cognitive-behavioraltherapyversusotherptsd...

The Scientific World JournalVolume 2012, Article ID 181847, 19 pagesdoi:10.1100/2012/181847

The cientificWorldJOURNAL

Review Article

Cognitive-Behavioral Therapy versus Other PTSDPsychotherapies as Treatment for Women Victims ofWar-Related Violence: A Systematic Review

N. Ines Dossa and Marie Hatem

Departement of Medecine Sociale et Preventive, Faculte de Medecine, Universite de Montreal, Montreal, QC, Canada H3C 3J7

Correspondence should be addressed to N. Ines Dossa, [email protected]

Received 30 October 2011; Accepted 5 December 2011

Academic Editor: Alexandre M. Valenca

Copyright © 2012 N. I. Dossa and M. Hatem. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

Although war-trauma victims are at a higher risk of developing PTSD, there is no consensus on the effective treatments for thiscondition among civilians who experienced war/conflict-related trauma. This paper assessed the effectiveness of the various formsof cognitive-behavioral therapy (CBT) at lowering PTSD and depression severity. All published and unpublished randomizedcontrolled trials studying the effectiveness of CBT at reducing PTSD and/or depression severity in the population of interest weresearched. Out of 738 trials identified, 33 analysed a form of CBTs effectiveness, and ten were included in the paper. The subgroupanalysis shows that cognitive processing therapy (CPT), culturally adapted CPT, and narrative exposure therapy (NET) contributeto the reduction of PTSD and depression severity in the population of interest. The effect size was also significant at a level of0.01 with the exception of the effect of NET on depression score. The test of subgroup differences was also significant, suggestingCPT is more effective than NET in our population of interest. CPT as well as its culturallyadapted form and NET seem effective inhelping war/conflict traumatised civilians cope with their PTSD symptoms. However, more studies are required if one wishes torecommend one of these therapies above the other.

1. Introduction

1.1. Background. Warfare and torture occur on a large scalein many countries resulting in widespread death, disability,and trauma [1]. In 1997, Amnesty International reportedthat human rights violations had been recorded in over150 countries worldwide [2]. Thus, the number of civiliansaffected by war, in comparison to military personnel, is risingbecause of the amount of cases of interpersonal violence[3]. According to the latest statistics of the United NationsHigh Commissioner for Refugees, there are approximately42 million “forcibly displaced persons” worldwide of whom15.2 million were refugees [4]. Those living in a war-affectedarea experience a range of severely traumatic experiences[5, 6]. For example, in the Democratic Republic of Congo,where a second civil war has been existent since 1998, it iscommon for civilians to be killed, kidnapped, sexuallyabused, enslaved, or tortured at gunpoint [7, 8]. Feeling

that one’s life is in danger, witnessing extreme violence oran individual’s death, separation from ones family, or beingdetained against one’s will, are diverse factors which can con-tribute to the development of various psychiatric diseases.This systematic review will focus on Posttraumatic StressDisorder (PTSD), the most commonly studied consequencein relation to the atrocities previously cited.

PTSD was first recognized following the devastating warexperiences of soldiers serving in Vietnam. Since then, theconcept has been adequately applied in the assessment ofvarious types of traumatic experience [9]. Most studiesreported high prevalence rates of PTSD among torturedrefugees (31% to 92%) and refugees affected by war trauma(23.5 to 77%) [9]. With the exception of 2 studies, those thatexamined gender differences in civilians’ responses to wartrauma found that females are more likely to develop PTSDthan males [9].

2 The Scientific World Journal

Even in instances where only a few women are on thefront line of combats, they and their children bear thebrunt of its physical, socioeconomic, and emotional impacts[10]. In fact, because they are unarmed, weak and oftenunaccompanied during times of armed conflicts, adolescentsand adult females are usually the first target of interpersonalviolence. They are particularly vulnerable to sexual violenceand intimidation at gunpoint, often used as a deliberatemilitary and political tactic during armed conflicts [11].It is common for combatants to use such action as away of humiliating and attacking the community of the“enemy,” since women are viewed in many cultures assymbolic representatives of caste, ethnic, or national identity[7, 12]. Several reports provided by female victims of warmention that they are left to pick up the pieces of livesand societies shattered by gun violence [12]. Besides theinfectious diseases (i.e., HIV), these victims often suffer fromseveral gynecological problems and posttraumatic disorders,which can have a serious impact on reproductive health.

Physical and sexual violence committed against womenduring war time have always being condemned by insti-tutions but more needs to be done to help the victimspick up the remaining pieces of life, regain confidence, andrecover from their trauma. Unfortunately, there is limitedand disparate information on what intervention is the mostappropriate and effective for this category of victims. Theprimary objective of this systematic review is to assesswhether the different forms of CBT can successfully helpadult civilians (specifically women) who experienced war-or-conflict-related trauma (imprisonment, torture, sexualabuse, rape, kidnapping, or detainment against will) copewith the symptoms of PTSD and depression. Secondary, weidentify which form of CBT is more efficient in reducing theseverity of the previously cited outcomes.

1.2. PTSD and Different Forms of CBT. Given the clinicalcomplexity of PTSD, it is not surprising that the developmentof treatments is quite challenging. Cognitive-behavioraltherapy (CBT) includes a number of diverse but related tech-niques such as exposure therapy, stress inoculation training,cognitive processing therapy, cognitive therapy, relaxationtraining, dialectical behavior therapy and acceptance, andcommitment therapy [13].

Exposure therapy (ET) refers to a series of proceduresdesigned to help individuals confront thoughts, and safe orlow-risk stimuli, that are feared or avoided [13]. Appliedto the treatment of PTSD, most exposure therapy programsinclude imaginal exposure to the trauma memory and invivo exposure to reminders of the trauma or triggers fortrauma-related fear and avoidance [13]. In 2002, Neuner’sresearch team developed a new form of ET called NarrativeExposure Therapy (NET). NET is a standardized short-termapproach in which the classical form of ET is adapted tomeet the needs of traumatized survivors of war and torture[14]. As most of the victims of organized violence haveexperienced many traumatic events, it is often impossiblefor them to identify the worst event before treatment. Toovercome this difficulty, the team combined with ET, the

testimony therapy’s approach of Lira and Weinstein designedto treat traumatized survivors of the Pinochet regime in Chile[15]. Instead of defining a single event as a target in therapy,the patient constructs a narration of his whole life from birthup to the present situation while focusing on the detailedreport of the traumatic experiences [14]. This treatmenthas shown low dropout rates in different studies. Manythink that the main motivator of NET is the anticipationof receiving a written biography upon completion, that canhelp participants pass on their story to their children, whilesimultaneously educating them [16].

