PTSD Distress Reduction Appropriate Intervention & Intervention Process Paper 1. Read/watch the attached files, ppt, and video, write a 500 words post that

PTSD Distress Reduction Appropriate Intervention & Intervention Process Paper 1. Read/watch the attached files, ppt, and video, write a 500 words post that answers all the questions below.

After watching the TED talk, reviewing the introduction, the chapter, and the articles of your choice, try to think of a way in which we could apply distress reduction on a larger, or community scale.
What would you do?
How would you do it?
Respond to the video: how did you feel prior to watching it? Afterwards? Was it hard to feel her pain? What, if anything, about it made you uncomfortable? Do you consider her trauma less important than the other parents who lost children?

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2/ Write a 100 words feedback to a classmate post that I will send later.

Respond constructively to a classmate—can you think of a way to improve what they suggested? Can your idea merge with theirs? Journal of Consulting and Clinical Psychology
2008, Vol. 76, No. 4, 686 – 694
Copyright 2008 by the American Psychological Association
0022-006X/08/$12.00 DOI: 10.1037/0022-006X.76.4.686
Treatment of Posttraumatic Stress Disorder by Trained Lay Counselors in
an African Refugee Settlement: A Randomized Controlled Trial
Frank Neuner
Patience Lamaro Onyut
University of Konstanz and vivo Germany
Vivo Uganda and Mbarara University of Science and
Verena Ertl, Michael Odenwald, Elisabeth Schauer, and Thomas Elbert
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
University of Konstanz and vivo Germany
Traumatic stress due to conflict and war causes major mental health problems in many resource-poor
countries. The objective of this study was to examine whether trained lay counselors can carry out
effective treatment of posttraumatic stress disorder (PTSD) in a refugee settlement. In a randomized
controlled dissemination trial in Uganda with 277 Rwandan and Somalian refugees who were diagnosed
with PTSD the authors investigated the effectiveness of psychotherapy administered by lay counselors.
Strictly manualized narrative exposure therapy (NET) was compared with more flexible trauma counseling (TC) and a no-treatment monitoring group (MG). Fewer participants (4%) dropped out of NET
treatment than TC (21%). Both active treatment groups were statistically and clinically superior to MG
on PTSD symptoms and physical health but did not differ from each other. At follow-up, a PTSD
diagnosis could not be established anymore in 70% of NET and 65% TC participants, whereas only 37%
in MG did not meet PTSD criteria anymore. Short-term psychotherapy carried out by lay counselors with
limited training can be effective to treat war-related PTSD in a refugee settlement.
Keywords: posttraumatic stress disorder, therapy, dissemination, war, refugees
Sudan (Karunakara et al., 2004), and in countries with a history of
war like Rwanda even 8 years postconflict (Pham, Weinstein, &
Longman, 2004).
Despite increasing evidence that PTSD is a major mental health
issue in many developing countries and refugee populations, intervention research on these populations has been largely neglected. Treatment studies in industrialized countries have shown
that PTSD caused by traumatic events like sexual violence, car
accidents, criminal attacks, and so forth can be well treated
through psychotherapy (Bradley, Greene, Russ, Dutra, & Westen,
2005). Trauma-focused approaches are currently considered to be
the most effective methods for the treatment of PTSD and are
recommended over symptom-oriented psychotherapy or pharmacological treatment (National Institute for Clinical Excellence,
2005). Trauma-focused psychotherapy encompasses a variety of
approaches including cognitive– behavioral methods that directly
target the traumatic event in psychotherapy. In general, measures
include encouraging the patient to talk about the traumatic event in
detail and to relive the experience in a safe environment.
As the context in war-affected populations in developing countries is different from the situation in industrialized countries, it is
unclear to what extent knowledge about PTSD theory and treatment can be transferred to developing countries. Many victims of
war-related trauma continue to live in unstable and unsafe living
conditions, affected by continuing threat, malnutrition, and poverty. It is not implausible to argue that this can interfere with the
effectiveness of psychological treatment. In addition, survivors
often report a series of traumatic experiences rather than a single
event (Neuner, Schauer, Karunakara, et al., 2004), which makes it
In 2004, political scientists counted more than 42 ongoing wars
and armed conflicts worldwide, almost all of them in developing
countries (Schreiber, 2005). In addition, many low-income countries continue to suffer the consequences of recent armed conflicts.
