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Resource activation for treating post-traumatic stress disorder, co-morbid symptoms and impaired functioning: a randomized controlled trial in Cambodia

Published online by Cambridge University Press:  02 November 2016

C. Steinert ,
P. J. Bumke ,
R. L. Hollekamp ,
A. Larisch ,
F. Leichsenring ,
H. Mattheß ,
S. Sek ,
U. Sodemann ,
M. Stingl  and
T. Ret
...Show all authors
C. Steinert*
Affiliation:
University of Giessen, Clinic for Psychosomatic Medicine and Psychotherapy, Ludwigstrasse 76, Giessen, Germany
P. J. Bumke
Affiliation:
Trauma Aid Germany, Schillerstrasse 6, Berlin, Germany
R. L. Hollekamp
Affiliation:
University of Giessen, Clinic for Psychosomatic Medicine and Psychotherapy, Ludwigstrasse 76, Giessen, Germany
A. Larisch
Affiliation:
University of Giessen, Clinic for Psychosomatic Medicine and Psychotherapy, Friedrichstrasse 33, Giessen, Germany
F. Leichsenring
Affiliation:
University of Giessen, Clinic for Psychosomatic Medicine and Psychotherapy, Ludwigstrasse 76, Giessen, Germany
H. Mattheß
Affiliation:
Psychotraumatology Institute Europe, Großenbaumer Allee 35a, Duisburg, Germany
S. Sek
Affiliation:
Department of Psychology, The Royal University of Phnom Penh, Russian Federation Boulevard, Toul Kork, Phnom Penh, Cambodia
U. Sodemann
Affiliation:
Trauma Aid Germany, In den Floragärten 41, Berlin, Germany
M. Stingl
Affiliation:
University of Giessen, Clinic for Psychosomatic Medicine and Psychotherapy, Ludwigstrasse 76, Giessen, Germany
T. Ret
Affiliation:
Department of Psychology, The Royal University of Phnom Penh, Russian Federation Boulevard, Toul Kork, Phnom Penh, Cambodia
H. Vojtová
Affiliation:
Slovak Institute for Psychotraumatology and EMDR, Legionarska 29, Trencin, Slovakia Charles University, Center for Neuropsychiatric Research of Traumatic Stress, Prague, Ke Karlovu 11, Prague, Czech Republic
W. Wöller
Affiliation:
Rhein-Klinik, Hospital for Psychsomatic Medicine and Psychotherapy, Luisenstrasse 3, Bad Honnef, Germany
J. Kruse
Affiliation:
University of Giessen, Clinic for Psychosomatic Medicine and Psychotherapy, Friedrichstrasse 33, Giessen, Germany University of Marburg, Clinic for Psychosomatic Medicine and Psychotherapy, Baldingerstrasse, Marburg, Germany
*
*Address for correspondence: C. Steinert, Ph.D., University of Giessen, Clinic for Psychosomatic Medicine and Psychotherapy, Ludwigstrasse 76, 35392 Giessen, Germany. (Email: christiane.steinert@psycho.med.uni-giessen.de)
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Abstract

Background

Mental health morbidity in post-conflict settings is high. Nevertheless, randomized controlled trials of psychotherapy on site are rare. Our aim was to integrate rigorous research procedures into a humanitarian programme and test the efficacy of resource activation (ROTATE) in treating post-traumatic stress disorder (PTSD), co-morbid symptoms and impaired functioning in Cambodia.

Method

A total of 86 out-patients with PTSD were randomly assigned to five sessions of ROTATE (n = 53) or a 5-week waiting-list control (WLC) condition (n = 33). Treatment was provided by six Cambodian psychologists who had received extensive training in ROTATE. Masked assessments were made before and after therapy.

Results

PTSD remission rates according to the DSM-IV algorithm of the Harvard Trauma Questionnaire were 95.9% in ROTATE and 24.1% in the WLC condition. Thus, patients receiving ROTATE had a significantly higher likelihood of PTSD remission (odds ratio 0.012, 95% confidence interval 0.002–0.071, p < 0.00001). Additionally, levels of anxiety, depression and impaired functioning were significantly reduced compared with the WLC condition (p < 0.00001, between-group effect sizes d = 2.41, 2.26 and 2.54, respectively). No harms were reported.

