Elsevier

Behaviour Research and Therapy

Volume 45, Issue 9, September 2007, Pages 2212-2220
Behaviour Research and Therapy

Shorter communication
Narrative exposure therapy for political imprisonment-related chronic posttraumatic stress disorder and depression

https://doi.org/10.1016/j.brat.2006.12.006Get rights and content

Abstract

The psychological consequences of traumatic stress may last even into old age. In persons in their 60s and 70s who had been victims of political detention and torture four decades ago, we compared the outcome of narrative exposure therapy (NET) to that of psychoeducation (PED) only. From a group of 59 former political detainees, 18 who fulfilled the full PTSD criteria according to the Composite International Diagnostic Interview (CIDI) were offered and accepted participation in the treatment study. The participants were randomly assigned to either one session of PED (n=9) or five sessions of NET (n=9). Symptoms of PTSD (CIDI) and depression (Beck Depression Inventory, BDI) were assessed prior to treatment and after a 6-month follow-up. NET but not PED produced a significant reduction in post-traumatic symptoms and depression scores. Four out of 9 of those who completed NET, compared to 8/9 of those within the PED group, still had PTSD 6 months after the treatment had ended. These results indicate that NET may lead to the alleviation of post-traumatic and depression symptoms even when the conditions persist for excessive time periods.

Introduction

As they grow older, survivors of political violence, torture, and terror often suffer from a complex pattern of trauma-spectrum disorders, in which patients present with post-traumatic symptoms usually together with somatic complaints, depression, and substance abuse (Bichescu et al., 2005; Brodaty, Joffe, Luscombe, & Thompson, 2004; Joffe, Brodaty, Luscombe, & Ehrlich, 2003). Such conditions of chronic PTSD are associated with severe functional and emotional impairment, resulting in a dramatic reduction in quality of life with negative economic consequences for the individual and society.

Research has demonstrated the effectiveness of exposure and cognitive-behavioral treatment in a range of victims from those with a history of sexual and physical assault to those having experienced accidents and natural disasters (e.g. Foa, Rothbaum, Riggs, & Murdock, 1991; Foa et al., 1999; Resick, Nishith, Weawer, Astin, & Feuer, 2002; Seidler & Wagner, 2006; Tarrier et al., 1999). Aid organizations for victims of political persecution and torture seek to provide various forms of psychological assistance. However, little is known about the usefulness of potential treatment approaches for victims of political violence, particularly for older individuals who have lived with decades of chronic PTSD. Most information in this area comes from several randomized controlled studies on refugees (i.e., Hinton et al., 2005; Neuner, Schauer, Klaschik, Karunakara, & Elbert, 2004). These studies indicate that culturally appropriate techniques based on cognitive-behavioral approaches and exposure may be most effective.

Narrative exposure therapy (NET; Schauer, Neuner, & Elbert, 2005), which was used in the present treatment study, is a standardized technique that is designed as a short-term approach and considers existing psychological theories and PTSD treatment approaches in order to address the needs of traumatized survivors of organized violence (Schauer et al., 2005). The cognitive processing model (summarized by Elbert, Rockstroh, Kolassa, Schauer, & Neuner, 2006; Neuner et al., 2004; Schauer et al., 2005; see also Ehlers & Clark, 2000) asserts that PTSD symptoms are maintained through a distortion of explicit autobiographic memory about traumatic events and its detachment from the contents of implicit memory, which produces a fragmented narrative of the traumatic memories. The emotional processing theory (Foa & Riggs, 1993; Foa & Rothbaum, 1998; Foa, Steketee, & Rothbaum, 1989) states that the habituation of emotional responses through exposure leads to a decrease in post-traumatic symptoms. Accordingly, the focus of NET is to integrate the generally fragmented, gap-filled reports of traumatic experiences into a coherent narrative and to bring about the habituation of emotional responses to reminders of the traumatic event. This procedure allows traumatic memories to be included in the biography in a narrative form, leading to the reorganization of the autobiographical memory and to the acceptance of the trauma as being in the past. Ideally, the NET-therapist engages in the story by continuously verbalizing and mirroring sensations, behavior, and details of the ‘now’ and ‘then’. S/he completely accompanies the narrating survivor at all levels of cognition, physiology, emotion, and meaning. The therapist's mindset can be described as empathic and non-judgemental, just like in humanistic therapies (e.g. client-centered therapy). However, the patient is guided towards confronting his/her fears along with his/her chronological narration.