Observers of current wars have noted that the main target of the
warring parties is the civilian population and that systematic atrocities including massacres and bombings are often carried out as
rational strategies (Kaldor, 1999). As a result, high and sustained
levels of traumatic stress affect both the mental health of individuals and the functioning of whole communities. One of the most
prevailing consequences of traumatic events is posttraumatic stress
disorder (PTSD). Recent epidemiologic community surveys in
war-torn areas found PTSD point prevalence rates between 15%
and 50% in different refugee populations (de Jong et al., 2001;
Karunakara et al., 2004), in Afghanistan (Scholte et al., 2004) and
Frank Neuner, Verena Ertl, Michael Odenwald, Elisabeth Schauer, and
Thomas Elbert, Department of Clinical Psychology, University of Konstanz, Konstanz, Germany, and vivo Germany, Allensbach, Germany;
Patience Lamaro Onyut, vivo Uganda, Mbarara, Uganda, and Department
of Science, Mbarara University of Science and Technology, Mbarara,
This research was supported by Deutsche Forschungsgemeinschaft
(DFG) and Bundesministerium fu?r wirtschaftliche Zusammenarbeit
(BMZ). We thank Mary Moran for training and treatment supervision and
Silke Gotthardt and Martina Ruf for assistance with clinical examinations.
Correspondence concerning this article should be addressed to Frank
Neuner, Department of Psychology, University of Konstanz, 78457 Konstanz, Germany. E-mail:
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
difficult to select only one significant event as the treatment focus.
However, the major challenge for any mental health provisioning
is the large gap between the high numbers of individuals in need
of psychological assistance in the affected communities and the
lack of qualified mental health professionals or counselors.
This implies the necessity of developing community-based
treatment approaches that are suitable for the requirements of the
field conditions in war-affected societies. The procedures have to
be culturally appropriate, short, and pragmatic enough so that they
can be easily disseminated to professionals with little or no training in mental health or counseling. In addition, treatment must
address the needs of victims of human rights abuses and political
violence and be able to deal with the effects of multiple traumatic
With these requirements in mind, we developed narrative exposure therapy (NET; Neuner, Schauer, Elbert, & Roth, 2002;
Schauer, Neuner, & Elbert, 2005) as a standardized short-term
approach that is based on the principles of cognitive– behavioral
exposure therapy by adapting the classical form of exposure therapy to meet the needs of traumatized survivors of war and torture.
Instead of defining a single event as a target in therapy, the patient
constructs a narration about his whole life from birth up to the
present situation while focusing on the detailed exploration of the
traumatic experiences. As with the tradition of testimony therapy
(Cienfuegos & Monelli, 1983), the resulting written documents
can be used for human rights purposes. In a randomized controlled
trial (Neuner, Schauer, Klaschik, Karunakara, & Elbert, 2004) it
could be shown that NET applied by professional Western therapists was well accepted by Sudanese refugees living in a Ugandan
refugee settlement and that four sessions of NET had a significant
and lasting impact on the reduction of PTSD symptoms.
NET is a strictly manualized approach. Previous experiences
with treatment dissemination have indicated that it is difficult to
maintain strict adherence to a manual once the close supervision
within a treatment trial is terminated. Since we aimed at the
development of a sustainable treatment practice, we included a
treatment group to simulate how NET might be used out of a trial
setting in a regular care system that allowed counselors to be
flexible in their treatment and to apply a variety of methods. We
refer to this treatment strategy as trauma counseling (TC). For this
purpose, the trainee group was trained in NET as well as in a
variety of basic counseling tools, including exposure procedures,
that have proven useful in a local counseling institution. The lay
counselors were encouraged to follow their own intuition in the
application of the treatment for an individual patient in TC.
The goal of the present trial was to examine whether trauma
treatment can be effectively disseminated to lay counselors chosen
from the selected refugee community itself. We used the most
stringent criterion for successful treatment dissemination by testing whether the therapies conducted by the trained counselors
themselves were effective. As we aimed at testing the effectiveness
of trauma treatment in natural conditions, we decided to choose a
refugee camp in a low-resource country as the location for the trial.
