A comparison of narrative exposure therapy, supportive counseling, and psychoeducation for treating posttraumatic stress disorder in an african refugee settlement

May combine two claims.

One year after treatment, 29% of NET participants, 79% of the supportive counseling group, and 80% of the psychoeducation group still fulfilled PTSD criteria.

“One year after treatment, only 29% of the NET participants but 79% of the SC group and 80% of the PE group still fulfilled PTSD criteria.”

May combine two claims.

The sphericity assumption was met for the SRQ, SF-12, and CIDI, but not for the PDS.

“The sphericity assumption was met for the SRQ, the SF-12, and the CIDI, but not for the PDS.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The reason for not participating or terminating treatment was generally lack of time due to need to cultivate fields at beginning of rainy season.

“The reason for not participating or for terminating treatment was generally due to a lack of time given the need to cultivate the fields at the beginning of the rainy season.”

May combine two claims.

The narrative exposure therapy group showed more improvement than the other groups on anxiety, depression, and overall mental health measures, but the difference was not significant, as 50% of this group was still classified as severely psychologically disturbed.

“The narrative exposure therapy group showed more improvement than the other groups, yet the difference was not significant, as 50% of this group was still classified as severely psychologically disturbed.”

May combine two claims.

71% of narrative exposure therapy patients no longer fulfilled the DSM-IV criteria for PTSD, a significantly larger proportion than in the two other groups.

“Despite the specific improvement of the narrative exposure therapy participants, the symptom scores still remained high but the change was clinically significant, as 71% of the narrative exposure therapy patients no longer fulfilled the DSM-IV criteria for PTSD, a significantly larger proportion than in the two other groups.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Only in the supportive counseling group did any patients fail to complete full treatment; 2 patients discontinued treatment.

“Only in the supportive counseling group did any patients fail to complete the full treatment; 2 patients in this group discontinued treatment.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The average time past since the worst period of traumatic events was 7.5 years (SD = 3.3).

“The average time past since the worst period of traumatic events was 7.5 years (SD ϭ 3.3).”

Classified as probably not a substantial claim.

No major deviations from treatment protocol were detected.

“No major deviations from treatment protocol were detected.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

As a consequence of randomization, 17 participants were offered NET, 14 were offered supportive counseling, and 12 were offered psychoeducation.

“As a consequence of the randomization procedure, 17 participants were offered narrative exposure therapy, 14 were offered supportive counseling, and 12 were offered psychoeducation.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The randomization procedure resulted in different group sizes.

“The randomization procedure resulted in different group sizes.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The majority of participants (52%) reported witnessing people badly injured or killed as worst event type; other worst event types were threats with weapons and kidnappings (17%), physical attacks (12%), torture (7%), combat experiences (7%), sexual assaults (5%), and natural disasters (2%).

“The majority of participants (52%) reported the witnessing of people badly injured or killed as worst event type (which included the killing of relatives as well as massacres and mutilations); further worst event types were threats with weapons and kidnappings (17%), physical attacks (12%), torture (7%), combat experiences (7%), sexual assaults (5%) and natural disasters (2%).”

Probably not a substantial claim: may not pass S3 (load-bearing).

With the exception of one respondent, all respondents were willing to participate.

“With the exception of only one respondent, all were willing to participate.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

In the NET group, 1 patient refused to participate; all other patients agreed.

“In the narrative exposure therapy group 1 patient refused to participate; all other patients agreed.”

Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

Narrative approaches seem ideally suited to cross-cultural applications because oral tradition is a common element among many cultures.

“The oral tradition is a common element among many cultures; thus narrative approaches seem ideally suited to cross-cultural applications.”

• AssumptionRests on an assumption: The oral tradition is a common element among many cultures.

Probably not a substantial claim: may not pass S3 (load-bearing).

Treatment adherence was monitored by requesting therapists to give a detailed account of participant's current life problems or life history at least once per treatment in supervision meetings.

“As audio recordings were not practicable in the setting, treatment adherence was monitored by requesting the therapists to give a detailed account of either the participant's current life problems (supportive counseling) or the participant's life history recorded thus far (narrative exposure therapy) at least once for each treatment in the supervision meeting.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The SF-12 was used to assess health-related quality of life in different cultures.

“This questionnaire was used to assess health-related quality of life in different cultures.”

• cites Ware, Kosinski, & Keller, 1996Not checked yet

  Not checked in the free run.

Classified as probably not a substantial claim.

The number of traumatic events reported for the 1-year follow-up period was entered as a covariate to control for possible confounding effect of further traumatic life events after treatment.

“To control for a possible confounding effect of further traumatic life events after treatment, the number of traumatic events reported for the 1-year follow-up period was entered as a covariate.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Psychological functioning was measured with the psychological health scale from the SF-12.

“Psychological functioning was measured with the psychological health scale from the 12-item version of the Medical Outcome Study Self-Report Form (SF-12; Ware, Kosinski, & Keller, 1996).”

• cites Ware, Kosinski, & Keller, 1996Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

Selected treatment sessions were directly observed by the first or second author.

