Intervention Journal

July 2014 - Volume 12 - Issue 2

From the editor… questions of evidence
Authors:
Tankink, Marian

SPECIAL SECTION

On the efficacy of Narrative Exposure Therapy: a reply to Mundt et al.
Authors:
Neuner, Frank; Schauer, Maggie; Elbert, Thomas
A short reaction to invited commentaries on Mundt et al., this issue
Authors:
Mundt, Adrian P.; Wünsche, Petra; Heinz, Andreas; Pross, Christian
A beneficiary's voice: a concluding commentary on NET by Ismael O.
Authors:
Neuner, Frank; Schauer, Maggie; Elbert, Thomas

ARTICLES

To be well at heart: women's perceptions of psychosocial wellbeing in three conflict affected countries
Authors:
Bragin, Martha; Onta, Karuna; Janepher, Taaka; Nzeyimana, Generose; Eibs, Tonka
Pathways to resilience in post genocide Rwanda a resources efficacy model
Authors:
Dushimirimana, Fabien; Sezibera, Vincent; Auerbach, Carl

FIELD REPORTS

REFLECTIONS, COMMENTS, LETTERS

REVIEWS

SUMMARIES

Summaries in Arabic
Authors:
Editors
Résumés en Français
Authors:
Editors
Summaries in Russian
Authors:
Editors
Summaries in Pashto
Authors:
Editors
Summaries in Sinhala
Authors:
Editors
Resumenes en Español
Authors:
Editors
Summaries in Tamil
Authors:
Editors

From the editor… questions of evidence

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Authors:
Tankink, Marian

SPECIAL SECTION

Introduction to a Special Debate: the role of brief trauma focused psychotherapies (such as Narrative Exposure Therapy) in areas affected by conflict

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Authors:
Ventevogel, Peter

Evaluating interventions for posttraumatic stress disorder in low and middle income countries: Narrative Exposure Therapy

This article provides a framework for evaluating randomised controlled efficacy trials for the treatment of posttraumatic stress disorder, in low and middle income countries, applied to Narrative Exposure Therapy. A list of methodological and conceptual indicators to evaluate trial data was developed and utilised to assess six trials. The efficacy of this therapy to reduce symptoms is mainly deduced from effects that were measured at long term follow-up points, and that had not been seen at relatively early follow-up points. Focused interventions, such as the Narrative Exposure Therapy, may be too short in duration to comprehensively address posttraumatic stress disorder developed as a consequence of serial, long term exposure to trauma with the consequent disruption of social contexts. The Narrative Exposure Therapy approach also does not consider the cultural and political context, nor the effect of traumatic events on communities and appears to be disconnected from more comprehensive care systems. As a result, data for the efficacy of this therapy in post disaster settings are not yet conclusive. Conceptual problems should be addressed in further effectiveness trials.

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Authors:
Mundt, Adrian P.; Wünsche, Petra; Heinz, Andreas; Pross, Christian

On the efficacy of Narrative Exposure Therapy: a reply to Mundt et al.

In their review article, Mundt et al. (2014), ‘Evaluating interventions for posttraumatic stress disorder in low and middle income countries: Narrative Exposure Therapy’, (Intervention, this issue) evaluated Narrative Exposure Therapy (NET) as an example of a short-term treatment for posttraumatic stress disorder that is applied in low and middle income, post conflict settings. They concluded that it is premature to recommend NET as a treatment approach. In this response, the clinicians and researchers who developed NET argue that the paper by Mundt et al. does not correctly represent the rationale of NET and that the methodological critique of the NET trials in the article is biased. Compared to other types of psychotherapy and psychosocial interventions in post conflict settings, the evidence base of NET is strong, and the application of NET within a sustainable mental healthcare system can be recommended.

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Authors:
Neuner, Frank; Schauer, Maggie; Elbert, Thomas

Vertical trauma focussed interventions versus broader horizontal psychosocial interventions

Despite an influx of agencies conducting psychiatric and psychosocial interventions worldwide, there is scarce agreement regarding treatment goals and best practice to deal with trauma related mental disorders. A systematic review of posttraumaticc stress disorder treatments concluded that scientific evidence on treatment modalities did not reach the level of certainty that would be desired. This commentary ends by outlining the kind of evidence that would be required.

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Authors:
Pedersen, Duncan

Do we really have enough evidence on Narrative Exposure Therapy to scale it up?