While increasing external validity with this approach we had to
take several risks and uncertainties into account. In particular,
unpredictable political events could lead to sudden waves of migration, which would interfere with a long-term observation of
study participants.
The treatment study was carried out for Rwandan and Somalian
refugees in the Nakivale refugee camp in southern Uganda. We
selected refugees without prior training in medical, psychological,
or social professions from these communities to be trained as lay
counselors for their own people. In a randomized controlled trial
we compared the decline of symptoms after six sessions of NET
versus six sessions of TC or a no-treatment monitoring group
(MG). The main outcome measure was the score of posttraumatic
stress symptoms, assessed by trained interviewers chosen from the
refugee community, and expert diagnosis of PTSD at 9-months
follow-up. As there is strong evidence that PTSD correlates with
impaired physical health (Schnurr & Green, 2003) and that disclosure of stressful events can improve physical symptoms (Pennebaker, 1997), we applied a scale of physical symptoms as an
additional outcome measure with the hypothesis that trauma treatment improves physical health.
We expected a superior development of the two active treatment
groups in comparison to the MG group at follow-up. We had no
specific hypothesis for the comparison of NET and TC, as we
could not predict whether the strict manual would be an advantage
or an unnecessary limitation for the trained counselors.
Site and Population
The Nakivale refugee settlement is one of eight official refugee
camps in Uganda. At the time the study was carried out, Nakivale
was host to 14,400 refugees—12,000 Rwandan refugees from the
conflicts in the early 1990s, 800 Somalians who fled to Uganda via
Kenya, and several small groups of refugees from other countries.
The Ugandan government and the Red Cross provided limited
basic health care in the settlement. The United Nations High
Commissioner for Refugees provided a basic food package of 5 kg
beans, 10 kg maize meal, and 5 L cooking oil monthly for each
registered refugee household. The refugees had to supplement this
food provision themselves, mostly by farming the pieces of land
that each registered refugee household had been allotted.
Permission to carry out the study was obtained from the Office
of the Prime Minister, Uganda. The ethical review boards of the
University of Konstanz in Germany and the Mbarara University of
Science and Technology in Uganda had approved the study protocol. During the preinquiry phase of the study, the communities
and their leaders were informed in meetings and supported the
proposed study.
A team of 12 research assistants was recruited from the refugee
community for an epidemiological study that preceded this trial,
half of them Somalians and the other half Rwandans. They were
trained in a 6-week course in principles of quantitative data collection and interviewing techniques. All instruments were translated into Af-Somali and Kinyarwanda through several steps of
translations, blind back–translations, and subsequent corrections
by independent groups of translators. Because of a high illiteracy
rate, all instruments (except for the expert evaluation) were administered in the form of standardized interviews by the trained
local team. Details of training and translation of the instruments
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
are described elsewhere (Onyut et al., 2004). After completing the
translations, we investigated the psychometric properties of the
translated scales in a validation study including a retest spanning a
2-week period and a cross-validation with expert rating. Details of
this validation study will be presented elsewhere.
Sociodemographic data and trauma exposure. A previously
developed sociodemographic survey (Karunakara et al., 2004) was
used to assess nutritional, educational, and socioeconomic as well
as displacement and general demographic information. Nutrition
was assessed by asking for the number of meals eaten the previous
day and by listing the various food items consumed. Since the
refugees rarely have a steady income flow, their economical status
was ascertained by counting the number of essential household
assets such as blankets, mattresses, cooking pots, and water containers. In analysis, the items were then weighted according to
current market prices in Uganda. Educational achievement was
indicated by the number of years of schooling completed. For the
assessment of traumatic experiences, a checklist of 31 different
types of traumatic events was administered (Karunakara et al.,
2004). Each event was scored as present or not present in the
respondent’s life. The number of different experienced and witnessed types of traumatic events was used for the estimation of the
severity of trauma exposure.