Stress Inoculation Training (SIT) is a multicomponentanxiety management treatment program that includes edu-cation, muscle relaxation training, breathing retraining, roleplaying, covert modeling, guided self-dialogue, and thoughtstopping [13]. Cognitive therapy (CT) predicated the ideathat it is one’s interpretation of an event rather than theevent itself that determines emotional reactions. It involvesidentifying erroneous or unhelpful cognitions, evaluating theevidence for and against these cognitions, and consideringwhether the cognitions are the result of cognitive biasesor errors, in the service of developing more realistic oruseful cognitions [13]. Cognitive processing therapy (CPT)implements exposure to the trauma memory via writing atrauma narrative and repeatedly reading it, and is combinedwith CT focused on themes of safety, trust, power/control,esteem, and intimacy [13]. A culturallyadapted form ofCPT was developed in 2004 by a team of researchers fromMassachusetts to fit the needs of traumatised Cambodianrefugees with pharmacotherapy-resistant PTSD [17]. Dialec-tical behavior therapy (DBT) is a comprehensive treatmentdeveloped for the treatment of individuals with borderlinepersonality disorder. An important aspect of DBT is skillstraining in affect regulation and interpersonal regulation.Some trauma survivors may have deficits in these skill areasthat render it difficult for them to tolerate or benefit fromtrauma-focused interventions such as ET [13].

CBT is the most studied treatments in the generalpopulation, and current guidelines recommend it as a first-line treatment for patients [13]. The different forms of CBThave been studied as treatment for PTSD since the early1960s [18]. However, the amount and quality of evidencevaries substantially from a program to another. CBT’sdifferent forms have been recognised as effective in helpingsurvivors of trauma resulting from accidents, rape and crimewitnessing; however, their effectiveness in helping war-or-conflict-related traumatised civilians is yet to be proven.

2. Methods

2.1. Search Methods for Identification of Studies. The rec-ommendations of the Cochrane Handbook for SystematicReviews of Interventions were followed in the design of thesearch strategy. The first author worked in collaborationwith professionals at the Paramedical library of Universityof Montreal. Their role was to evaluate the research strategyand advise on the possible missed channels of search. TheCochrane Central Register of Controlled Trials (CENTRAL),

The Scientific World Journal 3

CINAHL, EMBASE, Entrez-Pubmed; PsycInfo, Web of Science,MEDLINE (OvidSP), and USA clinical trials databases weresearched. In addition, the dissertation and thesis databasewas also reviewed for relevant publications. The keywordsrelated to trauma (PTSD, posttraumatic stress disorders,stress disorders) were first used to extract publications onthe subject. In order to refine the results to the populationof interest (civilians, adults), studies conducted with thecombatants (with keywords veterans and military person-nel) and the young traumatised civilians (with keywordsadolescent∗, youth∗, child∗) were excluded. Since a lotof the interventions in countries affected by war/conflictare conducted by diverse humanitarian organisations (i.e.,WHO, IANSA, UNHCR), these organisation websites werescanned for useful publications on the subject. A manualsearch was also performed using the reference list of reviewsand books published on PTSD treatment in the populationof interest [13, 19, 20]. This step was completed by searchingpotential publications with the keywords related to eachform of CBT (exposure therapy, stress inoculation training,cognitive processing therapy, etc.).

2.2. Criteria for Considering Studies for This Paper. The inclu-sion criteria consisted of studies describing a randomisedcontrolled trial in which the intervention compared anyform of CBT to a control (no treatment, delayed treatment,treatment as usual, or non-CBT psychotherapy). The studyneeded to be designed to reduce PTSD symptoms amongcivilians who experienced one or multiple trauma duringwar-or-conflict. Study participants were required to be adultswith the status of refugees, asylum seekers, or internallydisplaced. Trials conducted with participants traumatisedby war/conflict related violence who were still living intheir country of origin were also included. Studies withparticipants with comorbidities were accepted provided theprimary objective of the trial was the reduction of PTSDsymptoms. The main comorbid conditions found in theincluded studies were depression, anxiety, suicidal ideations,neck-focused and orthostasis-triggered panic attacks, withflashbacks during attacks and somatoform disorders. Mostof the studies excluded participants with organic mentaldisorder, bipolar disorder, mental retardation, schizophrenia,psychosis, and drug abuse. The instruments used for theassessment of PTSD symptoms and severity had to be basedon DSM’s or ICD’s criteria for a study to be eligible.

2.3. Data Collection and Analysis. The Cochrane Handbookfor Systematic Reviews of interventions [21] was used todevelop the methods of this paper. All studies resulting fromsearch strategy were assessed for potential inclusion. Theywere excluded if the randomization process was incomplete,there was no control group or no data was reported. Thestudies in which civilians and army/police officers werecombined were also excluded because of the different naturein which they are exposed to trauma. A data extraction formwas designed. The first author performed the initial dataextraction, and the Review Manager software (RevMan 5)was used to enter the data a second time. The articles’ authors

were contacted for further details on their studies if the trialconditions or data reported were unclear.

2.4. Assessment of Risk of Bias in Included Studies. The firstauthor assessed the risk of bias in included studies con-sidering criteria outlined in the Cochrane Handbook forSystematic Reviews of Interventions [22] and the secondauthor reviewed the assessment for accuracy. Methods usedfor generation of the randomization sequence were describedfor each trial if reported. To assess the bias introducedinto each study, five key domains were considered: sequencegeneration, allocation concealment, blinding of participants,blinding of assessors, and completeness of outcome data.

2.5. Missing Data. Data was analysed with the available in-formation for each group participants according to theirallocation.

2.6. Data Synthesis. A meta-analysis method with a random-effect was chosen since different instruments were used toassess PTSD or depression severity in the included trials. Infact, the use of a random-effects meta-analysis allows theincorporation of the heterogeneity existing among studies.

Two subgroup analyses were conducted with the ReviewManager software (RevMan 5): the first assessed the effectsof the treatments on PTSD score and the second assessed theeffect of the treatments on depression score. The subgroupanalyses also compared one form of CBT to the other. Eachanalysis investigates potential sources of heterogeneity, asdifferences in the type of intervention, participants’ profile,or intervention setting (e.g., length and number of sessions)may affect the treatment effects. The analyses were conductedaccording to Deeks et al.’s method, integrated in RevMan 5software [23].

