Trajectories of posttraumatic stress symptoms during and after Narrative Exposure Therapy (NET) in refugees

Elisa Kaltenbach, Katharin Hermenau, Maggie Schauer, Katalin Dohrmann, Thomas Elbert, Inga Schalinski, Elisa Kaltenbach, Katharin Hermenau, Maggie Schauer, Katalin Dohrmann, Thomas Elbert, Inga Schalinski

Abstract

Background: Trauma-focused therapy approaches are recommended as treatment for posttraumatic stress disorder (PTSD). This includes the treatment of trauma-related suffering in refugee populations. However, there is a lack of knowledge about symptom trajectories in refugees living in volatile conditions. This has led to fear of "retraumatisation" and general skepticism in clinicians concerning the use of exposure therapy.

Methods: To test the relevance of this concern, we investigated PTSD symptom trajectories and potentially influencing factors during the course of Narrative Exposure Therapy (NET) in a refugee sample living in Germany. Refugees filled out the PTSD Checklist prior to each treatment session and also during follow-up interviews. Therapists continuously documented positive and negative life events as well as the content of the treatment sessions. Additionally, structured clinical interviews were conducted pre-treatment and at follow-up time points.

Results: On average, clients presented with substantial decreases in PTSD symptoms already during and after NET. However, symptom trajectories differed and ranged from fast responders to slow responders to no immediate response during treatment. Importantly, a persistent worsening of symptoms was not observed, also not after exposure to the most distressing events. In contrast, stressful life experiences seemed to aggravate PTSD symptoms.

Conclusions: Consistent with earlier studies, NET leads to clinically and behaviorally relevant reductions in PTSD symptoms both throughout and following treatment in refugees living in volatile conditions. Concerns about imaginal exposure in refugees were not substantiated. While stressful life events contributed to transient symptom increases, they weren't found to prevent the overall effectiveness of NET.

Trial registration: NCT02852616.

Keywords: Imaginal exposure; PTSD; Refugee; Symptom trajectories; Trauma therapy.

Conflict of interest statement

The authors declare no conflicts of interest with respect to the authorship or the publication of this article.

Figures

Fig. 1
Fig. 1
Flow of clients through the study. C = structured clinical interview, S = self-rating
Fig. 2
Fig. 2
Trajectories of self-rated PTSD symptoms during and after NET. The bold line represents the smoothed overall mean and the grey shade marks the 95% confidence interval. The individual courses are depicted by the thin lines. The dotted lines mark the time after NET. T1 is the beginning of NET, Q25, Q50, Q75, Q100 are the summarized quartiles during NET. F3 and F6 are the 3- and 6-month follow-up assessments
Fig. 3
Fig. 3
Groups of symptom courses during NET. Fast response is classified as those with a decrease of at least 10 points between T1 and Q25. Slow response is classified as those with a decrease of at least 10 points between T1 and Q75. No immediate response is classified as those who showed a change of less than 10 points over the course of NET. Groups are depicted with the lines, the individual persons are depicted with the according signs. T1 is the beginning of NET, Q25, Q50, Q75, Q100 are the summarized quartiles during NET. Negative values represent symptom improvements in respect to baseline, whereas positive values show aggravations

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