Outcome measures. The Posttraumatic Stress Diagnostic
Scale (PDS; Foa, 1995) is a widely used instrument for the
assessment of PTSD diagnosis and severity. It consists of a frequency rating of each of the 17 criteria of PTSD according to the
Diagnostic and Statistical Manual of Mental Disorders (4th ed.;
American Psychiatric Association, 1994); each item is scored
between 0 and 3. The wording of the PDS items had to be adapted
during the translation process to ensure semantic equivalence
across the languages. In our translation, the sum score reached a
retest reliability of rtt? .87 over a 2-week period. Rather than
relying on a cutoff criterion, we established the diagnosis of PTSD
according to the fulfillment of the DSM–IV criteria assessed
through the corresponding items. In a previous validation study in
the same population, the PDS had reasonable diagnostic utility
against an expert PTSD diagnosis that was based on the respective
section of the Composite International Diagnostic Interview
(CIDI; World Health Organization, 1997), with a sensitivity of .86
and a specificity of .88 (? ? .74; p ? .001; N ? 98). Physical
health was assessed with a checklist of those six illnesses and
symptoms that had been present in more than 25% in the previous
survey (cough, diarrhea, flu, pain, fever, and headache). The
physical symptom score was calculated as the sum of symptoms/
diseases present during the last 4 weeks.
Expert evaluation. The DSM–IV diagnosis of PTSD was assessed with the PTSD part of the CIDI. The interviewers were
PhD-level psychologists or graduate students from Konstanz University who had been trained extensively in PTSD assessment with
the CIDI and other instruments in previous field or laboratory
studies with refugees from various cultures. The items of the
interview were translated before the interview and presented with
the help of trained local translators. Further inquiries about details
and examples of symptoms were made by the experts with the help
of the translators to ensure a correct understanding of the symptoms and to validate the clinical significance of symptoms of
In order to detect a moderate effect size difference between NET
and TC (between-groups difference of the standardized withingroup pre- and posttest differences; d ? 0.40), in this trial we
would need at least 133 participants for analysis at the power level
p? ? .90. On the basis of our experiences in refugee camps, we
expected a relatively high attrition (up to 40%) of subjects from
randomization to the last follow-up session, as some participants
may migrate to distant locations. As a consequence, we planned to
recruit 222 participants for the active treatment groups. For the
comparison with the MG group we expected a higher effect size
difference of d ? 0.80, which would require 66 participants for
analysis at p? ? .90. Given the attrition rate of 40%, this would
require 110 subjects for analysis. To allow randomization by
alternating allocation of randomly ordered participants (see below), we decided to recruit 55 participants for the MG group.
Data collection for the study was carried out in the years 2003
and 2004. The study followed an epidemiological investigation
that also served as a screening procedure for the present trial.
Within the survey, 1,422 refugees (906 Rwandans and 516 Somalians) were randomly chosen using a clustered sampling. The same
set of instruments was used for this trial. Of the 884 refugees who
fulfilled DSM–IV criteria of PTSD (assessed with the PDS), we
chose for this trial those 277 individuals who lived in two villages
closest to the research base in the settlement.
We defined drug abuse (assessed using a checklist of common
drugs in Nakivale, including Khat and Waragi), obvious mental
retardation, and psychosis as exclusion criteria; however, none of
the refugees approached for the trial was excluded because of these
reasons. The participants were assigned to the groups in the following way: The list of participants was ordered randomly; the
first 4 were consecutively assigned to the NET, TC, NET, and TC
groups; and the fifth was assigned to the MG (monitoring) group.
This procedure was repeated until all 277 participants were assigned.
Participants were approached by their counselors at their homestead and informed about the study protocol. If participants agreed,
they signed an informed consent that was read and explained in
detail to them. They were not informed about their group allocation before consenting. All refugees who were approached agreed
to participate. Participants who were allocated to the MG group
were informed that they would have the chance to receive the
superior treatment in case the trial showed the effectiveness of at
least one therapy.
The participants who received treatment were reassessed 3 and
6 months later by the same local research assistants who had
carried out the interviews for the survey. They were blind with
respect to the particular treatment condition. As we wanted to
avoid too many assessments without offering assistance, the participants in the MG group were retested at the 6- and 9-months
time points only. At 9 months after baseline the psychopathological status of the participants in all three groups was assessed by a
group of five expert interviewers who were not involved in any
other scientific or clinical task in the trial and who were blind with
respect to the particular treatment provided. All assessment took
place at the…
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