3. Results

3.1. Results of the Search. Out of 738 trials initially identifiedfrom the databases, 33 publications studying the effectivenessof one of the forms of CBT were found. Figure 1 presentsthe flow of information through the different phases of thereview. None of those publications assessed the role of CT,ACT, or RT in PTSD symptoms reduction in the populationof interest. Ten of the 33 trials were included in the paper.Tables 1 and 2, respectively, provide details of the includedand excluded trials and in the last case the reason for theirexclusion.

The two outcomes of interest in this paper (PTSDand depression severity) were monitored with differentpsychometric instruments and reported on a continuousscale (scores of PTSD and depression) (see Table 1 fordetails). Only three trials used an instrument that wasadapted to their population of interest [17, 24, 25].

Among the ten studies included in this paper one assessedCPT’s effectiveness in PTSD severity reduction [26], fourstudied culturallyadapted CPT’s effectiveness [17, 24, 25, 27],and five assessed NET’s effectiveness [16, 28–31]. Theculturallyadapted CPT trials were conducted by a team of


10 trials included in review

9 trials included in meta- analysis

Articles found through othersources (books and othersystematic reviews): 113

Articles found with the databases withthe keywords related to PTSD, adults,

and noncombatants: 8830

7087 publications afterduplicates were removed

738 publications remainingand screened for potential

inclusion

33 full-text articles assessedfor eligibility

Exclusion of publicationsthat does not concern thepopulation of interest(war/conflict-traumatisedcivilians)

One trial excluded becauseof the nature of dataprovided

Exclusion of duplicates

Exclusion of publicationsthat did not assess theeffectiveness of one theform of CBT

23 articles excluded fromreview, see table 2 forreasons

(n = 473)

Figure 1: Flow chart of the systematic review.

researchers located in Massachusetts (USA) with Cambodianand Vietnamese refugees [17, 24, 25, 27], who had beenunder pharmacotherapy for at least one year and werestill meeting PTSD criteria. Even if the culturallyadaptedCPT was their second treatment, its effectiveness could bemeasured since all patients continued use of their drugsand PTSD severity was measured at baseline. The five trialsthat used NET as the intervention group’s treatment wereconducted by German Researchers of University of Konstanzand Bielefeld [16, 28–31]. One trial conducted in Romaniainvolved former political detainees [28], and three trials tookplace in Uganda with Rwandan and Somalian participantsliving in a refugee camp [16, 30, 31]. The fifth trial wasconducted in Germany with asylumseekers from differentorigins [29].

Two out of ten trials required interpreters for the therapysessions [16, 29]. Concerning the four culturallyadapted CPTtrials, the therapy sessions were led by a therapist who wasfluent in Cambodian. Finally regarding the three NET trialsthat did not require an interpreter, the therapy was eitherconducted by the therapists in the native language [28], or bylay counsellors and community-based lay therapists trainedby the team of researchers [30, 31].

3.2. Risk of Bias in Included Studies. The quality of theincluded trials varied from one study to the other. Table 3summarizes each trial’s quality according to the five criteria

examined: adequate sequence generation, allocation conceal-ment, incomplete outcome data addressed, and blinding ofassessors, blinding of participants.

3.3. Effects of Interventions. Table 4 summarises the effectsof each intervention on PTSD and depression scores. It alsoincludes details about participant compliance to the allocatedintervention and the PTSD remission rate in each group.

3.4. Subgroup Analysis: Culturallyadapted CPT versus CPTversus NET. We did not exclude the Neuner et al., 2008 [30]study which reported a high attrition rate because the riskof bias was judged as medium. In fact, the authors reportedthat dropouts did not significantly differ from treatmentcompleters in age, nationality, number of event types, orpretest PTSD score and health scores (all P values > 0.20).Furthermore, different circumstances of the refugee camps(independent of the treatment) could explain those dropoutswhich will then be random.

Outcome 1: PTSD (Figure 2). One trial was excluded fromthe meta-analysis because rather than providing a globalscore, it provided the scores of severity for each criterion ofPTSD symptoms (reexperiencing, avoidance/numbing, andhyperarousal).


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omen

repr

esen

t31

.2%

ofpa

rtic

ipan

ts.

Post

trau

mat

icD

iagn

osti

cSc

ale

(PD

S;Fo

aet

al.,

1995

)[5

0].

HSC

L-25

.2:

pre

and

post

trea

tmen

t

Neu

ner

etal

.,20

04[1

6]

NE

Tve

rsus

PE

D(n

otr

eatm

ent)

NE

Tve

rsus

SCP

ED

grou

ph

ad1

sess

ion

oftr

eatm

ent.

NE

Tan

dSC

grou

psh

ad4

sess

ion

sof

ther

apy.

Sess

ion

sla

sted

90m

ins,

exce

ptio

nal

ly12

0m

ins.

Wit

nes

sin

gpe

ople

badl

yin

jure

dor

kille

d;th

reat

sw

ith

wea

pon

s,ki

dnap

pin

gs,a

ttac

ks,

tort

ure

,com

bat

expe

rien

ces,

sexu

alas

sau

lts

and

nat

ura

ldi

sast

ers.

43pa

rtic

ipan

tsal

loca

ted

toei

ther

NE

Tor

SCin

terv

enti

ons

wit

hP

ED

asco

ntr

ol.

Wom

enre

pres

ent,

resp

ecti

vely

,75%

,57.

1%an

d53

.3%

ofP

ED

,SC

and

NE

Tgr

oups

.

CID

I(C

IDI;

WH

O,1

997)

[47]

and

Post

trau

mat

icD

iagn

osti

cSc

ale

(PD

S;Fo

aet

al.,

1995

)[5

0].

Self

-rep

orti

ng

Qu

esti

onn

aire

-20

(SR

Q-2

0;H

ardi

ng

etal

.,19

80)

[51]

.

4:pr

e-tr

eatm

ent,

post

-tre

atm

ent,

4m

onth

san

d1

year

afte

rtr

eatm

ent.

Neu

ner

etal

.,20

08[3

0]

NE

Tve

rsus

notr

eatm

ent

(MG

)N

ET

vers

usT

CPa

rtic

ipan

tsre

ceiv

edsi

xse

ssio

ns

(las

tin

gbe

twee

n1

and

2h

rs)

ofN

ET

orT

C.

Nu

mbe

rof

trau

mat

icev

ents

was

repo

rted

,bu

tty

pes

oftr

aum

aw

ere

not

.

277

part

icip

ants

(Rw

anda

nan

dSo

mal

ian

refu

gees

)w

ere

allo

cate

dto

eith

erN

ET,

TC

(Tra

um

aco

un

selli

ng)

,or

MG

(mon

itor

ing

grou

p).