Conclusions

ROTATE was efficacious in treating Cambodian patients with high symptom levels of PTSD, emotional distress and impaired functioning. ROTATE is a brief, culturally adaptable intervention focusing on stabilization and strengthening resources rather than trauma confrontation. It can be taught to local professionals and paraprofessionals and enhance access to mental health care for patients in need.

Keywords

Cambodiapost-traumatic stress disorderpsychotherapyrandomized controlled trialsresource activation
Type
Original Articles
Information
Psychological Medicine , Volume 47 , Issue 3 , February 2017 , pp. 553 - 564
Copyright
Copyright © Cambridge University Press 2016 

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References

Bellak, L, Hurvich, M, Gediman, HK (1973). Ego Functions in Schizophrenics, Neurotics, and Normals: A Systematic Study of Conceptual, Diagnostic, and Therapeutic Aspects. Wiley: New York.Google Scholar
Bisson, J, Andrew, M (2007). Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews, issue 3, CD003388.CrossRefGoogle ScholarPubMed
Blanchard, EB, Jones-Alexander, J, Buckley, TC, Forneris, CA (1996). Psychometric properties of the PTSD Checklist (PCL). Behaviour Research and Therapy 34, 669–673.CrossRefGoogle ScholarPubMed
Bradley, R, Greene, J, Russ, E, Dutra, L, Westen, D (2005). A multidimensional meta-analysis of psychotherapy for PTSD. American Journal of Psychiatry 162, 214–227.CrossRefGoogle ScholarPubMed
Bumke, PJ, Sodemann, U (2010). The efficacy of EMDR in a new context: some findings from the ACEH survey. Presented at the 1st EMDR Asia Conference, Bali, Indonesia.Google Scholar
Bumke, PJ, Sodemann, U (2014). Interpersonal violence – consequences and therapies. Trauma Mekong – Program for trauma treatment in Thailand, Cambodia, and Indonesia. Final Report, part two, 2014.Google Scholar
Cloitre, M, Koenen, KC, Cohen, LR, Han, H (2002). Skills training in affective and interpersonal regulation followed by exposure: a phase-based treatment for PTSD related to childhood abuse. Journal of Consulting and Clinical Psychology 70, 1067–1074.CrossRefGoogle ScholarPubMed
Cohen, J (1988). Statistical Power Analysis for the Behavioral Sciences. Erlbaum: Hillsdale, NJ.Google Scholar
de Jong, JT, Komproe, IH, Van Ommeren, M (2003). Common mental disorders in postconflict settings. Lancet 361, 2128–2130.CrossRefGoogle ScholarPubMed
Deva, MP, D'Souza, R, Sundram, S (2009). Regional update: Cambodia. Asian Journal of Psychiatry 2, 120–121.CrossRefGoogle ScholarPubMed
Devilly, GJ, McFarlane, AC (2009). When wait lists are not feasible, nothing is a thing that does not need to be done. Journal of Consulting and Clinical Psychology 77, 1159–1168.CrossRefGoogle Scholar
Dubois, V, Tonglet, R, Hoyois, P, Sunbaunat, K, Roussaux, JP, Hauff, E (2004). Household survey of psychiatric morbidity in Cambodia. International Journal of Social Psychiatry 50, 174–185.CrossRefGoogle ScholarPubMed
Ertl, V, Pfeiffer, A, Schauer, E, Elbert, T, Neuner, F (2011). Community-implemented trauma therapy for former child soldiers in Northern Uganda: a randomized controlled trial. JAMA 306, 503–512.CrossRefGoogle ScholarPubMed
Freud, A (1936). The Ego and the Mechanisms of Defence. International Universities Press: New York.Google Scholar
Furukawa, TA, Noma, H, Caldwell, DM, Honyashiki, M, Shinohara, K, Imai, H, Chen, P, Hunot, V, Churchill, R (2014). Waiting list may be a nocebo condition in psychotherapy trials: a contribution from network meta-analysis. Acta Psychiatrica Scandinavica 130, 181–192.CrossRefGoogle ScholarPubMed
Hinton, DE, Kredlow, MA, Pich, V, Bui, E, Hofmann, SG (2013). The relationship of PTSD to key somatic complaints and cultural syndromes among Cambodian refugees attending a psychiatric clinic: the Cambodian Somatic Symptom and Syndrome Inventory (CSSI). Transcultural Psychiatry 50, 347–370.CrossRefGoogle ScholarPubMed
