

METHOD

N = 47 traumatized youth (M_age = 17.00, 94% male) participated in a group intervention comprising six 90-min group sessions (exposure in sessions 2-5). It is based on trauma-focused CBT principles. The individual stress level was assessed by the participants and group facilitators at the beginning, during, and at the end of every session.

RESULTS

During the sessions including exposure, the stress level of the participants was higher than during sessions without exposure (Z = - 3.79; p ≤ .001). During the exposure sessions, the participants showed significant changes in stress level (d = 0.34-0.87) following an inverse U-shaped trend.

CONCLUSION

The results show that exposure is feasible within the scope of a trauma-focused group intervention for youth. The further dissemination of trauma-focused group treatments is an important component in the mental health care of children and youth who are traumatized.

Lost in Transition? Evidence-Based Treatments for Adolescents and Young Adults with Posttraumatic Stress Disorder and Results of an Uncontrolled Feasibility Trial Evaluating Cognitive Processing Therapy

Posttraumatic stress disorder (PTSD) is not uncommon among adolescents and young adults (AYAs). Left untreated, transition to adulthood might be especially challenging and/or prolonged for AYAs. However, it is unclear whether AYAs are adequately represented in current PTSD treatment research and whether they benefit to the same degree as younger or older individuals. In the first part of the paper, we reflect on developmental considerations in the treatment of AYAs and give an overview of current age-specific results in PTSD treatment research. Furthermore, we review individual trauma-focused evidence-based treatments that were examined in AYAs over the last 10 years. In the second part, we present data from an uncontrolled feasibility trial evaluating cognitive processing therapy (CPT) with some age-adapted modifications and an exposure component (written accounts). We treated 17 AYAs (aged 14 to 21) suffering from posttraumatic stress symptoms (PTSS). At posttreatment, participants had improved significantly with respect to clinician-rated PTSS severity (d = 1.32). Treatment gains were maintained throughout the 6-week and 6-month follow-ups. Results indicated that CPT, with only minor adaptations, was feasible and safe in AYAs. The recommendations for future research focus on the inclusion of young adults in trials with adolescents, more refined age reporting in clinical trials, and the encouragement of dismantling studies in youth. To conclude, clinical recommendations for caregiver involvement and the addressing of developmental tasks, motivational issues and emotion regulation problems are discussed.

Psychological Intervention and Treatment for Posttraumatic Stress Disorder During Pregnancy: A Systematic Review and Call to Action

Posttraumatic stress disorder (PTSD) during pregnancy is a significant global mental health concern that affects up to 1 in 5 trauma-exposed pregnant women and is associated with an increased risk of adverse maternal and infant complications and health outcomes. This systematic literature review, conducted in accordance with PRISMA guidelines, examined findings from studies of psychological interventions and treatments for prenatal PTSD to inform recommendations for future research. Relevant evidence was identified from reference reviews and electronic databases (i.e., PubMed, Google Scholar, PsychInfo, and Scopus). Included studies reported on the effect of nonpharmacological intervention or treatment of PTSD symptomatology delivered during pregnancy, with at least one postintervention follow-up collected during pregnancy to assess prenatal treatment outcomes. The systematic review was augmented with a discussion of lower-level evidence. Of the 954 articles screened, six peer-reviewed, quantitative reports met the inclusion criteria and featured three empirically based interventions, including two randomized controlled trials: Two psychoeducation interventions for PTSD and one treatment study of interpersonal psychotherapy in trauma-exposed pregnant women. Effect sizes for PTSD symptom change ranged from small to large, Cohen's d/η_p ² = 0.16-0.78. No studies examined evidence-based PTSD treatments (e.g., exposure therapy, cognitive processing therapy). A risk of bias assessment indicated variability in study quality. This review demonstrates that research on prenatal PTSD symptoms, diagnosis, and treatment is extremely limited despite a clear link between prenatal PTSD and perinatal complications. Early evidence supports further scientific inquiry into psychoeducation, psychotherapy treatments (e.g., exposure therapy), integrated prenatal care approaches, and community-based approaches.

Lay-delivered talk therapies for adults affected by humanitarian crises in low- and middle-income countries

BACKGROUND

Published by the World Health Organization (WHO) and United Nations High Commissioner for Refugees (UNHCR) in 2015, the mental health Gap Action Programme Humanitarian Intervention Guide (mhGAP-HIG) recommends brief versions of structured psychological interventions for people experiencing symptoms of common mental disorders (CMDs). mhGAP-HIG acknowledges a growing body of evidence suggesting these interventions can be delivered by lay workers to people affected by humanitarian crises in low- and middle-income countries (LMICs). However, there has not yet been a systematic review and synthesis of this evidence. This paper reports the results of a systematic review of qualitative, quantitative, and mixed-methods studies assessing the implementation and/or effectiveness of talk therapies for CMDs when provided by lay workers in LMICs to adults who have survived or are currently living in humanitarian situations.