As organized violence usually involves prolonged, severe, and/or multiple exposures to trauma, in most cases it is difficult and unreasonable to identify a ‘worst’ event. Moreover, trying to approach a traumatic scene using a ready-made “technique” may be inappropriate or even immoral, as in the case of severe abuses of human rights. The goal of NET is more holistic. The life of the person as a whole is examined, from birth to the present day, with the purpose of gradually identifying all positive and negative emotional moments. This approach is the main difference between NET and most cognitive-behavioral techniques (e.g., Prolonged Exposure; Foa et al., 1991). The detailed description of personal experience in NET facilitates imaginary exposure to the trauma; emotional memories are put into words and contrasted with the emotional experience elicited during the recall (Neuner, 2003; Neuner et al., 2004; Schauer et al., 2005). The act of reliving one's own life, by seeing, hearing, smelling, etc. scenes from the past, allows one not only to understand the meaning and the development of the person but also to recognize coherences, life-patterns, coincidences, and not least of all who the survivor was when encountering the first (second, third etc.) trauma. In this way, the elements of an emotional network can be assigned to a specific place and time in the life-story.

The human rights awareness of the NET procedure, the way of writing down the whole life of the patient, and the distribution of the document in a ritualized manner to be signed by all witnesses present during the narration was based on Testimony Therapy (TT), an intervention created by Lira and Weinstein (Cienfuegos & Monelli, 1983) to treat traumatized survivors of the Pinochet regime in Chile and successfully applied in an uncontrolled trial to Bosnian refugees in the USA (Weine, Kulenovic, Pavkovic, & Gibbons, 1998). In this way, the narratives serve not only therapeutic but also social and political purposes by the documentation of human rights violations (Neuner et al., 2004; Schauer et al., 2005). NET has been successful even in those who continue to live in unsafe conditions (Neuner et al., 2004).

In Romania, given threats of reprisal in response to disclosing information on the political detention regime after release, the awareness that most groups have been infiltrated by secret police informants, the further persecution that affected most of the political detainees after release, and the fact that a definitive lustration law is still to be developed, most of the former political prisoners refrained from giving accounts of their political persecution and imprisonment trauma (for more details, see Deletant, 1999). Following the political change in 1989, the Romanian media initially paid attention to political persecution during communism. However, shortly afterwards, the fascination with a subject that had been a taboo was replaced by indifference and neglect, and published memoirs received attention only among former activists (Kanterian, 2002).

The present treatment study was conducted on survivors of political detention during the former Romanian Communist regime. We evaluated the usefulness of NET (Schauer et al., 2005) in comparison with psychoeducation (PED) in a randomized controlled clinical trial. Based on previous findings (Neuner et al., 2004), the hypothesis was that NET but not PED would reduce symptoms of PTSD and depression. Additionally, we based our hypothesis on the idea that in a country where terror and political constraint affected the entire society, by limiting one's means of expression to the extreme (Deletant, 1999), telling one's own story in a way that is meaningfully incorporated into the autobiography and grasping the disturbance mechanisms relieves the distress by eliciting a sense of self-knowledge and by increasing the awareness of political injustice.

Section snippets

Setting

The present study built on a previous survey of the long-term consequences of political imprisonment under the Communist regime in Romania for 59 victims (for details, see Bichescu et al., 2005). Participants who fulfilled the diagnostic criteria for chronic full PTSD at the time of the above-mentioned survey (n=18) were told in advance that if they agreed, they would be offered participation in a treatment study that would address their suffering related to their traumatic experiences during

Symptom scores

Table 2 presents the results of the post-traumatic and depression scores for pre-treatment and 6-month follow-up. Effect sizes were calculated as the change of the mean between pretest and follow-up examination divided by the pooled standard deviation of the outcome variable at pre- and follow-up test. Furthermore, differences between groups were evaluated separately for each outcome variable by repeated-measures ANOVA with the treatment group (NET vs. PED) as the between-subjects factor and

Discussion

The present study aimed at evaluating the effectiveness of NET for former political detainees living in their country of origin by means of a randomized controlled trial. No refusals to participate or dropouts were recorded, which indicated the need for psychological assistance of psychologically traumatized, former political prisoners in Romania. The lack of dropouts in the NET is in line with the study on the Sudanese refugees in North Uganda (Neuner et al., 2004), which has examined the

Acknowledgments

The study was supported by the Hans-Böckler-Foundation and by the Deutsche Forschungsgemeinschaft (El 101/18). Preliminary results from this study were presented at the 9th European Conference on Traumatic Stress (June 2005).

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