Wom

enre

pres

ent,

resp

ecti

vely

,49.

1%,5

3.2%

and

50.5

%of

MG

,TC

,an

dN

ET

grou

ps.

CID

Ian

dP

DS.

Non

e

3ti

mes

for

NE

Tan

dT

Cgr

oups

:at

pre-

trea

tmen

t,3

and

6m

onth

sp

ostt

reat

men

t.M

Gw

aste

sted

atpr

etre

atm

ent,

6an

d9

mon

ths.


Ta

ble

1:C

onti

nu

ed.

Stu

dies

(au

thor

,yea

r)

Form

ofC

BT

offer

ed(n

um

ber

ofse

ssio

ns

and

len

gth

)

Des

crip

tion

oftr

aum

aPa

rtic

ipan

tsan

dre

part

itio

nby

sex

PT

SDdi

agn

osis

and

seve

rity

asse

ssm

ent

Dep

ress

ion

asse

ssm

ent

Nu

mbe

rof

asse

ssm

ents

and

tim

ing

Ert

let

al.2

011

[31]

NE

Tve

rsus

Aca

dem

icca

tch-

upor

wai

ting

list.

Part

icip

ants

rece

ived

8se

ssio

ns

ofN

ET.

Abd

uct

ion

/ex

per

ien

ced

orw

itn

esse

dtr

aum

a.

85fo

rmer

lyab

duct

edyo

uth

sw

ere

allo

cate

dto

one

the

3gr

oups

.B

etw

een

42an

d67

%of

the

part

icip

ants

ofea

chgr

oup

wer

ew

omen

.

CA

PS.

MIN

I.

4as

sess

men

tsfo

rea

chgr

oup

atpr

etre

atm

ent,

3,6

and

12m

onth

s.

Kru

seet

al.2

009

[26]

CP

Tve

rsus

usua

lcar

e.25

hou

rsof

man

ual

ized

trau

ma-

focu

sed

psyc

hot

her

apy

(CP

T)

Tort

ure

,mas

sra

pe,

gen

ocid

e,ex

puls

ion

Part

icip

ants

(Bos

nia

n)

wer

ebe

twee

n18

and

61ye

ars

old

and

wit

hou

tn

ose

riou

sill

nes

sor

alco

hol

/dru

gde

pen

den

ce.

67.7

%of

part

icip

ants

wer

ew

omen

.

Hav

ard

Trau

ma

Qu

esti

onn

aire

(PT

SDev

ent

sect

ion

);Sy

mpt

omC

hec

klis

t(S

CL-

90R

)

Non

e2

asse

ssm

ents

:bef

ore

and

afte

rin

terv

enti

on.


Ta

ble

2:Tr

ials

excl

ude

dfr

omth

ispa

per

and

reas

onfo

rex

clu

sion

.

Stu

dyA

uth

ors,

year

Form

ofC

BT

stu

died

Rea

son

for

excl

usi

on

[52]

D’A

rden

ne

etal

.,20

07C

PT

Th

ree

inte

rven

tion

grou

psan

dn

oco

ntr

ol.R

ando

miz

atio

npr

oces

sw

asn

otap

plie

d.

[53]

Du

ffy

etal

.,20

07C

T27

%of

inte

rven

tion

grou

pan

d28

%of

dela

yed

trea

tmen

tgr

oup

wer

epo

lice

orar

my

office

r.[5

4]G

rey

and

You

ng

2008

CP

TA

case

stu

dy.

[55]

Hin

ton

and

Ott

o20

06So

mat

ical

ly-f

ocu

sed

CP

TD

escr

ibes

only

the

ben

efit

ofco

nsi

deri

ng

aso

mat

ic-f

ocu

sed

CB

T.[5

6]Sc

hulz

etal

.,20

06C

PT

Not

ara

ndo

miz

edco

ntr

olle

dtr

ial.

[57]

Sten

mar

ket

al.,

2008

NE

Tve

rsu

sU

sual

care

Rec

ruit

men

tan

din

terv

enti

ons

ongo

ing

atti

me

ofre

view

.

[58]

Hei

lman

nan

dM

akes

tad

2008

NE

TSo

me

part

icip

ants

hav

en

otex

peri

ence

dw

ar-o

r-co

nfl

ict

rela

ted

trau

ma.

Abs

ence

ofda

taon

con

trol

grou

p.[5

9]Ja

cob

etal

.su

bmit

ted

NE

TN

otye

tco

mpl

eted

byau

thor

s;da

tan

otav

aila

ble.

[60]

Hal

vors

enan

dSt

enm

ark

2010

NE

TN

ora

ndo

miz

atio

n,o

nly

one

inte

rven

tion

grou

pw

asas

sess

edbe

fore

and

afte

rth

erap

yse

ssio

ns.

[61]

Flax

man

and

Bon

d20

10SI

Tve

rsu

sA

CT

Part

icip

ants

wer

en

otw

ar/c

onfl

ict-

trau

mat

ized

civi

lian

s.[6

2]Iv

erso

net

al.,

2011

CP

TPa

rtic

ipan

tsw

ere

not

war

/con

flic

t-tr

aum

atiz

edci

vilia

ns.

[63]

Gal

ovsk

iet

al.,

2009

CP

TPa

rtic

ipan

tsw

ere

not

war

/con

flic

t-tr

aum

atiz

edci

vilia

ns.

[64]

Ott

oan

dH

into

n20

06M

odifi

edE

TN

oqu

anti

tati

veda

tare

port

ed.

[65]

Pau

nov

ican

dO

st20

01C

PT

vers

us

ET

No

con

trol

grou

p.T

he

two

grou

psre

ceiv

eda

form

ofC

BT.

[66]

Hen

sel-

Dit

tman

net

al.,

subm

itte

dN

ET

vers

us

SIT

No

con

trol

grou

p.T

he

two

grou

psre

ceiv

eda

form

ofC

BT.

[67]

Wag

ner

etal

.,20

07D

BT

No

quan

tita

tive

data

but

only

qual

itat

ive

desc

ript

ion

.

[69]

Tarr

ier

etal

.,19

99C

Tve

rsu

sE

TPa

tien

tsdi

dn

otex

peri

ence

war

trau

ma

and

the

two

grou

psre

ceiv

eda

form

ofC

BT

(no

con

trol

grou

p).

[70]

Tarr

ier

etal

.,19

99C

Tve

rsu

sE

TPa

tien

tsdi

dn

otex

peri

ence

war

trau

ma

and

the

two

grou

psre

ceiv

eda

form

ofC

BT

(no

con

trol

grou

p).


