Narrative exposure therapy can reduce PTSD symptoms in former child soldiers

Former child soldiers from Northern Uganda who received a short-term trauma-focused intervention had a greater reduction of symptoms of posttraumatic stress disorder than soldiers who received other therapy, according to a study in the August 3 issue of JAMA, a theme issue on violence and human rights.

It is currently estimated that approximately 250,000 children younger than 18 years are actively involved as child soldiers in hostilities in 14 countries or territories worldwide. The civil war in Northern Uganda lasted more than 2 decades and has affected virtually the entire Northern Ugandan population. "Throughout the war and thereafter, the Northern Ugandan communities have been confronted with large numbers of formerly abducted children, adolescents, and young adults returning after their rescue, flight, or release. The successful reintegration of these former child soldiers continues to be a major challenge," according to background information in the article. "Despite high rates of impairment, there have been no randomized controlled trials examining the feasibility and efficacy of mental health interventions for former child soldiers."

Verena Ertl, Ph.D., of Bielefeld University, Bielefeld, Germany, and colleagues conducted a randomized controlled trial to test the feasibility and effectiveness of narrative exposure therapy for the treatment of former child soldiers with posttraumatic stress disorder (PTSD). Narrative exposure therapy is a short-term, trauma-focused treatment developed for use in low-resource countries affected by crises and conflict. During narrative exposure therapy the participant constructs a detailed chronological account of his or her own biography in cooperation with a therapist to reconstruct fragmented memories of traumatic events and to achieve habituation.

The trial included 85 former child soldiers with PTSD from a population-based survey of 1,113 Northern Ugandans ages 12 to 25 years. The study was conducted in camps for internally displaced persons between November 2007 and October 2009. Participants were randomized to 1 of 3 groups: narrative exposure therapy (n = 29), an academic catch-up program with elements of supportive counseling (n = 28), or a waiting list (n = 28). Symptoms of PTSD, depression, and related impairment were assessed using various analytic tools before treatment and at 3 months, 6 months, and 12 months postintervention. Treatments were carried out in 8 sessions by trained local lay therapists, directly in the communities.

The researchers found that PTSD symptom severity was significantly more improved in the narrative exposure therapy group than in the academic catch-up and waiting-list groups. In one measure of clinically significant change, 20 of 25 participants (80 percent) in the narrative exposure therapy group were found to have improved with regard to PTSD severity. "In the academic catch-up and waiting-list conditions, 11 of 23 (47.8 percent) and 14 of 28 (50 percent), respectively, showed clinically relevant improvement. Subgroup comparisons revealed that improvement was significantly greater in the narrative exposure therapy group vs. the academic catch-up group and the narrative exposure therapy vs. the waiting-list groups," the authors write. At 12 months, 68 percent of the narrative exposure therapy participants, 52.2 percent of the academic catch-up participants, and 53.6 percent of the waiting-list participants no longer fulfilled criteria for PTSD.

Also, a larger within-treatment effect size was seen in the narrative exposure therapy group, with a 51.6 percent reduction in the PTSD symptom score from pretreatment assessment to 12-month follow-up compared with the academic catch-up group (30.9 percent symptom severity reduction) and the waiting-list group (30.4 percent symptom severity reduction).

"Moreover, results indicated that there were additional positive effects of treatment on associated problems not primarily targeted, such as depression, suicidal ideation, feelings of guilt, and important indicators of readjustment such as stigmatization and functioning," the researchers add.

The authors note that the findings of this study indicate that narrative exposure therapy can be applied successfully by community-based lay therapists without a mental health or medical background.