METHODS

Seven electronic databases were searched: MEDLINE, Embase, PsycINFO, PsycEXTRA, Global Health, Cochrane Library, and ClinicalTrials.gov . We also hand-searched the contents pages of three academic journals, reference lists of 30 systematic reviews, and online resource directories of two mental health networks. A preliminary list of included studies was circulated to topical experts for review, and all included studies were backward and forward searched. All titles, abstracts, and full-texts were independently double-screened. Quality appraisal and data extraction were carried out by a single reviewer and checked by a second reviewer, using standardised tools. Any disagreements were discussed and referred to a third reviewer as needed.

RESULTS

We identified 23 unique studies and carried out a narrative synthesis of patient and implementation outcome data. Every evaluation of the effectiveness of lay-delivered talk therapies for adults affected by humanitarian crises in LMICs showed some treatment effect for at least one CMD, and often multiple CMDs. Implementation research generally found these interventions to be acceptable, appropriate and feasible to implement, with good fidelity to manualised therapies.

CONCLUSION

Although results are promising, particularly for individually-delivered talk therapies based on cognitive behavioural therapy techniques, there is a high degree of heterogeneity in this literature. We make several recommendations on how to improve the quality and generalisability of research on this topic, to facilitate further evidence synthesis.

TRIAL REGISTRATION

PROSPERO registration number: CRD42017058287 .

Unaccompanied minors’ experiences of narrative exposure therapy

Despite the understanding that unaccompanied minors’ (UAM) experience high rates of post-traumatic stress, the provision of evidence-based trauma-focused therapies is low for this population. Narrative exposure therapy (NET) is an effective short-term intervention for treating post-traumatic stress disorder (PTSD) after multiple traumatic experiences, such as those experienced by UAM. Within the existing literature, there is a lack of research investigating unaccompanied minors’ experiences of NET or any trauma-focused therapy. Participants were four UAM experiencing PTSD who formed part of a pilot delivery of NET within a dedicated child and adolescent mental health service for refugee children. Semi-structured interviews were conducted and transcripts were analysed using interpretative phenomenological analysis (IPA). This project identified five themes that encapsulated unaccompanied minors’ experiences of receiving NET, including the process of preparing for this therapy, what it was like to receive it, and the differences they identified at the end of treatment. The significance of this taking place within a safe therapeutic relationship was explored within the context of the attachment losses experienced by UAM, and the impact this has on emotion regulation was considered. The potential of a reduction in PTSD symptoms facilitating a positive spiral in adolescence was reflected on within this paper.

Key learning aims

(1)

Practical guidelines for online Narrative Exposure Therapy (e-NET) - a short-term treatment for posttraumatic stress disorder adapted for remote delivery

Background: Online therapy has become increasingly desirable and available in recent years, with the current COVID-19 pandemic acting as a catalyst to develop further protocols enabling therapists to conduct online treatment safely and efficaciously. Offering online treatment potentially means that treatments are available to clients who would otherwise have no access, closing the gap in the provision of mental health services worldwide. Objective: This paper focuses on practical guidelines using online Narrative Exposure Therapy (e-NET). It aims to be an addition to the general manual of NET to enable therapists to deliver online treatment. The face-to-face version of NET is a well-known short-term and evidence-based treatment for posttraumatic stress disorder; e-NET is currently being tested in several additional trials. Methods: The differences between NET and e-NET are elaborated and depicted in detail. Results: Difficulties encountered in e-NET delivery, e.g. confidentiality, dealing with interruptions, comorbid symptoms among others, are similar to those that occur during face to face interventions but the solutions have to be adapted. Dissociation is often regarded as a challenge in face-to-face treatment, and requires particular attention within the online setting. Therefore, tools for addressing dissociation in this particular setting are presented. Conclusions: These practical guidelines show the advantages as well as the challenges therapists face when conducting e-NET. They aim to empower therapists working with trauma clients to conduct e-NET confidently and safely.

A systematic review of clinical effectiveness of psychological interventions to reduce post traumatic stress symptoms following childbirth and a meta-synthesis of facilitators and barriers to uptake of psychological care

AIM

To review the literature on psychological interventions for post-traumatic stress following childbirth (PTSDFC) and determine clinical effectiveness. To synthesise the qualitative literature on the facilitators and barriers to uptake of care for PTSDFC.