Ta

ble

2:C

onti

nu

ed.

Stu

dyA

uth

ors,

year

Form

ofC

BT

stu

died

Rea

son

for

excl

usi

on[6

8]So

mn

ier

and

Gen

efke

1986

Not

indi

cate

dN

oqu

anti

tati

veda

ta.T

ype

ofth

erap

yu

ncl

ear.

[71]

Boe

hle

inet

al.,

2004

Not

indi

cate

dN

ota

ran

dom

ized

con

trol

led

tria

l.[1

4]N

eun

eret

al.,

2002

NE

TA

case

repo

rt.

[72]

Schu

lzet

al.,

2006

CP

TN

ota

ran

dom

ized

con

trol

led

tria

l.


Ta

ble

3:R

isk-

of-b

ias

tabl

eof

the

9in

clu

ded

tria

ls.

Stu

dyA

dequ

ate

sequ

ence

gen

erat

ion

Allo

cati

onco

nce

alm

ent

Inco

mpl

ete

outc

ome

data

addr

esse

dB

lindi

ng

ofas

sess

ors

Blin

din

gof

part

icip

ants

Bic

hes

cuet

al.,

2007

[28]

Yes:

assi

gnm

ent

thro

ugh

ara

ndo

mse

lect

ion

proc

edu

re(n

ame-

card

s)to

eith

erN

ET

orP

ED

grou

p

No

Yes:

no

drop

out

repo

rted

amon

gpa

rtic

ipan

tsw

ho

star

ted

tria

l

No:

anat

tem

ptw

asm

ade.

Blin

din

gw

asfi

nal

lyim

poss

ible

due

toth

ela

rge

diff

eren

ces

inpr

oced

ure

san

dn

um

ber

ofse

ssio

ns

betw

een

the

2gr

oups

No:

anat

tem

ptw

asm

ade.

Blin

din

gw

asfi

nal

lyim

poss

ible

due

toth

ela

rge

diff

eren

ces

betw

een

the

two

grou

ps

Hin

ton

etal

.,20

04[1

7]

Yes:

part

icip

ants

wer

eal

lra

ndo

mly

assi

gned

but

the

met

hod

was

not

desc

ribe

d

No

Yes:

no

drop

out

repo

rted

amon

gpa

rtic

ipan

tsw

ho

star

ted

tria

l

No:

no

atte

mpt

was

mad

eN

o:n

oat

tem

ptw

asm

ade

Hin

ton

etal

.,20

05[2

4]

Yes:

pati

ents

wer

est

rati

fied

byge

nde

rw

ith

ran

dom

allo

cati

onto

eith

erth

eIT

orD

Tgr

oup

deci

ded

bya

coin

toss

No

Yes:

no

drop

out

repo

rted

amon

gpa

rtic

ipan

tsw

ho

star

ted

tria

l

Yes:

but

blin

din

g’s

inte

grit

yw

asn

otte

sted

No:

no

atte

mpt

was

mad

e

Neu

ner

etal

.,20

04[1

6]

Yes:

pati

ents

wer

era

ndo

mly

assi

gned

toei

ther

NE

T,SC

orP

ED

grou

pby

usi

ng

adi

ce

No

Yes:

mis

sin

gda

taw

ere

esti

mat

edw

ith

are

stri

cted

max

imu

mlik

elih

ood

proc

edu

re.

Yes:

inte

rvie

wer

sw

ere

blin

ded

for

part

icip

ant’s

trea

tmen

tco

ndi

tion

.

No:

no

atte

mpt

was

mad

e


Ta

ble

3:C

onti

nu

ed.

Stu

dyA

dequ

ate

sequ

ence

gen

erat

ion

Allo

cati

onco

nce

alm

ent

Inco

mpl

ete

outc

ome

data

addr

esse

dB

lindi

ng

ofas

sess

ors

Blin

din

gof

part

icip

ants

Neu

ner

etal

.,20

08[3

0]

Yes:

pati

ents

wer

era

ndo

mly

allo

cate

dto

agr

oup

byal

teri

ng

allo

cati

onof

ran

dom

lyor

dere

dpa

rtic

ipan

ts.

How

ever

,met

hod

was

not

desc

ribe

d

No

Yes:

but

part

ly.A

uth

ors

repo

rted

ah

igh

glob

alat

trit

ion

rate

,23%

,53

.1%

and

61%

at,

resp

ecti

vely

,3m

onth

s,6

mon

ths

and

9m

onth

s.A

uth

ors

chos

eto

appl

ym

ixed

-eff

ects

mod

els

inst

ead

ofa

last

-obs

erva

tion

-car

ried

-fo

rwar

d(L

OC

F)pr

oced

ure

,con

side

red

too

con

serv

ativ

e.

Yes

No:

no

atte

mpt

was

mad

e

Neu

ner

etal

.,20

10[2

9]

Yes:

part

icip

ants

wer

era

ndo

miz

edto

NE

Tor

TAU

grou

pw

ith

abl

ock

per

mu

tati

onpr

oced

ure

wit

hbl

ocks

of4

pati

ents

No

Yes:

low

drop

out

rate

(6.3

%).

Au

thor

su

sed

mix

edeff

ects

mod

els

inst

ead

ofan

LOC

Fpr

oced

ure

toh

andl

em

issi

ng

data

.Th

ism

eth

oddi

dn

otpr

obab

lyin

trod

uce

asi

gnifi

can

tbi

asbe

cau

seof

the

smal

lnu

mbe

rof

drop

outs

(2)

No:

blin

dnes

sco

uld

not

bem

ain

tain

edin

all

case

sso

we

can

not

rule

out

anas

sess

orbi

as

No:

no

atte

mpt

was

mad

e

Ott

oet

al.,

2003

[25]

Yes:

part

icip

ants

wer

era

ndo

mly

assi

gned

toei

ther

Sert

ralin

eal

one

orSe

rtra

line

+C

BT,

but

met

hod

was

not

desc

ribe

d

No

Yes:

no

drop

out

was

repo

rted

duri

ng

tria

l

No:

no

atte

mpt

ofbl

indi

ng

asse

ssor

sw

asm

ade

No:

no

atte

mpt

was

mad

e

Ert

let

al.,

2011

[31]

Yes

No

Yes:

mix

edeff

ects

mod

elw

asu

sed

Yes:

psyc

hol

ogis

tsw

ere

blin

ded

totr

eatm

ent

con

diti

ons

No

Hin

ton

etal

.,20

09[2

7]Ye

s:ra

ndo

mal

loca

tion

bya

coin

toss

No

Yes

No

No

Kru

seet

al.,

2009

[26]

Yes:

firs

t35

pati

ents

assi

gned

toin

terv

enti

ongr

oup

No

Yes

No

No


Ta

ble

4:E

ffec

tive

nes

sof

the

diff

eren

tfo

rms

ofC

BT,

com

plia

nce

rate

toal

loca

ted

inte

rven

tion

&re

mis

sion

rate

inea

chgr

oup.

