Cited by 646Posttraumatic Stress Disorder ResearchMigration, Health and TraumaPsychoanalysis and Psychopathology Research

The DOI matches its Crossref record; 31 of the 31 references it cites were found in a registry or an index; none of the 20 sources its claims cite is checked for support yet.

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

Open access
Neuner, Frank, Schauer, Margarete, Klaschik, Christine, Karunakara, Unni, Elbert, Thomas·2004·Journal of Consulting and Clinical Psychology

Abstract

Little is known about the usefulness of psychotherapeutic approaches for traumatized refugees who continue to live in dangerous conditions. Narrative exposure therapy (NET) is a short-term approach based on cognitive-behavioral therapy and testimony therapy. The efficacy of narrative exposure therapy was evaluated in a randomized controlled trial. Sudanese refugees living in a Ugandan refugee settlement (N = 43) who were diagnosed as suffering from posttraumatic stress disorder (PTSD) either received 4 sessions of NET, 4 sessions of supportive counseling (SC), or psychoeducation (PE) completed in 1 session. 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. These results indicate that NET is a promising approach for the treatment of PTSD for refugees living in unsafe conditions.

Overview

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TL;DR

In a randomized controlled trial with Sudanese refugees living in a Ugandan settlement, narrative exposure therapy (NET) produced better long-term PTSD outcomes than supportive counseling (SC) or psychoeducation (PE). One year after treatment, only 29% of NET participants still met PTSD criteria, compared with 79% of SC and 80% of PE participants.

Key findings

  • Among refugees with PTSD (N = 43), 1-year follow-up PTSD diagnosis was 29% (4/14) for NET, 79% (11/14) for SC, and 80% (8/10) for PE; group differences were significant, χ²(2, N = 38) = 9.48, p < .01.
  • NET showed significantly greater improvement on PTSD measures: PDS Time × Treatment interaction, F(6, 54) = 4.30, p = .01, η² = .31; CIDI Time × Treatment interaction, F(2, 34) = 4.87, p = .01, η² = .21; contrasts favored NET over both SC and PE.
  • No significant Time × Treatment effects were found for comorbid anxiety/depression (SRQ-20) or psychological health (SF-12); at 1 year, 50% of NET, 77% of SC, and 91% of PE participants were still classified as severe mental health cases by SRQ-20 cutoff.
  • Post hoc, more NET participants left the settlement (62%) than SC (7%) or PE (17%), χ²(2, N = 40) = 12.34, p < .01; those who left reported fewer traumatic event types (M = 2.50, SD = 1.97) than those who stayed (M = 4.00, SD = 2.40), t(39) = 2.20, p = .03.

Methods

  • Randomized controlled trial in Imvepi settlement, northern Uganda; 77 previously surveyed refugees were screened, 43 met DSM-IV PTSD criteria and were randomized by dice to NET (n = 17), SC (n = 14), or PE (n = 12).
  • Treatment consisted of 4 sessions for NET and SC, or 1 session for PE; sessions were 90 min, extendable to 120 min for exceptional sessions; assessments occurred pretreatment, posttreatment, 4 months, and 1 year.
  • Outcomes included CIDI PTSD interview, PDS, SRQ-20, SF-12, and a 31-item trauma event checklist; analyses used repeated measures ANOVA/MANOVA, Bonferroni-corrected contrasts (α = .025), restricted maximum likelihood for missing data, and adjustment for further traumatic events.

Limitations

  • Stated by the authors: treatment was delivered by well-trained European psychologists, making it costly and not directly scalable; exact session duration was not monitored, so a dosage effect cannot be fully ruled out; the supportive counseling condition may not represent current standard counseling; comorbid anxiety and depression remained high across groups; the migration finding was post hoc.
  • Evident from the text: the sample was small with unequal group sizes; 1-year follow-up was affected by substantial migration/attrition, especially in the NET group (62% had left the settlement), which may bias follow-up comparisons; follow-up extended only to 1 year, and refugees continued to live in unsafe conditions.

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Integrity signals

Registry

Crossref · 10.1037/0022-006x.72.4.579

Cites

31 of 31 references verified0 citation errors · 0 not checkable

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Claims the paper makes

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  • It may state two separate claims as one. 19
  • Probably not a substantial claim. 41
51 of 51
  • The paper relies on this without support.

    Little is known about the usefulness of psychotherapeutic approaches for traumatized refugees who continue to live in dangerous conditions.

    “Little is known about the usefulness of psychotherapeutic approaches for traumatized refugees who continue to live in dangerous conditions.”
  • The paper relies on this without support.

    Knowledge about effective treatment of PTSD in war-affected civilian populations is still scarce.

    “In contrast, the knowledge about effective treatment of PTSD in populations of civilians who have been affected by war is still scarce.”
  • The paper relies on this without support.