BACKGROUND

The context of childbirth trauma differs from that of other events perceived as traumatic. Current guidance on treatment for PTSDFC requires further clarification.

METHOD

Web of Knowledge, CINAHL, MEDLINE, PSYCINFO, the Cochrane Central Register of Controlled Trials (CENTRAL), Open Grey, UKCTG, and the ISRCTN were consulted to include journal articles published in English.. Articles were segregated according to methodology and appraised using the Mixed Methods Appraisal Tool.

RESULTS

A total of 5355 papers were identified with five quantitative and 13 qualitative included in the review. Four types of interventions were identified: eye movement desensitisation and reprocessing, trauma focussed CBT, debriefing and expressive writing. All showed some effectiveness in treating PTSDFC. Themes emerging from the meta-synthesis included women finding it difficult to recognise having a problem, needing validation and only seeking help 'at breaking point'. Women wanted health professionals actively asking in a non-judgemental way at different time points and providing support and listening, ideally with continuity of carer to make sense of their experiences.

LIMITATIONS

Quantitative studies were not disaggregated by intervention timing or follow-up duration. A single independent reviewer with team discussion was utilised.

CONCLUSION

There is little definitive evidence assessing the effectiveness of psychological interventions for PTSDFC. There are psychological barriers for women accessing help for traumatic childbirth which services can mitigate.

[The Diagnostic and Therapeutic Care of Abused Children and Adolescents]

The Diagnostic and Therapeutic Care of Abused Children and Adolescents In the following article, an overview of the current German health care situation concerning child abuse, neglect and maltreatment is provided. Interdisciplinary institutions of child protection are important initial contact points for families and professionals wishing to receive help. Furthermore, trauma clinics, victim support organizations and specialized counselling centers are indispensable to meet the complex needs of victims. Overall, the availability and accessibility of the support system in Germany is still insufficient and the number of unknown and untreated cases remains high. An improvement of the current situation should be of high governmental priority.

Online narrative exposure therapy for parents of children with neurodevelopmental disabilities suffering from posttraumatic stress symptoms - study protocol of a randomized controlled trial

BACKGROUND

Parents of children with intellectual and neurodevelopmental disorders (IDD) often experience traumatic events in the care of their children. This leads to comparatively high numbers of mental health problems such as posttraumatic stress disorder (PTSD) in those parents. Intervention approaches for parents of children with IDD are scarce and many parents remain without support.

OBJECTIVE

This study aims to test the feasibility and efficacy of online Narrative Exposure Therapy (eNET) with parents of children with IDD.

METHODS

The study follows a randomized waitlist-control design. eNET is an exposure-based PTSD intervention and includes 8-12 90-minute sessions. All sessions will be conducted via video calls with trained paraprofessionals. We aim to include 50 parents, approximately 25 in the immediate intervention group and 25 in the waitlist group. Waitlist participants will receive the same intervention after a three-month wait period. All participants need to either fulfill full or subclinical PTSD symptoms according to DSM-5. Feasibility and efficacy of the intervention will be measured with pre, post, and 2 and 6 months follow-up surveys focusing on PTSD symptoms. Secondary outcomes include other health-related outcomes such as physical symptoms, depression symptoms, anxiety symptoms and functionality.

CONCLUSIONS

The proposed study allows us to test the feasibility and efficacy of eNET in a sample of parents of children with IDD. There are so far no published studies on the evidence of eNET; this study is one of the first randomized controlled trials investigating the feasibility and efficacy of eNET and therefore will have implications on further research and practice.Clinical trial registration: NCT04385927Date and version identifier: 22 July 2021.

Narrative Exposure Therapy in Patients With Posttraumatic Stress Disorder and Borderline Personality Disorder in a Naturalistic Residential Setting: A Randomized Controlled Trial

Background: Comorbid Posttraumatic Stress Disorder (PTSD) increases the already high symptom burden of patients with Borderline Personality Disorder (BPD). As the gold standard for BPD treatment, Dialectical Behavior Therapy (DBT), does not focus on PTSD, other treatment approaches are needed. Narrative Exposure Therapy (NET) was designed to address multiple traumatic events and may be especially useful in this patient group. The aim of the present study was to determine the efficacy of NET compared to DBT based treatment (DBT-bt) in a randomized controlled trial. Methods: Female patients (n = 60) with BPD and comorbid PTSD were randomized to either a 10-week residential NET or DBT-bt. The primary outcome was change in PTSD severity as assessed by the Clinician Administered PTSD Scale (CAPS). Mixed linear models as well as reliable change, remission, and response rates were used to compare improvement across treatment groups. Results: Mixed linear model showed that patients in both treatments improved significantly over time across all outcome measures. This improvement was not more pronounced in NET (no significant time × type of treatment effect). However, NET resulted in a higher remission rate as compared to DBT-bt. PTSD remission was accompanied by BPD remission in all cases. Conclusions: This study shows the value of trauma-focused therapy in patients with BPD and PTSD for recovery in both disorders. To shorten the duration of both illnesses as much as possible, future studies should focus on the factors predicting treatment success and enabling patients to benefit from trauma-focused treatment as soon as possible. Trial registration: ClinicalTrials.gov, identifier: NCT02517723.