Hinton, DE, Otto, MW (2006). Symptom presentation and symptom meaning among traumatized Cambodian refugees: relevance to a somatically focused cognitive–behavior therapy. Cognitive and Behavioral Practice 13, 249–260.CrossRefGoogle ScholarPubMed
Jegannathan, B, Kullgren, G, Deva, P (2015). Mental health services in Cambodia, challenges and opportunities in a post-conflict setting. Asian Journal of Psychiatry 13, 75–80.CrossRefGoogle Scholar
Kernberg, OF (1976). Object-relations Theory and Clinical Psychoanalysis. Aronson: New York.Google Scholar
Kleijn, WC, Hovens, JE, Rodenburg, JJ (2001). Posttraumatic stress symptoms in refugees: assessments with the Harvard Trauma Questionnaire and the Hopkins Symptom Checklist-25 in different languages. Psychological Reports 88, 527–532.CrossRefGoogle ScholarPubMed
Korn, DL, Leeds, AM (2002). Preliminary evidence of efficacy for EMDR resource development and installation in the stabilization phase of treatment of complex posttraumatic stress disorder. Journal of Clinical Psychology 58, 1465–1487.CrossRefGoogle ScholarPubMed
Kraemer, HC, Kupfer, DJ (2006). Size of treatment effects and their importance to clinical research and practice. Biological Psychiatry 59, 990–996.CrossRefGoogle ScholarPubMed
Kruse, J, Joksimovic, L, Cavka, M, Woller, W, Schmitz, N (2009). Effects of trauma-focused psychotherapy upon war refugees. Journal of Traumatic Stress 22, 585–592.CrossRefGoogle ScholarPubMed
Lampe, A, Hofmann, P, Gast, U, Reddemann, L, Schüßler, G (2014). Long-term course in female survivors of childhood abuse after psychodynamically oriented, trauma-specific inpatient treatment: a naturalistic two-year follow-up. Zeitschrift für Psychosomatische Medizin und Psychotherapie 60, 267–282.CrossRefGoogle ScholarPubMed
Luborsky, L (1984). Principles of Psychoanalytic Psychotherapy. Manual for Supportive–Expressive Treatment. Basic Books: New York.Google Scholar
Markowitz, JC, Petkova, E, Neria, Y, Van Meter, PE, Zhao, Y, Hembree, E, Lovell, K, Biyanova, T, Marshall, RD (2015). Is exposure necessary? A randomized clinical trial of interpersonal psychotherapy for PTSD. American Journal of Psychiatry 172, 430–440.CrossRefGoogle ScholarPubMed
Mollica, RF, Brooks, R, Tor, S, Lopes-Cardozo, B, Silove, D (2014). The enduring mental health impact of mass violence: a community comparison study of Cambodian civilians living in Cambodia and Thailand. International Journal of Social Psychiatry 60, 6–20.CrossRefGoogle ScholarPubMed
Mollica, RF, Caspi-Yavin, Y, Bollini, P, Truong, T, Tor, S, Lavelle, J (1992). The Harvard Trauma Questionnaire. Validating a cross-cultural instrument for measuring torture, trauma, and posttraumatic stress disorder in Indochinese refugees. Journal of Nervous and Mental Disease 180, 111–116.CrossRefGoogle ScholarPubMed
Mollica, RF, McInnes, K, Sarajlic, N, Lavelle, J, Sarajlic, I, Massagli, MP (1999). Disability associated with psychiatric comorbidity and health status in Bosnian refugees living in Croatia. JAMA 282, 433–439.CrossRefGoogle ScholarPubMed
Mollica, RF, Wyshak, G, de Marneffe, D, Khuon, F, Lavelle, J (1987). Indochinese versions of the Hopkins Symptom Checklist-25: a screening instrument for the psychiatric care of refugees. American Journal of Psychiatry 144, 497–500.Google ScholarPubMed
Neuner, F, Onyut, PL, Ertl, V, Odenwald, M, Schauer, E, Elbert, T (2008). Treatment of posttraumatic stress disorder by trained lay counselors in an African refugee settlement: a randomized controlled trial. Journal of Consulting and Clinical Psychology 76, 686–694.CrossRefGoogle Scholar
Otto, MW, Hinton, DE (2006). Modifying exposure-based CBT for Cambodian refugees with posttraumatic stress disorder. Cognitive and Behavioral Practice 13, 261–270.CrossRefGoogle ScholarPubMed
