Impact and cultural acceptance of the Narrative Exposure Therapy in the aftermath of a natural disaster in Burundi

Background: In the aftermath of natural disasters, affected populations are at risk of suffering from trauma-related mental health disorders such as posttraumatic stress disorder (PTSD) or depression. Particularly in poor post-conflict regions, these mental disorders have the potential to impair the ability of individuals to move on with their lives. We aimed to evaluate the feasibility, cultural acceptance, and effect of a trauma-focused psychotherapy, Narrative Exposure Therapy (NET), in the aftermath of a flood disaster in Burundi. Methods: Fifty-one individuals who were living in emergency camps overseen by the Burundian Red Cross in the aftermath of a flood disaster, and who had lost homes and close relatives, were invited to participate in semi-structured diagnostic interviews. Trained Burundian psychology students conducted these interviews, and six sessions of NET were offered to the 15 individuals most affected by trauma-related symptoms. An additional group of psychology students, blind to the treatment conditions, conducted three and 9 months follow-ups with them including also 25 participants who had reported significant but less severe trauma-related symptoms, assessing mental health symptoms, acceptance of NET, stigmatization due to trauma symptoms, and participants’ economic well-being. Results: Between baseline and 9-months post-intervention assessment, symptoms of PTSD (Hedges’ g = 3.44) and depression (Hedges’ g = 1.88) improved significantly within participants who received NET and within those who received no treatment (Hedges’ gPTSD = 2.55; Hedges’ gdepression = 0.72). Furthermore, those who received NET felt less stigmatized by their participation in the intervention than by the trauma-related mental health symptoms they experienced. Overall, participants reported that they would be willing to forego as much as 1 month’s worth of income in exchange for receiving trauma-focused interventions in the months following the disaster. Conclusions: Individuals severely affected by trauma-related mental health symptoms might benefit significantly from NET in the aftermath of natural disasters, while less affected individuals seem to recover spontaneously. Despite significant challenges conducting NET in emergency camps in the aftermath of natural disaster in a post-conflict country, such interventions are feasible, appreciated and might have long-lasting impacts on the lives of survivors if conducted with due respect to participants’ privacy. Trial registration: UKCR2014 , the 19.06.2014, retrospectively registered

Commentary on Raghuraman et al. (2021). On the Long-Term Efficacy and Effectiveness of Narrative Exposure Therapy

In the past years, several systematic reviews and meta-analyses have been published assessing the effectiveness of narrative exposure therapy [NET; (Lely et al., 2019; Raghuraman et al., 2021; Siehl et al., 2021; Wei and Chen, 2021)]. The meta-analyses had different aims and came to different conclusions about the effectiveness of NET. Lely et al. (2019) and Wei and Chen (2021) focused on between-treatment effects, post intervention, comparing NET with active and non-active control- treatment-conditions. In addition to comparing between-treatment effects Raghuraman et al. (2021) and Siehl et al. (2021) assessed also the temporal stability of the effects. The latter two studies investigated the reduction of symptom severity of posttraumatic stress disorder (PTSD) and the percentage of PTSD diagnoses over several follow-up periods. Raghuraman et al. (2021) indicated a medium standardized mean difference (SMD) in favor of NET in comparison to active and inactive control groups in the long-term and no benefit regarding PTSD diagnoses. The authors cautioned against using the existing evidence to inform policies and guidelines. In contrast, Siehl et al. (2021) found a large SMD in favor of NET compared to active or inactive control groups in the long-term. They reported an improvement of effectiveness over time when analyzing active control groups and concluded that NET is an effective treatment approach in post-conflict settings and refugee populations, highlighting the high external validity of the trials. Acknowledging the significant efforts of both author groups to select, code, and analyze the existing evidence, we aim to clarify potential underlying reasons for the differences between the two meta-analyses. The purpose of this commentary is two-fold: (a) discuss more generally ways to assess the quality of a treatment, such as NET, that is used in a broad range of contexts and (b) more specific differences between the two meta-analyses in (1) selecting and analyzing strategies, and (2) potential coding errors

Treating Traumatized Offenders and Veterans by Means of Narrative Exposure Therapy

Hecker T, Hermenau K, Crombach A, Elbert T. Treating Traumatized Offenders and Veterans by Means of Narrative Exposure Therapy. Frontiers in Psychiatry. 2015;6:80

When combat prevents PTSD symptoms—results from a survey with former child soldiers in Northern Uganda

Weierstall R, Schalinski I, Crombach A, Hecker T, Elbert T. When combat prevents PTSD symptoms—results from a survey with former child soldiers in Northern Uganda. BMC Psychiatry. 2012;12(1): 41

The Suitability of the Childhood Trauma Questionnaire in Criminal Offender Samples