Exposure therapy for PTSD during pregnancy: a feasibility, acceptability, and case series study of Narrative Exposure Therapy (NET)

Background

Prenatal posttraumatic stress disorder (PTSD) is a significant complication of pregnancy linked to increased risk of adverse perinatal outcomes. Although 1 in 5 pregnant trauma-exposed individuals have PTSD, most PTSD treatment trials exclude participants who are pregnant, and none focus on treatment specifically during pregnancy. Moreover, access to mental health treatment is particularly challenging in low-resource settings with high rates of trauma. This study examined implementation of Narrative Exposure Therapy (NET), a short-term evidence-based PTSD treatment, in an urban prenatal care setting. Partial telehealth delivery was used to increase accessibility. Study aims were to examine (a) feasibility, (b) acceptability, and (c) case-based treatment outcomes associated with NET participation.

Method

Eight pregnant participants (median age = 27, median gestational week in pregnancy = 22.5) received up to six sessions of NET with partial telehealth delivery. PTSD and depression symptoms were assessed at pre-treatment intake (T1), at each session (T2), and 1-week post-treatment (T3). A multiple case study approach was used to examine recruitment and engagement, retention, treatment completion, treatment barriers, use of telehealth, participants’ experiences of treatment, and PTSD and depression symptoms.

Results

Nine of the 16 participants (56%) who were invited to participate engaged in treatment, and one dropped out after the first session. Eight participants completed the minimum “dose” of 4 NET sessions (N = 8/9, 89%). Seven participants gave the highest ratings of treatment acceptability. The most frequently reported barriers to treatment were competing priorities of work and caring for other children. Pre-post treatment symptom measures revealed clinically meaningful change in PTSD severity for nearly all participants (7/8, 88%).

Conclusions

Results suggest that a brief exposure therapy PTSD treatment can be successfully implemented during pregnancy, suggesting promising results for conducting a larger-scale investigation.

Trial registration ClinicalTrials.gov, NCT04525469. Registered 20 August 2020–Retrospectively registered, https://register.clinicaltrials.gov/prs/app/template/EditRecord.vm?epmode=View&listmode=Edit&uid=U00058T2&ts=3&sid=S000A59A&cx=-w1vnvn

Adverse Childhood Experiences, Trauma Symptoms, Mindfulness, and Intimate Partner Violence: Therapeutic Implications for Marginalized Men

Adverse childhood experiences (ACEs) and trauma symptoms have been linked with intimate partner violence (IPV) perpetration and victimization among men, yet the field lacks depth in several key areas hampering progress toward violence intervention. Specifically, posttraumatic stress disorder (PTSD) dominates the field's scope of trauma symptoms under study, limiting understanding of other manifestations of trauma especially among men. Furthermore, most research focuses exclusively on men's physical IPV perpetration and rarely focuses on other types of IPV, severity of violence, or men's victimization. Also, few studies examine potential protective factors grounded in the ACE framework, such as mindfulness, among clinical populations. Finally, most research has not focused on men of color, despite some racial/ethnic minority groups disproportionate rates of IPV exposure. Therefore, the relationships between IPV frequency and severity (psychological, physical, injury) and ACEs, PTSD, trauma symptomology (separate from PTSD), and mindfulness self-efficacy were examined in a sample of 67 predominantly low-income men of color in a batterer intervention program. More than half of the sample (51.5%) reported exposure to four or more ACEs, and 31.1% met the clinical cutoff for a probable PTSD diagnosis. Higher ACE scores predicted increased rates for nearly all types of self-reported IPV perpetration and victimization. PTSD symptoms and complex trauma symptom severity together explained between 13% and 40% of IPV outcomes, and each was uniquely associated with certain types of self-reported IPV victimization and perpetration frequency and severity. Mindfulness self-efficacy was associated with decreased self-report psychological IPV perpetration and victimization frequency and severity. Clinical implications relevant to marginalized men are reviewed, including screening, training, and potential therapeutic interventions.