Tria

lFo

rmof

CB

TE

ffec

tive

nes

sof

the

ther

apy

onP

TSD

/dep

ress

ion

seve

rity

Com

plia

nce

rate

toal

loca

ted

inte

rven

tion

Rem

issi

onra

tein

grou

ps

Hin

ton

etal

.,20

09[2

7]

Cul

tura

llyA

dapt

edC

PT,

imm

edia

teve

rsus

dela

yed

trea

tmen

t

PT

SD:b

etw

een

-gro

up

effec

tsi

zeba

sed

onfi

rst

and

seco

nd

asse

ssm

ent=

1.98

.D

epre

ssio

n:E

ffec

tn

otre

port

ed

100%

inim

med

iate

and

dela

yed

trea

tmen

tgr

oups

Not

rep

orte

d

Hin

ton

etal

.200

4[1

7]

Cul

tura

llyA

dapt

edC

PT

vers

usco

ntro

l(de

laye

dtr

eatm

ent)

PT

SD:b

etw

een

-gro

up

effec

tsi

zeba

sed

onfi

rst

and

seco

nd

asse

ssm

ent=

2.5

Dep

ress

ion:

Bet

wee

n-g

rou

peff

ect

size

base

don

firs

tan

dse

con

das

sess

men

t=2.

0

100%

Not

repo

rted

Hin

ton

etal

.200

5[2

4]

Cul

tura

llyA

dapt

ed-C

BT

vers

usco

ntro

l(de

laye

dtr

eatm

ent)

PT

SD:b

etw

een

-gro

up

effec

tsi

zeba

sed

onfi

rst

and

seco

nd

asse

ssm

ent=

2.17

Dep

ress

ion:

Bet

wee

n-g

rou

peff

ect

size

base

don

firs

tan

dse

con

das

sess

men

t=2.

77

100%

Not

repo

rted

Ott

oet

al.2

003

[25]

Cul

tura

llyA

dapt

edC

PT

vers

usco

ntro

l(se

rtra

line

alon

e)

PT

SD:g

loba

lsco

ren

otpr

ovid

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Study or subgroup

1.1.1 Culturally adapted CPT

Hinton et al. 2009

Hinton et al., 2004

Hinton et al., 2005

Subtotal (95% CI)

1.1.2 NET

Bichescu et al., 2007

Ertl et al. 2011

Neuner et al., 2004

Neuner et al., 2008

Neuner et al., 2010

Subtotal (95% CI)

Test for overall effect:

1.1.3 CPT

Kruse et al. 2009

Subtotal (95% CI)

Heterogeneity: Not applicable


Total (95% CI)


Mean

46.83

1.7

39.25

5.4

46.73

8.9

5.4

26

2.2

SD

17.17

0.5

19.92

1.3

19.24

2.7

6.6

9.2

0.7

Total

12

6

2038

9

26

14

111

16176

3434

248

Mean

74.25

3.3

73.05

9.9

52.93

13.4

5.3

34.1

3.6

SD

9.43

0.8

9.43

4.1

20.83

3.3

5.7

6.1

0.3

Total

12

6

2038

9

28

11

83

16147

3030

215

Weight

10.6%

8.2%

11.4%30.2%

10.3%

12.3%

10.9%

12.9%

11.6%57.9%

11.8%11.8%

100%

IV, random, 95% CI

Intervention Control Std. mean difference Std. mean difference

IV, random, 95% CI

0 2 4Favours intervention Favours control−4 −2

Z= 3.68 (P=0.0002)

Z= 7.4 (P < 0.00001)

Z= 2.34 (P=0.02)

Test for overall effect: Z= 7.04 (P < 0.00001)

Heterogeneity: τ2 = 0 χ2= 0.15, = 2 (P = 0.93); I2 = 0%

Heterogeneity: τ2 = 0.35; χ2 = 18.81, = 4 (P = 0.0009); I2 = 79%

Heterogeneity: τ2 = 1.08; χ2 = 81.84, = 8 (P <.0.00001); I2 = 90%

Test for subgroup differences: χ2 = 17.3, = 2 (P = 0.0002), I2 = 88.4%

−1.91 [−2.91,−0.92]

−2.21 [−3.78,−0.65]

−2.13 [−2.92,−1.34]−2.07 [−2.64,−1.49]

−1.41 [−2.47,−0.35]

−0.3 [−0.84, 0.23]

−1.46 [−2.37,−0.56]

0.02 [−0.27, 0.3]

−1.01 [−1.75,−0.27]−0.72 [−1.33,−0.12]

−2.51 [−3.18,−1.85]−2.51 [−3.18,−1.85]

−1.38 [−2.12,−0.65]

; df

df

df

df

Figure 2: Forest plot of subgroup analysis culturallyadapted CPT versus NET versus CPT; Outcome: PTSD severity.

The results indicate that culturallyadapted CPT can suc-cessfully help the adult civilians who experienced war-or-conflict related trauma. The effect size of 7.04 indicates thatthe intervention group (immediate treatment) outperformedthe control group in terms of reduction of symptomsseverity (delayed treatment) by seven times the standarddeviation. This effect size is also highly significant at a levelof 0.01 (P < 0.00001). One should note that there is noheterogeneity between the culturallyadapted CPT trials asindicated by the I square percentage (I2 = 0%).

Figure 2 also shows that NET can successfully help adultcivilians traumatised by war-or-conflict related violence toreduce the severity of their PTSD symptoms. The effectsize of 2.34 is also significant at a level of 0.05 (P =0.02). Contrary to the culturallyadapted CPT, there is a highheterogeneity between the NET trials (I2 = 79%).

According to the results of our analysis, CPT comparedto a control group (treatment as usual, which included socialsupport, medical treatment as usual, and psychoeducation)can also successfully help reduce the severity of the PTSDsymptoms in patients of our population of interest. Theeffect size of 7.40 was highly significant at a level of 0.01(P < 0.00001).

In addition, a subgroup difference test was conducted.The results indicated that there is a significant differencebetween the effectiveness of the different forms of CBTversus a control (delayed treatment, treatment as usual, orpsychoeducation/trauma counselling). After comparing theeffect size, one can say that culturallyadapted CPT and CPTare more effective than NET in reducing the severity of PTSDsymptoms.

