Treating PTSD in refugees and asylum seekers within the general health care system. A randomized controlled multicenter study

Objective

There has been uncertainty about whether refugees and asylum seekers with PTSD can be treated effectively in standard psychiatric settings in industrialized countries. In this study, Narrative Exposure Therapy (NET) was compared to Treatment As Usual (TAU) in 11 general psychiatric health care units in Norway. The focus was on changes in symptom severity and in the diagnostic status for PTSD and depression.

Method

Refugees and asylum seekers fulfilling the DSM-IV criteria for PTSD (N = 81) were randomized with an a-priori probability of 2:1 to either NET (N = 51) or TAU (N = 30). The patients were assessed with Clinician Administered PTSD Scale, Hamilton rating scale for depression and the MINI Neuropsychiatric Interview before treatment, and again at one and six months after the completion.

Results

Both NET and TAU gave clinically relevant symptom reduction both in PTSD and in depression. NET gave significantly more symptom reduction compared to TAU as well as significantly more reduction in participants with PTSD diagnoses. No difference in treatment efficacy was found between refugees and asylum seekers.

Conclusions

The study indicated that refugees and asylum seekers can be treated successfully for PTSD and depression in the general psychiatric health care system; NET appeared to be a promising treatment for both groups.

ClinicalTrials.gov registry number

NCT00218959.     

Cognitive Analytic Therapy: time and process

Cognitive Analytic Therapy (CAT) is an increasingly popular brief therapeutic approach for use with a variety of types of clinical problem. This paper outlines the key components of CAT and demonstrates its use by case examples. The history of CAT is traced, particularly the concept of Reciprocal Roles which was developed from Object Relations Theory. It is suggested that CAT has considerable potential as a collaborative, active therapy, with particular application to difficult patients such as those with borderline personality disorder. Some of the differences from other psychodynamic therapies are described, and an assessment of its future role is provided.     

Brief encounters and available places to land

In this paper the author addresses the process of ending in brief therapy. While recognizing the importance of attending to the symbolic meaning of the ending itself and the need to interpret this as it manifests in the transference, he points out the limitations of such an approach. He highlights the significance of the environment of interpersonal relationships and family systems and the wider communities in which the client lives. He suggests that the therapist needs to assess the extent to which these can provide an environment that facilitates the client's development and working through as the therapy ends. The therapist needs to establish whether the patient will have an available place to land, and one that provides sufficient security and safety for the client's onward journeying and exploration without the therapist. The author's conceptualization of 'landing at the end of brief therapy' links together Malan's triangles of insight with Sullivan's concept of the ordinary solution and selective inattention and Gustafson's concept of dilemmas to add depth to the therapeutic effectiveness with which the practitioner can approach brief therapy in general, and the ending in particular. The article concludes with a case example that illustrates these themes.     

Behavioural Treatment of Post-Traumatic Stress Disorder Associated with Recovered Memories

Post-traumatic stress disorder (PTSD) is sometimes associated with recovered memories (RMs) of traumatic events. That is, the sufferer reports having forgotten traumatic events for a period of time, only to recall them later on. As the memories of traumatic events are recalled, post-traumatic stress disorder may emerge. The cause of recovered memories is uncertain and is the subject of debate. Some recovered memories may be reasonably accurate, while others may be ''recollections'' of imagined rather than actual events. It is unclear whether conventional PTSD therapies, such as behaviour therapy, are appropriate and effective in treating PTSD-RM. The present article considers these issues in the context of a case study, in which a patient with PTSD-RM was treated with behaviour therapy ( in vivo and imaginal exposure). The patient sought treatment because he wanted relief from his PTSD symptoms, regardless of whether his recovered memories were accurate (he was completely convinced in the accuracy of the memories). Treatment outcome was compared with the outcome of 13 PTSD patients who did not have recovered memories, who were also treated with behaviour therapy. Results suggest that PTSD-RM can be effectively treated with behaviour therapy. However, such treatment is unlikely to be appropriate for all cases of PTSD- RM. Selection criteria are discussed.     

Cognitive Coping vs Emotional Disclosure in the Treatment of Anxious Children: A Pilot-Study

The present pilot-study was a first attempt to examine the effectiveness of the cognitive component of cognitive behaviour therapy for children with anxiety problems. A total of 24 highly anxious children were assigned to 1 of 2 intervention conditions: a Cognitive Coping intervention, which focussed primarily on the cognitive component of cognitive behaviour therapy, or an Emotional Disclosure intervention in which children were invited to write about their fears and anxious experiences. Children completed self-report questionnaires of anxiety disorders symptoms and worry at 3 points in time: (i) 6 weeks before treatment (i.e. baseline), (ii) at pre-treatment, and (iii) at post-treatment. The results showed, firstly, that levels of anxiety disorder symptoms and worry remained relatively stable over a 6-week waiting period and then decreased substantially after the interventions. This suggests that the children did not suffer from momentary anxiety and worry complaints and that treatments generally were effective in reducing these symptoms. Secondly, although within-group comparisons suggested that treatment effects were somewhat larger in the Cognitive Coping condition than in the Emotional Disclosure condition (effects sizes for anxiety disorders symptoms and worry were, respectively, 1.03 and 0.87 for Cognitive Coping vs 0.54 and 0.39 for Emotional Disclosure), statistical tests could not substantiate this impression, probably due to a lack of power as a result of the small numbers of children in both intervention conditions.     

Consulting with gargoyles: applying narrative ideas and practices in counselling supervision

This article explores waysin which narrative ideas and practices might influence supervisory relationships in counselling and psychotherapy,and questions some of the taken-for-granted assumptions implicit within counselling supervision. This paper, which represents ‘work in progress’ towards further conversations, rather than an exhaustive study,is illustrated with stories from the author'sown practice as a supervisor and trainer and educator of supervisors.     

Design as a Tool for Family Evolutionary Guidance

This article begins by describing the impact of systems science on the field of marriage and family therapy, discussing that systems concepts are broadly disseminated but have become diluted. The author describes the educational program at a marriage and family therapy graduate institute where students utilize social systems design in their research projects as well as their work with clients. The article outlines the specifications of the Idealized Systems Design (ISD) teaching system, its relationship with the larger institution, as well as its purposes and systemic functions. Application of ISD to the field of marriage and family therapy is emphasized, demonstrating its use in helping facilitate individual, family, and community health as a research tool as well as a set of intervention tools for the practicing therapist.     

The role of therapy productiveness on MFT clients’ intentions to persist in therapy

Many clients drop out of therapy before reaching their goals (Bohart &; Wade, 2013 Bohart, A. C., &; Wade, A. M. (2013). The client variables in psychotherapy. In M. Lambert (Ed.) Bergin &; Garfield’s Handbook of psychotherapy and behavior change. (p. 219–257). New York: Wiley. [Google Scholar]), though being in therapy produces more change than not being in therapy (Lambert, 1992 Lambert, M. J. (1992). Implications of outcome research for psychotherapy integration. In J. C. Norcross &; M. R. Goldfried (Eds.), Handbook of psychotherapy integration (pp. 94–129). New York: Basic Books. [Google Scholar]). To investigate the factors that affect clients’ decisions to persist in therapy, we surveyed a convenience sample of 72 clients of MFTs in individual, couple or family therapy currently in treatment in a community-based therapy center. We tested moderation using regression analysis to determine the extent to which productiveness moderates the relationship between therapeutic alliance and intended persistence. Results showed that productiveness moderated the relationship between therapeutic alliance and intended persistence. Specifically, higher levels of therapy productiveness strengthened the relationship between therapeutic alliance and therapy persistence. Implications for future research and practice are presented and discussed.