Systematic review and meta-analyses of the long-term efficacy of narrative exposure therapy for adults, children and perpetrators

Objective: Narrative Exposure Therapy (NET) is a short-term trauma-focused intervention originally developed for treating survivors of war and torture. The neurobiological theoretical foundations of NET would suggest that the approach should have long term beneficial effects. We tested this assumption and also provided an extensive overview of all NET studies for adults, for children (KIDNET), and for perpetrators (Forensic Offender Rehabilitation NET; FORNET).Method: Following a systematic literature review, we conducted meta-analyses with all studies that had control conditions, and with all Randomized Controlled Trials (RCTs). We assessed between-groups short- (< 6 months) and long-term (≥ 6 months) effect sizes for symptoms of posttraumatic stress disorder (PTSD) and depression.Results: In a total of 56 studies from 30 countries comparing 1370 participants treated with NET to 1055 controls, we found large between group effect sizes regarding the reduction of PTSD symptoms in favor of NET. Analyses of RCTs with active controls yielded small to medium effect sizes in the short-term, and large effect sizes in the long-term.Conclusions: NET, KIDNET, and FORNET yield beneficial and sustainable treatment results for severely traumatized individuals living in adverse circumstances. Studies in highly developed health care systems comparing NET with other evidence-based trauma-focused interventions are needed.

Establishing Context to Build Capacity: A Qualitative Study to Determine the Feasibility, Utility, and Acceptability of a Complex Trauma Training for Psychologists Working in Urban Migrant Communities in Northern Peru

Across Latin America, increasing access to mental health care has become a priority. Management of common mental disorders is shifting to primary care, and community mental health centers (CMHCs) are being established to treat severe needs. In urban migrant communities on the outskirts of Trujillo, Peru, five new CMHCs have been built to treat complex mental health concerns, partially in response to high rates of domestic violence and child maltreatment. However, psychologists have no training in the treatment of interpersonal trauma. This study sought to determine the utility of such a training and identify areas for cultural adaptation. Six focus groups were conducted with CMHC psychologists. Findings revealed that, while a culturally-adapted training in trauma-focused treatment is desired, sociocultural barriers to ensuring the physical and psychological safety of the service user must be considered, as well as provider barriers including short treatment packages, insufficient physical infrastructure, and unstable work conditions.

The Mindfulness-Based Phase-Oriented Trauma Therapy (MB-POTT): Hypnosis-informed mindfulness approach to trauma

Hypnosis has long been successfully used in the treatment of trauma and related disorders. In this paper, I describe a hypnosis-informed approach to PTSD using mindfulness. The Mindfulness-Based Phase-Oriented Traumatic Therapy (MB-POTT) follows the phase-oriented tradition that was originally proposed by Pierre Janet, later expanded by Daniel Brown and Erika Fromm using clinical hypnosis. MB-POTT comprises four distinct, yet recursive, stages: (1) therapeutic alliance building and symptom stabilization, (2) formation of a narrative about the trauma, (3) re-creation of meaning of life after trauma, and (4) future symptom management. In explaining these categories, I delineate the nature of mindfulness, both similarities and dissimilarities to hypnosis, with an emphasis on techniques that resemble hypnotic approaches (e.g., ego state therapy, ego-strengthening). Finally, I provide a case study in which MB-POTT was implemented with a client who suffered from PTSD after a near-fatal industrial accident.

A survey of evidence-based practice, training, supervision and clinician confidence relating to post-traumatic stress disorder (PTSD) therapies in UK child and adolescent mental health professionals

Background: Post-Traumatic Stress Disorder (PTSD) in children and adolescents has received increasing recognition in recent decades. Despite development of treatments and improved dissemination efforts, research has identified a number of barriers to implementing these approaches. Objective: This study sought to understand what interventions mental health professionals working with children and adolescents utilised to treat PTSD, their training and supervision, their confidence in assessing and treating PTSD, and how these factors relate to clinicians characteristics (e.g. age, gender, professional background). Method: The study comprised an internet-delivered survey of clinicians working in child and adolescent mental health services in the UK (N = 716). Results: Many clinicians (>40%) had not received training in working with PTSD, with considerable variation between professional background. Lack of training and supervision was associated with reduced clinician confidence in treating children with PTSD (possible range 0-10; training M = 7.54, SD = 1.65, no training M = 5.49, SD = 2.29; supervision M = 7.53, SD = 1.63, no supervision M = 5.98, SD = 2.35). Evidence-based therapies for PTSD such as Trauma-Focused Cognitive-Behavioural Therapy and Eye Movement Desensitisation and Reprocessing were only endorsed modestly by clinicians (58.4% and 37.5%, respectively). Regression analyses identified that lack of training and supervision were significant barriers to the use of evidence-based interventions. Other predictors of clinician confidence and use of evidence-based interventions included profession and years of experience. Participants almost universally wanted more training in working with PTSD. Conclusions: Evidence-based treatments are not currently universally delivered by mental health professionals in the UK, with certain professions particularly lacking training and confidence with this condition. Training around trauma and PTSD may be an ongoing need to boost and maintain confidence in working with PTSD in youth.