“In addition, selected treatment sessions were directly observed by the first or second author.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The informed consent and study protocol were approved by the Ethical Review Board of the University of Konstanz and by the Ugandan National Council for Science and Technology, Kampala.

“The informed consent and the study protocol were approved by the Ethical Review Board of the University of Konstanz and by the Ugandan National Council for Science and Technology, Kampala.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Expert interviewers were doctoral-level psychologists or graduate students from Konstanz University trained in PTSD assessment with the CIDI.

“The expert interviewers were doctoral-level psychologists or graduate students from Konstanz University who had been trained in PTSD assessment with the CIDI in previous field or laboratory studies.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Except for the 4-month follow-up, all research assistants were supervised at least once a week throughout the study.

“Except for the period of the 4-month follow-up, which was carried out by the interviewers alone, all research assistants were supervised at least once a week throughout the study, which included a review of the quality of their work and the discussion of possible emotional strain caused by interviews and translations.”

Probably not a substantial claim: may not pass S3 (load-bearing).

A problem-solving approach specifically developed for trauma counseling in Africa was generally used to maintain a minimal level of standardization in supportive counseling.

“To maintain a minimal level of standardization, a problem-solving approach, specifically developed for trauma counseling in Africa (Amani Trust, 1997), was generally used.”

• cites Amani Trust, 1997Not checked yet

  Not checked in the free run.

Classified as probably not a substantial claim.

Local and expert interviewers who carried out posttests and follow-up tests were blind to participants' treatment condition.

“The local and expert interviewers who carried out the posttests, as well as the follow-up tests, were blind for the individual participant's treatment condition.”

May combine two claims.

The assumption of a homogeneous variance-covariance matrix was met for the PDS, so a multivariate analysis of variance was calculated for this measure.

“As the assumption of a homogeneous variance-covariance matrix inherent in a multivariate approach was met for the PDS (verified with Box's M test), a multivariate analysis of variance instead of a univariate approach was calculated for this measure.”

May combine two claims.

Testimony therapy was created by Lira and Weinstein to treat traumatized survivors of the Pinochet regime in Chile and was successfully applied in an uncontrolled trial to Bosnian refugees in the United States.

“we based our approach on testimony therapy, a method of therapy created by Lira and Weinstein (published under the pseudonyms Cienfuegos and Monelli, 1983) to treat traumatized survivors of the Pinochet regime in Chile and successfully applied in an uncontrolled trial to Bosnian refugees in the United States (Weine, Kulenovic, Pavkovic, & Gibbons, 1998).”

• cites Cienfuegos and Monelli, 1983 sourceNot checked yet

  Not checked in the free run.

• cites Weine, Kulenovic, Pavkovic, & Gibbons, 1998Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

Weekly meetings were scheduled to supervise the quality of treatments.

“Weekly meetings were scheduled to supervise the quality of treatments.”

Classified as probably not a substantial claim.

DSM-IV diagnosis and severity of PTSD was assessed with the PTSD portion of the Composite International Diagnostic Interview (CIDI).

“The DSM-IV diagnosis and severity of PTSD was assessed with the PTSD portion of the Composite International Diagnostic Interview (CIDI; World Health Organization, 1997).”

• cites World Health Organization, 1997Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

The SRQ-20 was used to indicate comorbid symptoms of anxiety and depression.

“The Self-Reporting Questionnaire 20 (SRQ-20; Harding et al., 1980) was used to indicate comorbid symptoms of anxiety and depression.”

• cites Harding et al., 1980 sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

Frequency and severity of PTSD symptoms was assessed with the PDS, modified in translation to simplify frequency rating.

“The frequency and severity of PTSD symptoms was assessed with the PDS (Foa, 1995), modified in the translation procedure to simplify the frequency rating of symptoms.”

• cites Foa, 1995Not checked yet

  Not checked in the free run.

Classified as probably not a substantial claim.

Missing data were estimated with a restricted maximum likelihood procedure to maximize use of information in this small sample.

“To maximize use of information in this study with a small sample size, missing data were estimated with a restricted maximum likelihood procedure.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Further inquiries about details and examples of symptoms were made by experts with translators to ensure correct understanding and validate clinical significance and severity rating of PTSD.

“Further inquiries about details and examples of symptoms were made by the experts with the help of the translators to ensure a correct understanding of the symptoms and to validate the clinical significance of symptoms and the severity rating of PTSD.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Therapists were trained in NET and supportive counseling by the first and second authors through direct observation of treatments.

“Therapists were trained in narrative exposure therapy and supportive counseling by the first and second authors-who had developed narrative exposure therapy and were educated in counseling-through direct observation of treatments.”

Classified as probably not a substantial claim. May combine two claims.

Distortion of explicit autobiographic memory about traumatic events leads to a fragmented narrative of traumatic memories, which results in maintenance of PTSD symptoms.

“Other theories suggest that the distortion of the explicit autobiographic memory about traumatic events leads to a fragmented narrative of the traumatic memories, which results in the maintenance of PTSD symptoms (Ehlers & Clark, 2000).”

• cites Ehlers & Clark, 2000Not checked yet

  Not checked in the free run.