Adverse childhood experiences (ACEs) are common in community samples and are associated with various dysfunctional physical, psychological, and behavioral consequences. In this regard, criminal offenders are at specific risk, considering their elevated ACE rates compared with community samples and the associations of ACEs with criminal behaviors. However, assessing ACEs in offender samples by self-reports has been criticized with regard to their validity and reliability. We examined the suitability of ACE-self-reports using the Childhood Trauma Questionnaire (CTQ) in a sample of 231 male offenders involved in the German criminal justice system by comparing self-reported to externally rated ACEs to externally rated ACEs based on the information from the offenders’ criminal and health-related files and on interviews conducted by forensically trained psychological/psychiatric experts. The accordance between self-ratings and expert ratings was examined considering mean differences, correlations, inter-rater agreement measures, and regression analyses. Offenders themselves reported a higher ACE burden than the one that was rated externally, but there was a strong relationship between CTQ self-assessments and external assessments. However, associations were stronger in offenders seen for risk assessment than in those evaluated for criminal responsibility. Overall, the CTQ seems suitable for use in forensic samples. However, reporting bias in self-reports of ACEs should be expected. Therefore, the combination of self-assessments and external assessments seems appropriate

Is the Implicit Association Test for Aggressive Attitudes a Measure for Attraction to Violence or Traumatization?

Traumatic exposure is particularly devastating for those who, at a young age, have become combatants or experienced massive adversity after abduction by armed movements. We investigated the impact of traumatic stressors on psychopathology among war-affected young men of Northern Uganda, including former child soldiers. Adaptation to violent environments and coping with trauma-related symptoms often result in an increasing appetite for violence. We analyze implicit attitudes toward violence, assessed by an Implicit Association Test (IAT), among 64 male participants. Implicit attitudes varied as a function of the number of experienced traumatic event types and committed offense types. As the number of traumatic experiences and violence exposure increased, more appetitive aggression was reported, whereas the IAT indicated increasingly negative implicit attitudes toward aggression. The IAT was also the strongest predictor of cortisol levels. Diffusion-model analysis was the best way to demonstrate IAT validity. Implicit measures revealed the trauma-related changes of cognitive structures

Succumbing to the Call of Violence – Sex-Linked Development of Appetitive Aggression in Relation to Familial and Organized Violence

Appetitive aggression is the attraction to violent behavior, which can peak in the experience of a combat high. In various war and conflict scenarios, members of armed groups have reported developing a desire to hunt and even kill humans. More recently, we reported that the phenomenon has also been observed in female ex-combatants with varying participation in warfare. Despite recent investigations on risk factors for appetitive aggression, sex-specific pathways in the development of appetitive aggression have not yet been delineated. This study investigated moderation effects of sex on previously identified risk factors for appetitive aggression by means of regression analyses in a sample of individuals with varying degrees of warfare participation (overall sample, n = 602). First examining a sample characterized by backgrounds heterogeneous in both sociodemographic data and war experiences, the analysis was then replicated in a subsample of fighters active during the civil war (combatant sample, n = 109). In both samples, regression analyses revealed significant moderation effects of sex. Childhood maltreatment and traumatic events had positive associations on the development of appetitive aggression for males but a negative (childhood maltreatment) or no (traumatic events) association for females. Perpetrated events were more strongly correlated with appetitive aggression for females than for males. This pattern was pronounced for the combatant sample. These results are in favor of sex-linked pathways. In both sexes, appetitive aggression may have evolved as a biologically prepared response to cruel environments but might develop along different trajectories. The current study highlights the need for addressing appetitive aggression in order to support peace-building processes and emphasizes sex specific starting-points

Screening for mental disorders in post-conflict regions using computer apps - a feasibility study from Burundi

A high level of psychosocial functioning is essential for survival in many resource-poor countries and is needed for development in these regions. Organized violence, often in combination with other stressors such as poverty and familial conflict, however, result in a range of mental disorders and damage socio-economic progress. An efficient assessment of mental health is a prerequisite for prevention and intervention measures. However, this may require considerable resources that are difficult to obtain in resource-poor countries. We present new methods for the efficient and effective assessment of mental, especially trauma- and stress-related disorders that can easily be administered by trained local paramedics. For decades, Burundi has been a staging ground for armed conflicts leaving behind many survivors with trauma-related illness. In a study with over 900 combatants and veterans from the military as well as former rebels in Burundi, we used a tablet-computer (ipad)-based survey for the assessment of trauma-related syndromes, especially PTSD, in need for treatment. All participants reported the experience of serious traumatic stressors and a substantial portion presented severe symptoms of the trauma-spectrum. Based on the PSS-I and other standardized screening instruments, an ipad app guided the semistructured clinical interviews. Psychologists from the University of Konstanz, the Burundian military as well as psychologist students from the University Lumie` re, Bujumbura, Burundi carried out the interviews. In this contribution, we use the Burundian example to portray the logistics and technology of data acquisition and present respective data. We demonstrate the feasibility of using a computerbased screening approach in the field and in clinical settings. We provide evidence, that the computerized assessment of clinical symptoms can be a useful tool for mental health assessment and screenings, both in research and practice

Is shame the missing link between traumatic experiences and post-traumatic stress disorder in Burundian children living on the streets?