An overview of systematic reviews on mental health promotion, prevention, and treatment of common mental disorders for refugees, asylum seekers, and internally displaced persons

BACKGROUND

Migrants who have been forced to leave their home, such as refugees, asylum seekers, and internally displaced persons (IDP), are likely to experience stressors which may lead to mental health problems. The efficacy of interventions for mental health promotion, prevention, and treatment may differ in this population.

OBJECTIVES

With this overview of systematic reviews, we will map the characteristics and methodological quality of existing systematic reviews and registered systematic review protocols on the promotion of mental health and prevention and treatment of common mental disorders among refugees, asylum seekers, and IDPs. The findings from this overview will be used to prioritise and inform future Cochrane reviews on the mental health of involuntary migrants.

METHODS

We searched Ovid MEDLINE (1945 onwards), Ovid Embase (1974 onwards), Ovid PsycINFO, ProQuest PTSDpubs, Web of Science Core Collection, Cochrane Database of Systematic Reviews, NIHR Journals Library, CRD databases (archived), DoPHER, Epistemonikos, Health Evidence, 3ie International Initiative for Impact Evaluation, and PROSPERO, to identify systematic reviews of mental health interventions for involuntary migrants. We did not apply any restrictions on date, language, or publication status to the searches. We included systematic reviews or protocols for systematic reviews of interventions aimed at refugees, asylum seekers, and internally displaced persons. Interventions must have been aimed at mental health promotion (for example, classroom-based well-being interventions for children), prevention of mental health problems (for example, trauma-focussed Cognitive Behavioural Therapy to prevent post-traumatic stress disorder), or treatment of common mental disorders and symptoms (for example, narrative exposure therapy to treat symptoms of trauma). After screening abstracts and full-text manuscripts in duplicate, we extracted data on the characteristics of the reviews, the interventions examined in reviews, and the number of primary studies included in each review. Methodological quality of the included systematic reviews was assessed using AMSTAR 2.

MAIN RESULTS

The overview includes 23 systematic reviews and 15 registered systematic review protocols. Of the 23 published systematic reviews, meta-analyses were conducted in eight reviews. It was more common for the search strategy or inclusion criteria of the reviews to state that studies involving refugees were eligible for inclusion (23/23), than for asylum seekers (14/23) or IDPs (7/23) to be explicitly mentioned. In most reviews, study eligiblity was either not restricted by participant age (9/23), or restricted to adults (10/23). Reviews commonly reported on studies of diagnosis or symptoms of post-traumatic stress disorder or trauma (11/23) and were less likely to report on depression or anxiety (6/23). In 15 reviews the intervention of interest was focused on/ specific to psychological therapy. Across all 23 reviews, the interventions most commonly identified from primary studies were general Cognitive Behavioural Therapy, Narrative Exposure Therapy, and a range of different integrative and interpersonal therapies. Even though many reviews included studies of participants without a diagnosis of a mental health problem, they often assessed mental health treatments and did not usually distinguish between promotion, prevention, and treatment in the review aims. Together the 23 systematic reviews included 336 references, of which 175 were unique primary studies. Limitations to the methodological quality of reviews most commonly related to reporting of selection criteria (21/23), absence of a protocol (19/23), reporting of study design (20/23), search strategy (22/23), and funding sources of primary studies (19/23).

AUTHORS' CONCLUSIONS

Gaps exist in the evidence on mental health interventions for refugees, asylum seekers, and internally displaced persons. Most reviews do not specify that internally displaced persons are included in the selection criteria, even though they make up the majority of involuntary migrants worldwide. Reviews specific to mental health promotion and prevention of common mental disorders are missing, and there is more evidence available for adults or mixed populations than for children. The literature is focused on post-traumatic stress disorder and trauma-related symptoms, with less attention for depression and anxiety disorders. Better quality systematic reviews and better report of review design and methods would help those who may use these reviews to inform implementation of mental health interventions.