This invited commentary reflects on utilising Narrative Exposure Therapy protocols in very different cultural setting than those they were originally developed for, and is a response to Mundt et al. (this issue) and Neuner, Schauer & Elbert (this issue). The author discusses several key issues that should be considered, including: the allegiance effect, demand characteristics, clinical efficacy, and ecological validity. Although randomised controlled trials have demonstrated impressive support for Narrative Exposure Therapy in conflict settings, several issues remain to be addressed prior to large scale use of the therapy within traditional cultures.

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Authors:
Fernando, Gaithri A.

Further thoughts on evaluating interventions for posttraumatic stress disorder in low and middle income countries

While agreeing that there are very few studies on Narrative Exposure Therapy, the author responds to the critique of Mundt et al. (elsewhere in this issue), by arguing that psychological interventions should not only, nor primarily, be evaluated by outcomes immediately after the end of the intervention. This is because psychological interventions, such as Narrative Exposure Therapy, aim to start a process of recovery that may continue long after treatment and eventually result in stronger change.

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Authors:
Yule, William

Don't fault RCTs for not testing systems of care

Among Mundt and colleagues’ (2014) criticisms of NET is that testing a particular intervention implies that it is meant to be delivered irrespective of systems of care. But trauma-focused treatments should be judged based on the specific problems they target; larger sets of problems are the purview of health systems research.

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Authors:
Rasmussen, Andrew

Experiences with Narrative Exposure Therapy across three income contexts

As members of an international nongovernmental organisation that operates across a variety of income contexts, and works with local counsellors to co-create local capacity in contexts ravaged by atrocities and deprivation, the authors offer their experiences with Narrative Exposure Therapy. The authors have found Narrative Exposure Therapy to be an effective clinical and training tool where practical considerations allow it. These considerations, including the high level of counsellor skill and the individual modality the therapy requires, should not be underestimated.

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Authors:
Northwood, Andrea; Orieny, Paul

A short reaction to invited commentaries on Mundt et al., this issue

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Authors:
Mundt, Adrian P.; Wünsche, Petra; Heinz, Andreas; Pross, Christian

A beneficiary's voice: a concluding commentary on NET by Ismael O.

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Authors:
Neuner, Frank; Schauer, Maggie; Elbert, Thomas

ARTICLES

Mediation of daily stressors on mental health within a conflict context: a qualitative study in Gaza

The Inter-Agency Standing Committee (IASC) Guidelines on Mental Health and Psychosocial Support (IASC, 2007) promote the provision of basic needs and community/family supports as key approaches to improve the overall wellbeing of people affected by crises, including conflict. However, positive impacts and/or evidence base for these initiatives, seen through the lens of psychological theory and research, are limited. A World Vision AusAID livelihoods project in Gaza was qualitatively examined in order to explore this question of how psychosocial supports improve wellbeing for men, women and children. Results of the qualitative examination presented in this paper show that locally prescribed feelings of wellbeing improved through the reduction of daily stressors and supported the model of a mediating relationship between traumatic events and mental health, as suggested by Miller & Rasmussen (2010). The paper also demonstrates the benefits of a multidisciplinary and integrated psychosocial support approach for programmes delivered with a whole-of-family perspective, which has more broadly supported the psychosocial needs of this conflict affected community. The paper further reflects on the important need for effective measurement models in relation to ascertaining impacts of integrated psychosocial support approaches.model ofamediating relationship between traumatic events and mental health, as suggested by Miller
&Rasmussen (2010).The paper also demonstrates the benefits of a multidisciplinary and integrated psychosocial
support approachfor programmesdelivered with a whole-of-family perspective, which has more broadly supported the
psychosocial needs of this conflict affected community.The paper further reflects on the important need for
effective measurement models in relation to ascertaining impacts of integrated psychosocial support approaches.