Background: Shame is an emotion reflecting an anticipated social devaluation of the self. It is strongly associated with experiences of humiliation and rejection in early life. Individuals suffering from post-traumatic stress disorder (PTSD) often struggle with shame. However, little is known about how shame contributes to the develop ment and maintenance of PTSD symptoms in children. The present study investi gated the ways childhood exposure to human-induced traumatic events promotes a coping mechanism of defeat and withdrawal facilitated by the experience of shame. We tested a dose–response relationship between lifetime experienced traumatic event types and PTSD in children using shame as a mediator. Methods: We conducted semi-structured interviews with 33 male children who lived and worked on the streets of Bujumbura, the capital of Burundi at the time of data collection. We assessed self-reported PTSD symptom severity, lifetime traumatic event load, violence experienced on the streets and shame intensity. Results: Mediation analyses revealed a significant indirect effect of lifetime traumatic events on PTSD symptom severity through shame intensity and a significant indirect effect of violence experienced on the streets on PTSD symptom severity through shame intensity. Conclusion: Our study suggests the mediating role of shame between traumatic experiences as well as violent experiences and PTSD symptom severity in children living on the streets. Shame in children suffering from PTSD seems to play a crucial role in the development and maintenance of PTSD symptoms

Children and the Cycle of Violence in Post-Conflict Settings : Mental Health, Aggression, and Interventions in Burundi

In this thesis I investigated the negative impact of maltreatment on the psychological wellbeing of children and adolescents who grew up in violent environments of the post-conflict country Burundi. Furthermore, the individual risk factors of these adolescents for engaging in everyday violence were assessed. Subsequently I evaluated the Forensic Offender Rehabilitation Narrative Exposure Therapy (FORNET) as a means of reducing violent behavior among adolescents.Research has demonstrated that trauma-related mental health disorders are common among war-affected populations. Children and adolescents growing up on the streets or in unstable family conditions in post-conflict settings are particularly vulnerable. Exposure to life-threatening situations, maltreatment and other forms of violence at early age most likely impede their development and exacerbate their risk to suffer from mental ill-health.Furthermore, violent environments also appear to foster aggressive behavior. A large number of studies have shown that posttraumatic stress disorder (PTSD) is associated with an increased likelihood of reactive aggressive responding. However, recent studies with serious offenders showed that violent behavior might also be perceived as appetitive, i.e., as exciting, fascinating and related to feelings of power. Appetitive aggression appears to be a useful adaption to adverse environments, which may also develop among children and adolescents. The mental health and the propensity to engage in violent behavior were investigated in 112 male children and adolescents. They were recruited from the streets (n = 15), families (n = 15), a residential center for former street children (n = 32) and other vulnerable children (n = 50) in Burundi. They were between 11 and 24 years old (mean = 15.9 years; SD = 3.0years). PTSD symptom severity was assessed with the University of California at Los Angeles PTSD Reaction Index (UCLA PTSD Index; Steinberg, Brymer, Decker, & Pynoos, 2004). The Minnesota International Neuropsychiatric Interview for Children and Adolescents (MINI-KID; Sheehan et al., 2010) was used to screen for depression, alcohol and substance dependence as well as for suicidal risk. In addition, physical health complaints were examined with a checklist. Aggression was assessed with an offense checklist, the Reactive Proactive Aggression Questionnaire (Raine et al., 2006) and the Appetitive Aggression Scale for Children (AAS-C). Among the adolescents in residential care, the 32 scoring highest in appetitive aggression were chosen to participate in an intervention study. Half of them received FORNET, the remaining 16 received treatment as usual. The follow-up assessment was conducted 4-7 months after completing treatment.Results showed that current street children were most affected by mental disorders. The children living in the residential center suffered more from PTSD symptoms than children who still lived with their families. In residential care, the current exposure to minor violence and neglect was positively associated with increased PTSD symptom severity. The latter impeded progress in school. Appetitive aggression was negatively related to PTSD symptoms. This indicates that appetitive aggression improves resilience against mental illhealth of adolescents who grew up in precarious conditions. Furthermore, appetitive aggression was a serious risk factor for current offenses. FORNET proved to be effective in reducing the involvement in everyday violence among adolescents (Hedges g =.62). In addition, the physical health of the FORNET treated participants improved (Hedges g =.56). The results disentangled different aspects of the cycle of violence: (1) Being a victim of even minor violent acts impairs mental health, which in turn impedes progress in school. Hence providing adolescents with a violence free environment is essential for successful integration into society. (2) Children and adolescents may develop appetitive aggression as an adaption to violent environments. While this protects their mental health in precarious conditions, it also increases their involvement in everyday violence. The FORNET is a promising approach to reducing violent behavior and to improving resilience against ill-health