Efficacy of Psychological Interventions on Depression Anxiety and Somatization in Migrants: A Meta-analysis

Many studies reveal the effectiveness of different psychological interventions on the adult refugees reporting mental health distress. Aim of this metanalysis was to test the efficacy of different psychological treatments on the depressive, anxiety and somatization symptoms on refugees and asylum seekers. Fifty-two studies, since 1997 to 2019, were included in the systematic review and 27 of those were included in the metanalysis. Studies providing a pre and post treatment methodological design were included. All treatments reported significant effects on the three outcomes. Qualitative observations showed a probability to have a significant pre-post treatment effects on trials with outcome of depression (56%), anxiety (44%), and somatization (42%). Cognitive behavioral treatment resulted the most effective treatment. The status of refugee compared to the status of asylum seeker seems to have a great effect on the effectiveness of the treatment.

A randomized comparison trial of culturally adapted HIV prevention approaches for Native Americans reducing trauma symptoms versus substance misuse: The Healing Seasons protocol

Native Americans (NA) experience interrelated risks of trauma exposure, substance use, and HIV risk behaviors that put them at increased risk for HIV infection. Despite these known risk factors, there are very few published randomized trials testing interventions to reduce trauma-related symptoms and substance misuse among NA.

METHODS

The Healing Seasons study is a randomized comparsion trial of two counseling strategies, Narrative Exposure Therapy (NET) addressing PTSD or Motivational interviewing with cognitive behavioral therapy skills training (MIST) addressing substance misuse as a means to prevent HIV among NA. Using a community-based participatory research approach, we adapted both evidence-based interventions to be specific to the risk contexts and realities of NA and to include psychoeducational and skill-building components that include cultural-specific stories, virtues, and traditional treatment strategies. Participants, 16 years and older, were recruited from a Pacific Northwest tribal community, screened over the phone, enrolled in person, and randomized in equal numbers to NET or MIST. We stratified by age (16-29 years and 30 or older) and gender (male or female identified) to ensure balance between treatment arms. The primary outcomes were number of sex partners and frequency of sexual acts (with and without condoms), sex under the influence of substances, frequency of substance use, and PTSD severity.

DISCUSSION

Behavioral interventions for NA are needed to prevent HIV risk behaviors when faced with trauma symptoms and substance misuse. This study will provide evidence to determine feasibility and efficacy of addressing related risk factors as part of counseling-based HIV prevention intervention to reduce sexual risk among this population.

TRIAL REGISTRATION

ClinicalTrials.gov number, NCT03112369, registered April 12, 2017.

Trajectories of posttraumatic stress symptoms during and after Narrative Exposure Therapy (NET) in refugees

BACKGROUND

Trauma-focused therapy approaches are recommended as treatment for posttraumatic stress disorder (PTSD). This includes the treatment of trauma-related suffering in refugee populations. However, there is a lack of knowledge about symptom trajectories in refugees living in volatile conditions. This has led to fear of "retraumatisation" and general skepticism in clinicians concerning the use of exposure therapy.

METHODS

To test the relevance of this concern, we investigated PTSD symptom trajectories and potentially influencing factors during the course of Narrative Exposure Therapy (NET) in a refugee sample living in Germany. Refugees filled out the PTSD Checklist prior to each treatment session and also during follow-up interviews. Therapists continuously documented positive and negative life events as well as the content of the treatment sessions. Additionally, structured clinical interviews were conducted pre-treatment and at follow-up time points.

RESULTS

On average, clients presented with substantial decreases in PTSD symptoms already during and after NET. However, symptom trajectories differed and ranged from fast responders to slow responders to no immediate response during treatment. Importantly, a persistent worsening of symptoms was not observed, also not after exposure to the most distressing events. In contrast, stressful life experiences seemed to aggravate PTSD symptoms.

CONCLUSIONS

Consistent with earlier studies, NET leads to clinically and behaviorally relevant reductions in PTSD symptoms both throughout and following treatment in refugees living in volatile conditions. Concerns about imaginal exposure in refugees were not substantiated. While stressful life events contributed to transient symptom increases, they weren't found to prevent the overall effectiveness of NET.

TRIAL REGISTRATION

NCT02852616.

Feasibility of narrative exposure therapy in an outpatient day treatment programme for refugees: improvement in symptoms and global functioning

BACKGROUND

 Refugees are at high risk for developing post-traumatic stress disorder (PTSD). Narrative exposure therapy (NET) is an evidence-based treatment of PTSD, designed for patients exposed to (multiple) traumatic events and recommended for patients with culturally diverse backgrounds. In clinical practice, adherence to the NET-protocol has been challenged because of psychosocial complexities and comorbid disorders. .