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Authors:
Schafer, Alison; Masoud, Hajar; Sammour, Rania

To be well at heart: women's perceptions of psychosocial wellbeing in three conflict affected countries

The devastating effects of armed conflict on women's psychological and social wellbeing have been documented and studied in recent years, leading to the inclusion of psychosocial programmes as standard practice in humanitarian intervention with conflict affected women. However, they have rarely been asked to define and operationalise psychosocial wellbeing in their own voices and within their own context, and thus it has been difficult to determine the effectiveness of such programmes. This has left the evidence base for effectiveness thin. This study utilised both participatory and ethnographic methods, using a purposive sample of 1,218 women, aged 18–65 in focus groups, and 79 key informants in Burundi, Nepal, and Northern Uganda. The study resulted in the development of interlinked constellations of positive and aspirational domains that comprise psychosocial wellbeing along with detailed examples. It suggests a replicable method to develop local indicators for the evaluation of future programmes for adult women affected by armed conflict, to include their views when planning programmes and policies for their benefit.

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Authors:
Bragin, Martha; Onta, Karuna; Janepher, Taaka; Nzeyimana, Generose; Eibs, Tonka

Social capital and mental health: connextions and complexities in contexts of post conflict recovery

In war affected populations there is often severe disruption of societal cohesion. Additionally, grief and traumatisation, along with insufficient health services and a lack of security, give rise to an increase of mental health problems. Social capital is potentially a key resource to support post conflict recovery, and is increasingly considered not merely as a resource supporting economic and social development, but also an important influence on population health. However, linkages between social capital and mental health are complex. Therefore, this article begins with an introduction to the construct of social capital, then provides an overview of the main findings on its relation to health and wellbeing, as well to mental health in general and in post emergency situations. Finally, it explores if social capital may be promoted intentionally, as pursued through a community based sociotherapy programme in Rwanda. While there appears to be a rationale for promoting social capital within post conflict settings, further work is required, both documenting reliable means of securing it and disentangling pathways of influence on social wellbeing and mental health.

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Authors:
Scholte, Willem F.; Ager, Alastair K.

Pathways to resilience in post genocide Rwanda a resources efficacy model

Field researchers and practitioners in the area of post conflict mental health have moved away from an exclusive concern with trauma and damage to a resilience perspective. This new perspective focuses on how traumatised individuals and communities reconstruct their lives and institutions. This qualitative study examines resilience in post genocide Rwanda, with the aim of developing a model for understanding resilient processes in the country. The authors used a sample of 20 participants, deemed resilient, who had made a satisfactory life adjustment and did not report any symptoms of posttraumatic stress disorder. Most were less than ten years old during the genocide, and all had lost one or both parents during that period. All were members of the Association des Etudiants et Éleves Rescapés du Genocide, a student organisation that served as a new family for the participants. The interviews were analysed using a qualitative research procedure. The analysis led to a description of the course of the participants’ lives during and after the genocide, and to a theoretical account of the factors that contributed to their resilience. The results suggest a ‘resources-efficacy-resilience’ model, in which the availability of resources creates self-efficacy that facilitates resilience, i.e. the ability overcome past trauma and create a successful life. The results suggest a structural model for programmes for assisted resilience in Rwanda and elsewhere.

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Authors:
Dushimirimana, Fabien; Sezibera, Vincent; Auerbach, Carl

FIELD REPORTS

Building resilience and preventing burnout among aid workers in Palestine: a personal account of mindfulness based staff care

The field report is a personal account of introducing the practice of mindfulness to humanitarian professionals working in East Jerusalem and the West Bank to help them reduce stress and address issues of burnout. Mindfulness refers to the systematic cultivation of awareness that emerges through paying attention to the present moment, with compassion and open hearted curiosity. Through cultivating mindful awareness, we discover how to live in the present moment, rather than brooding about the past or worrying about the future. Through mindfulness based interventions, the author, a psychologist with humanitarian experience, aims to foster a culture of ‘learning and care’ among aid workers and their agencies. The underlying vision acknowledges the interconnection between personal health and global health, between personal transformation and global transformation.

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Authors:
Pigni, Alessandra

REFLECTIONS, COMMENTS, LETTERS

After the December 2013 Central African Republic civil unrest: getting psychosocial support to Red Cross volunteers

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Authors:
Nyssens, Olivier

REVIEWS

'Not who we are...' A documentary about the lives of Syrian women in Lebanon

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Authors:
Rabaia, Yoke

SUMMARIES

Summaries in Arabic

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Authors:
Editors

Résumés en Français

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Authors:
Editors

Summaries in Russian

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Authors:
Editors

Summaries in Pashto

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Authors:
Editors

Summaries in Sinhala

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Authors:
Editors

Resumenes en Español

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Authors:
Editors

Summaries in Tamil

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Authors:
Editors