Outcome 2: Depression (Figure 3), Analysis Included Onlythe Five Trials Which Reported a Depression Score for TheirParticipants. As indicated in Figure 3, culturallyadapted CPTcan successfully help the population of interest reduce theseverity of their depression symptoms. The effect size of 6.27is highly significant at a level of 0.01 (P < 0.00001). Re-garding the PTSD outcome, there is no heterogeneity be-tween the trials (I2 = 3%). The effectiveness of NET in thereduction of depression severity is low with an effect sizeof 1.67, which is not significant at a level of 0.01. However,the test of subgroup differences is significant at a level of0.01 (P < 0.00008). This indicates that the effectiveness ofculturallyadapted CPT in depression severity reduction ishigher than NET’s.

4. Discussion

This paper summarises the results of ten trials, which re-cruited a total of 473 men and women, all traumatised duringwar-or-conflict. The studies took place in different countries(industrialised and developing) characterised by a varietyof health systems and existing protocol for psychologicalsupport offered to war- and conflict-traumatised individ-uals. Participants included Cambodian refugees resettledin USA [17, 24, 25], refugees from multiple countries inGermany [29], Somalian and Rwandan refugees [16, 30, 31],and Romanian tortured political detainees [28]. All theincluded studies were considered good quality because theabsence of participants’ blindness was not considered asimportant in this type of trial. In fact, this condition is


Study or subgroup

1.2.1 Culturally adapted CPT

Hinton et al., 2004

Hinton et al., 2005

Subtotal (95% CI)


1.2.2 NET

Bichescu et al., 2007

Neuner et al., 2004

Neuner et al., 2010

Subtotal (95% CI)


Total (95% CI)


Mean

2.1

1.72

5.8

11

2.6

SD

0.5

0.43

2.6

5.1

9.2

Total

6

20

26

9

14

16

39

65

Mean

3.2

2.94

15.3

14.4

2.9

SD

0.6

0.45

8.7

4.1

0.5

Total

6

20

26

9

11

16

36

62

Weight

16.5%

20.8%

37.2%

19.4%

21.2%

22.1%

62.8%

100%

IV, random, 95% CI

Intervention Control Std. mean difference Std. mean difference

IV, random, 95% CI

0 2 4

Favours intervention Favours control

Heterogeneity: τ2 = 0.01; χ2 = 1.04, = 1 (P = 0.31); I2 = 3%

Heterogeneity: τ2 = 0.25; χ2 = 4.69, = 2 (P = 0.1);I2 = 57%

Heterogeneity: τ2 = 1.1;χ2 = 24.07, = 4 (P <.0.0001); I2 = 83%

Test for subgroup differences: χ2 = 11.22, = 1 (P = 0.0008), I2 = 91.1%

Z = 6.27 (P <.0.00001)

Z = 1.67 (P = 0.1)

Z = 2.5 (P = 0.01)

−1.84 [−3.28,−0.39]

−2.72 [−3.6,−1.84]

−2.47 [−3.24,−1.7]

−1.41 [−2.47,−0.35]

−0.7 [−1.52, 0.12]

−0.04 [−0.74, 0.65]

−0.64 [−1.38, 0.11]

−1.3 [−2.32,−0.28]

−4 −2

df

df

df

df

Figure 3: Forest plot of subgroup analysis culturallyadapted CPT versus NET versus CPT; Outcome: Depression severity.

difficult to meet because it is neither possible nor ethicalto withhold from the patient information on the type ofhealthcare received.

The first subgroup analysis revealed that CPT, cultur-allyadapted CPT, and NET can significantly contribute tothe PTSD severity reduction. However, the first two formsof CBT seem to have a higher effect on PTSD severityreduction than NET. We cannot exclude the possibility thatthose two forms of CBT might be the most adapted to theneeds of patients of the population of interest. However,other reasons might have resulted in the superiority effectobserved. First, it is possible that culturallyadapted CPTand CPT had a higher effect on PTSD severity reductionbecause they were all conducted in the participants’ nativelanguage by people familiar with their culture. In fact, notall of the NET trials were conducted in the participants’native language, and the amount of trials available was toolow to conduct a subgroup analysis that assesses the impactof interpreters on PTSD severity reduction. The observeddifference might have also resulted from the variety ofparticipants included in the NET trials compared to the otherforms. In fact, the NET trials were conducted in differentcountries (Uganda, Germany, and Romania) with differentsettings and participants from different origins, while allthe culturallyadapted CPT were conducted in Massachusettswith participants living in a more stable economic/politiccontext. It is possible that participants who are still livingin the conflict-affected country are less inclined to fullybenefit from the success of psychotherapy even when theyneed it. This idea derived from the comparison of the trialconducted by Bichescu et al. [28] to the ones conducted inUganda [16, 30]. The former trial is the most effective, andthis is likely due to the fact that the communist regime inRomania was over and most of the participants are livingin a more peaceful environment than the refugees living incamps (most of them without decent lodging, food, or healthservices). Our hypothesis seems to be confirmed with the

results of the trials that studied the effectiveness of NETamong refugees in Germany, results which were in favour ofthe intervention.

The second subgroup analysis conducted revealed thatculturallyadapted CPT and NET were effective in reducingthe severity of depression in our population of interest.However, the effect size of NET therapy compared tocontrol condition (Psychoeducation, Trauma Counselling orNo treatment) was not significant. With regards to PTSDoutcome, results show that culturallyadapted CPT is moreeffective than NET in depression severity reduction. Thereasons described earlier might have also caused the resultsobtained.

A finding that is also important to discuss concerns theheterogeneity between the included trials. As reported earlier,there is a high homogeneity between the culturallyadaptedCPT trials, results that can be explained by the fact thatthe three trials were led by the same therapist with similarparticipants in terms of type of trauma experienced (Cam-bodian genocide). In contradiction, a high heterogeneitybetween the NET trials was found, results that can be easilyexplained by the different settings of NET trials (severalinstruments used to assess PTSD severity, different numberof sessions, variable length of session, interpreters recruitedor not, participants from different origins, etc.).