OBJECTIVE

The current study investigated the feasibility of NET embedded in an outpatient day treatment programme for refugees and examined reduction in PTSD symptoms and improvement of global functioning as well as correlates of change. .

METHOD

Participants were patients who consecutively entered an outpatient daytreatment programme from 2013-2017. The majority had a history of prior unsuccessful treatment. PTSD was assessed with the Clinically Administered PTSD Scale (CAPS) before and after finishing NET. Global Assessment of Functioning (GAF) was used to examine changes in functioning. Changes in PTSD scores and functioning were analyzed using paired t-tests and reliable change indices. Patients showing significant improvement were compared to those who did not, on patient and treatment characteristics, including sex, age, region of origin, childhood trauma and treatment duration and dosage of NET. .

RESULTS

Of 97 patients, 76 (78.4%) completed NET. Completers had a longer residency and were more likely to have a partner. Significant reductions in PTSD symptoms and improvements in global functioning were observed. Twenty-eight percent showed reliable improvement with large effect sizes. Four patients did no longer meet the criteria for PTSD. No strong moderators for changes were found. Patients who did not improve more often had a history of childhood trauma.

CONCLUSIONS

NET embedded in an outpatient day treatment programme appears to be feasible. In those who improved, a substantial decline in symptoms and improvement of functioning were observed. The findings suggest that a socially supportive living environment enhances acceptability of trauma-focused treatment in refugees.

Evaluating narrative exposure therapy for post-traumatic stress disorder and depression symptoms: A meta-analysis of the evidence base

Narrative exposure therapy (NET) is an intervention for trauma spectrum disorders. Originally developed to treat refugee populations, NET has since been tested for efficacy across different settings. In this review, the NET evidence base is examined through a retrieval, synthesis and appraisal of randomized controlled trials (RCTs) published since 2002. Two independent reviewers (S. R. and N. S.) searched online databases including EMBASE, PsycINFO and PubMed. Twenty-four RCTs were selected for a meta-analysis of three outcomes: post-traumatic stress disorder (PTSD) diagnosis and PTSD and depression symptoms. All outcomes were analysed at short-term (3-4 months), midterm (6-7 months) and long-term (≥12 months) data points. A random-effects model was applied to yield standardized mean differences (SMDs) and odds ratios (ORs) as indicators of NET treatment effect. Subgroup analyses for type of trauma and type of control groups were conducted to examine potential heterogeneity. For the NET group, moderate effect sizes for PTSD symptom severity were observed at midterm and long term and at midterm for depression symptom severity. The number of PTSD diagnoses decreased significantly in the short term for the NET condition, but this was not sustained at the long term. Caution must be exercised when interpreting these results due to high heterogeneity estimates and low quality of evidence across trials. Potential small-study effects further complicate the interpretation of the findings. Recommendations are made for augmenting statistical significance research with qualitative analyses of NET efficacy to better inform clinical practice.

Proof of Concept of an Eclectic, Integrative Therapeutic Approach to Mental Health and Well-Being Through Virtual Reality Technology

Across three studies, we provide a proof-of-concept evaluation of an integrative psychotherapeutic application of virtual reality (VR) technology. Study 1 (n = 36) evaluated an unguided “safe-place” imagery task, where participants were instructed “to create a safe space… [such as] a scene, item, design, or any visual representation that makes you feel safe” using either the Google Tilt Brush application (VR condition), the standard Microsoft Paint application (2-D condition), or via eyes-closed mental imagery alone (IMG condition). Study 2 (n = 48) evaluated a narrative episodic recall task, where participants viewed their childhood and adult homes and places of schooling either using either the Google Earth VR application (VR condition) or the standard Google Earth application (2-D condition) or recalled these places with their eyes closed via mental imagery alone (IMG condition). Finally, Study 3 (n = 48) evaluated a guided wilderness imagery task, during which different scripts were narrated, specifically, a trail walk in autumn, a spring meadow, and a hillside walk in snowy winter, while either these same scenes were visually presented using the Nature Treks VR application (VR condition), the scenes were presented using the same software but shown on standard computer monitor (2-D condition), or participants’ eyes were closed (IMG condition). Order of intervention format was randomized across participants. Across all three studies, quantitative survey ratings showed that the VR format of intervention delivery produced greater positive affect and satisfaction and perceived credibility ratings as an intervention for trauma- and stressor-related disorders and psychological well-being as rated by university students who varied in traumatic and stressful life event history and symptoms of posttraumatic stress disorder, whereas qualitative findings revealed additional themes of experiential response including increased experience of presence and vividness in the VR condition. Future research directions and clinical applications are discussed.