Classified as probably not a substantial claim.

Each participant was randomly assigned using a dice to one of three treatment groups: narrative exposure therapy, supportive counseling, or psychoeducation only.

“Each participant was randomly assigned (using a dice) to one of three treatment groups: narrative exposure therapy, supportive counseling, or psychoeducation only.”

Classified as probably not a substantial claim.

It was not possible to determine a supportive counseling procedure representative of the current standard because of the variety of mainly nonstandardized approaches currently applied in the field.

“On considering the variety of mainly nonstandardized approaches currently applied in the field, we felt it was not possible to determine a supportive counseling procedure that was representative for the current standard.”

• AssumptionRests on an assumption: In most cases, counseling procedures and duration of treatment are not rigorously standardized.

Probably not a substantial claim: may not pass S3 (load-bearing).

In Paunovic and Ost (2001), exposure-based treatment and combined cognitive-exposure treatment were similarly effective for refugees.

“Both treatments were similarly effective.”

• cites Paunovic and Ost (2001)Not checked yet

  Not checked in the free run.

Classified as probably not a substantial claim.

To rule out a possible therapist effect, each therapist provided approximately the same number of treatments in all conditions.

“To rule out a possible therapist effect, each therapist provided approximately the same number of treatments in all conditions.”

Classified as probably not a substantial claim. May combine two claims.

A basic restriction of supportive counseling to exclude talk about specific past traumatic events was established and achieved easily given severity of symptoms and high avoidance.

“To distinguish supportive counseling from narrative exposure therapy, we established a basic restriction of supportive counseling to exclude talk about specific past traumatic events, a goal that was achieved easily given the severity of the symptoms and the high level of avoidance in these patients.”

Probably not a substantial claim: may not pass S2 (checkable).

Reconstruction of autobiographic memory and a consistent narrative should be used in conjunction with exposure therapy.

“Thus, the reconstruction of autobiographic memory and a consistent narrative should be used in conjunction with exposure therapy.”

Classified as probably not a substantial claim.

Self-rating of symptoms and functioning was carried out with standardized clinical instruments.

“Self rating of symptoms and functioning was carried out with the use of standardized clinical instruments.”

Classified as probably not a substantial claim.

All participants randomized to treatment, including 1 refusal and 2 dropouts, were included in the analyses.

“All participants who were randomized to treatment, including the 1 who refused participation in the narrative exposure therapy group and the 2 dropouts in the supportive counseling group, were included in the analyses.”

Classified as probably not a substantial claim.

Because randomization resulted in different baseline levels for some measures, repeated measures ANOVAs were calculated with time as a four-level within-subject variable and treatment group as a three-level between-subjects variable for each outcome measure.

“As the randomization procedure resulted in different baseline levels for some measures, repeated measures ANOVAs were calculated with time as a four-level within-subject variable and treatment group as a three-level between-subjects variable for each outcome measure.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The SRQ-20 had been widely used in African settings previously.

“This instrument had been widely used in African settings previously.”

• cites Harding et al., 1980 sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Therapists were doctoral-level psychologists or graduate students with education and experience in other treatment approaches including counseling.

“Therapists were doctoral-level psychologists or graduate students with education and experiences in other treatment approaches including counseling.”

May combine two claims.

Refugees who left the settlement moved to safer places and reported a significantly lower number of traumatic event types.

“The comparison of the number of traumatic event types reported by the refugees for the 1 year period after treatment indicated that although almost all participants (93%) reported the witnessing or experiencing of one or more further traumatic events, those who left the settlement did indeed move to safer places and reported a significantly lower number of event types.”

Classified as probably not a substantial claim.

Differences between single treatment groups were analyzed with Fisher's exact tests, Bonferroni corrected to alpha = .025.

“Differ- ences between single treatment groups were analyzed with Fisher's exact tests (Bonferroni corrected ␣ ϭ .025).”

May combine two claims.

All but one of the participants who presented with PTSD in the screening interview agreed to participate in treatment, and only in the supportive counseling condition did two patients prematurely terminate treatment.

“All but one of the participants who presented with PTSD in the screening interview agreed to participate in treatment, and only in the supportive counseling condition did two patients prematurely terminate treatment.”

May combine two claims.

Extended treatment sessions were scarce (about 10%) and occurred in all conditions, but the exact duration of each treatment was not monitored and a dosage effect cannot be fully ruled out.

“Although extended sessions were scarce (about 10%) and occurred in all conditions, we did not monitor the exact duration of each treatment and cannot fully rule out a dosage effect.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The significance level was Bonferroni corrected to an alpha of .025 for the contrast analyses.

“As two calculations were carried out for each measure, significance level was Bonferroni corrected to an ␣ of .025for the contrast analyses.”

May combine two claims.

This study does not fully prove the usefulness of any psychotherapeutic approach for war-torn populations, because the treatment was carried out by well-trained European psychologists.

“In spite of the promising treatment effect found in this trial, this study does not fully prove the usefulness of any psychotherapeutic approach for war-torn populations, as the treatment was carried out by well-trained European psychologists.”