Reddemann, L (2011). Psychodynamic Imaginative Trauma Therapy PITT – Manual. Klett-Cotta: Stuttgart.Google Scholar
Sachsse, U, Vogel, C, Leichsenring, F (2006). Results of psychodynamically oriented trauma-focused inpatient treatment for women with complex posttraumatic stress disorder (PTSD) and borderline personality disorder (BPD). Bulletin of the Menninger Clinic 70, 125–144.CrossRefGoogle ScholarPubMed
Sherman, JJ (1998). Effects of psychotherapeutic treatments for PTSD: a meta-analysis of controlled clinical trials. Journal of Traumatic Stress 11, 413–435.CrossRefGoogle ScholarPubMed
Silove, D (2012). Do conflict-affected societies need psychiatrists? British Journal of Psychiatry 201, 255–257.CrossRefGoogle ScholarPubMed
Silove, D, Manicavasagar, V, Mollica, R, Thai, M, Khiek, D, Lavelle, J, Tor, S (2007). Screening for depression and PTSD in a Cambodian population unaffected by war: comparing the Hopkins Symptom Checklist and Harvard Trauma Questionnaire with the structured clinical interview. Journal of Nervous and Mental Disease 195, 152–157.CrossRefGoogle Scholar
Sonis, J, Gibson, JL, de Jong, JT, Field, NP, Hean, S, Komproe, I (2009). Probable posttraumatic stress disorder and disability in Cambodia: associations with perceived justice, desire for revenge, and attitudes toward the Khmer Rouge trials. JAMA 302, 527–536.CrossRefGoogle ScholarPubMed
Steinert, C, Bumke, PJ, Hollekamp, RL, Larisch, A, Leichsenring, F, Mattheß, H, Sisokhom, S, Sodemann, U, Stingl, M, Thearom, R, Vojtová, H, Wöller, W, Kruse, J (2016). Treating post-traumatic stress disorder by resource activation in Cambodia. World Psychiatry 15, 183–185.CrossRefGoogle ScholarPubMed
Steinert, C, Hofmann, M, Leichsenring, F, Kruse, J (2015). The course of PTSD in naturalistic long-term studies: high variability of outcomes. A systematic review. Nordic Journal of Psychiatry 69, 483–496.CrossRefGoogle ScholarPubMed
Summerfield, D (2008). How scientifically valid is the knowledge base of global mental health? BMJ (Clinical Research Ed.) 336, 992–994.CrossRefGoogle ScholarPubMed
Tol, WA, Barbui, C, Galappatti, A, Silove, D, Betancourt, TS, Souza, R, Golaz, A, van Ommeren, M (2011). Mental health and psychosocial support in humanitarian settings: linking practice and research. Lancet 378, 1581–1591.CrossRefGoogle ScholarPubMed
Tolin, DF, McKay, D, Forman, EM, Klonsky, ED, Thombs, BD (2015). Empirically supported treatment: recommendations for a new model. Clinical Psychology: Science and Practice 22, 317–338.Google Scholar
UN Development Programme (2015). Human Development Report 2015 (http://hdr.undp.org/sites/default/files/2015_human_development_report.pdf).Google Scholar
Van de Put, W, Eisenbruch, M (2002). The Cambodian experience. Chapter 2. In Trauma, War and Violence: Public Mental Health in Socio-Cultural Context (ed. de Jong, JTVM), pp. 93–156. Kluwer Academic/Plenum Publishers: New York.Google Scholar
von Peter, S (2008). The experience of ‘mental trauma’ and its transcultural application. Transcultural Psychiatry 45, 639–651.CrossRefGoogle ScholarPubMed
Wallerstein, R (1989). The Psychotherapy Research Project of the Menninger Foundation: an overview. Journal of Consulting and Clinical Psychology 57, 195–205.CrossRefGoogle ScholarPubMed
Wöller, W, Leichsenring, F, Leweke, F, Kruse, J (2012). Psychodynamic psychotherapy for posttraumatic stress disorder related to childhood abuse – principles for a treatment manual. Bulletin of the Menninger Clinic 76, 69–93.CrossRefGoogle ScholarPubMed
Wöller, W, Mattheß, H (2016). ROTATE. Resource-Oriented Trauma Therapy Combined with EMDR Resource Installation. Treatment Manual. Version 1.0, July 2016 (http://www.rhein-klinik.de/fileadmin/content/rhein/Publikationen/2016_07_05_Woeller___Matthess_2016_ROTATE_Manual_Version_1.0.pdf). Accessed July 2016.Google Scholar