CPT is the most studied treatment in relation to PTSDsymptoms and severity in the general population. Moreover,it is the most recommended treatment in the general pop-ulation based on the studies conducted in the industrialisedcountries. This form of CBT also seems efficient in helpingwar-traumatised adult civilians. In fact, when amalgamatedwith a meta-analysis, the CPT trials revealed a stronger effectsize of the treatment compared to the control group (waitinglist or delayed treatment). Our results also indicate that CPTseems the most indicated treatment to reduce depressionseverity. However, the trials’ small sample sizes and the factthat every trial was conducted with patients originating from


three countries (Bosnia for CPT, Vietnam and Cambodia forits culturallyadapted form) make it impossible to generalizeCPT’s effectiveness to every post war and conflict trauma-tised patient. Our results also emphasize the necessity oftaking culture into account while designing interventions forPTSD patients or refugees of non-western countries since theculturallyadapted CPT seems more effective than the NET inPTSD and depression severity reduction.

In comparison to CPT, NET is a more contemporarymethod and more researched method of treatment in thepopulation of interest (5 out of 10 trials compared it toanother type of therapy). NET also seems to be the mostadapted method to our population of interest because it isdesigned to suit their need and its effectiveness has beenproven in different trials. Our meta-analysis also confirmedthat it can help subjects of our population of interest inlowering the severity of their PTSD and depression symp-toms. Even if NET does not appear to be the most effectivetreatment, the fact that it has been applied with success toparticipants from diverse origins (Romania, Somalia, Sudan,Turkey, Balkans, and Uganda) makes it easier to generalise itseffectiveness among the population of interest. We also thinkthat this form of CBT will probably benefit from integratingthe variable of culture into the design of their sessions.

As indicated in the title of this paper, we were interestedin assessing the effectiveness of the different forms of CBTaccording to the sex of the participants in order to find whichtreatment is the most effective for women. Unfortunately,this was not possible because even if most of the trialsincluded men, and women none of them reported theirresults according to the sex or gender of participants. Wethink that subsequent trials should assess the difference oftreatment effect between men and women since previousstudies on PTSD symptoms and its severity revealed adifference of its rate between men and women in the samepopulation, women being at higher risk of developing it [32–34]. Thus, we highly suggest that future researches take thesex/gender variable into account since an increasing numberof studies suggest its role in several health matters [35, 36].

5. Potential Biases in the Review Process

First, the selection of a specific category of war-traumatisedpatients (adults) might seem arbitrary. We thought that it isimportant to separate adults from young ones because thetype of CBT and NET treatment used in those categoriesare not the same. We also separated those categories of agebecause we felt that the process of healing might be differentbetween an adult who is usually the victim of violence anda child/adolescent who is usually a witness and/or victimof that violence. Secondly, although an extensive list ofdatabases was used for study selection, we cannot rule out thepossibility that some articles may have been missed with ourresearch strategy. In fact, since five out of ten of the studieswere conducted by German researchers we cannot excludethe fact that some of their studies were not found in theEnglish databases used.

6. Main Conclusions of the Study andImplications for Practice

This systematic review demonstrates that culturallyadaptedCPT, CPT, and NET can successfully help war-or-conflict-traumatised civilians in reducing their PTSD symptoms.However, only the culturallyadapted CPT seems effective inreducing the depression score of civilians who experiencedwar-or-conflict related violence. Even if the subgroup anal-ysis clearly demonstrates that CPT and its culturallyadaptedform are more effective than NET, more evidence is neededin order to specifically recommend one of the forms of CBTover the other for our population of interest.

7. Implications for Research

7.1. Recommendations for Study Designs. More researchneeds to be carried out on CBT (specifically its cultur-allyadapted form) and NET treatment effectiveness in PTSDseverity reduction within our population of interest. In fact,these people need to cope with the symptoms, in order tobe able to contribute to the prosperity and well-being oftheir societies. It is also important that researchers agreeon common characteristics which will allow conduct of abetter comparison between studies in the future, in order torecommend a specific treatment. They should agree on theinstruments, the number of sessions given, and their length.For example, in the CBT trials the number of sessions wasdifferent from one study to another. It is also importantthat the same type of control group be used for each trial(delayed-treatment or treatment as usual). In fact, therewas a difference in the type of control group between thetrials that used NET as an intervention. Trials comparingthese two methods to a standard treatment might also bea good idea and collaboration between the varying teams(Hinton and Neuner teams) would certainly help this. Toensure the quality of the trials, researchers must also besure to conceal allocation (none of the reviewed studiesdid so) and blind the assessors (followed by a test ofthe blindness integrity). Moreover, researchers must makecertain that enough participants in the intervention andcontrol group are included in the trial. In fact, a keylimitation in most studies is the sample size. Only one studyincluded an adequate number of participants (n = 111) inthe intervention group, but also reported a high number oflosses to followup, which made the results partly subject tothe risk of bias such as incomplete outcome data.

7.2. Integrating Cultural Validity. There is not only a questionof cultural validity regarding the PTSD itself (and its associ-ated comorbidities), but also the instruments and specialistsused to assess it remain important. In fact, some arguethat PTSD symptoms may have various values or meaningsdepending on the different cultures, and some symptomsmay not be perceived as distressing among certain groups[37]. The validity of applying a western-based trauma model,and the label PTSD to people from nonwestern countrieshas also been questioned [38]. Summerfield has even raised


some fierce criticisms on the programs that do not integratethe question of validity when working with nonwestern pop-ulations. Surprisingly, none of the NET trials included leadresearchers originating from the refugee population, a situa-tion that most likely reduces the possibility of including theaspect of cultural validity in the intervention.

7.3. Research on Other Promising Treatments. Aside fromNET and CPT, different therapies have been studied in ourpopulation of interest. One of them, testimonial psychother-apy, was used as treatment for the intervention group inan RCT [39]. This intervention was conducted with nondis-placed Mozambican civilians who had experienced traumaduring a civil war in Mozambique. Several writers havenoted that testimony psychotherapy offers survivors sometherapeutic benefits in their trauma recovery [40]. As NET, itallows participants to have a written testimony at the end ofthe treatment with a benefit of a high completion rate. Familygroup therapy has also been described as potentially efficientin the population of interest. This treatment might be evenmore effective when several patients or traumatized personsbelong to the same family, a situation that is fairly common[41–43]. This therapy gives the patients the advantage toreceive social support from their family which facilitates theiraccess and use of mental health services. Unfortunately, noneof the interventions using this method were in the form of anRCT.

Authors’ Contribution

The research and selection of articles were conducted by N. I.Dossa who also analysed and discussed the results and madethe preceding recommendations. M. Hatem helped in the de-velopment of the background, the questions and the compar-isons and the review of the work at each step of the reviewprocess.

Disclosure

N. I. Dossa is a Ph. D. student whose project concerns womenvictim of war-or-conflict related trauma.

Funding

N. I. Dossa received a grant from the Sainte-Justine Hospitalfor this paper.

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