    Very little clinical research has been conducted on how to adequately support and treat war-torn populations.

    “Notwithstanding the considerable attention war-torn populations have received from psychosocial organizations in recent years, very little clinical research has been conducted on how to adequately support and treat these groups.”
  • The paper relies on this without support.

    Treatment protocols for PTSD typically require a safe and reassuring environment, which is difficult to meet in refugee camps and settlements.

    “Furthermore, it is questionable if any psychological assistance can be successful given that treatment protocols for PTSD typically require the establishment of a safe and reassuring environment, conditions that are difficult to meet within the context of refugee camps and settlements.”
  • The paper relies on this without support.

    Any psychotherapy work in this context must be brief given large numbers of people and limited monetary resources.

    “In addition, any psychotherapy work that will take place must be brief given large numbers of people and limited monetary resources.”
  • The paper relies on this without support.

    Any broad scale treatment program must be pragmatic and easy for local personnel to learn, even with little or no access to medical or psychological education or additional training.

    “Any broad scale treatment program must be pragmatic and easy for local personnel to learn, even with little or no access to medical or psychological education or additional training.”
  • The paper relies on this without support.

    The method must be adaptable to any cultural environment and easily implemented.

    “Consequently, the method must be adaptable to any cultural environment and easily implemented.”
  • The paper relies on this without support.

    The 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.”
  • The paper relies on this without support.

    In most cases, counseling procedures and duration of treatment are not rigorously standardized.

    “In most cases, the counseling procedures and duration of treatment are not rigorously standardized.”
  • The paper relies on this without support.

    As of yet there is no clinical trial that examined the efficacy of counseling approaches for traumatized refugees.

    “Little knowledge about the efficacy of counseling in general exists (Bower et al., 2002), and as of yet there is no clinical trial that examined the efficacy of counseling approaches for traumatized refugees.”
  • The paper relies on this without support.

    In exposure therapy, the majority of patients undergo habituation of emotional response to traumatic memory, which leads to remission of PTSD symptoms.

    “In the process, the majority of patients undergo a habituation of the emotional response to the traumatic memory, which consequently leads to a remission of PTSD symptoms.”
  • The paper relies on this without support.

    As most victims of organized violence have experienced many traumatic events, it is often impossible to identify the worst event before treatment.

    “As most of the victims of organized violence have experienced many traumatic events, it is often impossible to identify the worst event before treatment.”
  • The paper relies on this without support.

    Recent theories of PTSD and emotional processing suggest that habituation of emotional responses is only one mechanism to improvement of symptoms.

    “However, recent theories of PTSD and emotional processing suggest that the habituation of the emotional responses is only one mechanism to improvement of symptoms.”
  • The paper relies on this without support.

    In Imvepi, most refugees had experienced multiple traumatic events in the Sudanese civil war before they fled to Uganda.

    “In Imvepi, most refugees had experienced multiple traumatic events in the Sudanese civil war before they fled to Uganda.”
  • The paper relies on this without support.

    Northern Uganda was not a safe exile for the refugees as settlements were threatened and attacked by Sudanese and Ugandan rebel armies.

    “However, northern Uganda was not a safe exile for the refugees as the settlements were threatened and attacked by Sudanese and Ugandan rebel armies.”
  • The paper relies on this without support.

    At the time of this study (2000-2001), living conditions were still scarce, with most refugees suffering from poor nutrition and poverty.

    “At the time of this study (2000 -2001), living conditions were still scarce, with most refugees suffering from poor nutrition and poverty.”
  • The paper relies on this without support.

    Currently about 200,000 Sudanese refugees live in Uganda; many have lived there for several years.

    “Currently about 200,000 Sudanese refugees live in Uganda; many of them have lived in the country for several years.”
  • The paper relies on this without support.

    The study is the first randomized controlled trial of treatment for traumatized survivors of war living in a developing country.

    “To our knowledge, this is the first randomized controlled trial of treatment for traumatized survivors of war living in a developing country.”
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Citations

Cites

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Research works printed but not linked: 3

  1. 1997, A trauma counselling handbook.
  2. Van der Veer, 1998, Counselling and therapy with refugees and victims of trauma, Vol. 2
  3. 1997, Composite International Diagnostic Interview (CIDI).

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Metadata

Authors
Neuner, F., Schauer, M., Klaschik, C., Karunakara, U., & Elbert, T.
Affiliations
Johns Hopkins University (US)
Corresponding author
Neuner, Frank
Venue
Journal of Consulting and Clinical Psychology
Published
2004
Volume
72
Issue
4
Pages
579-587
ISSN
  • 0022-006X (ISSN-L)
  • 1939-2117
OpenAlex
W2161634282
Cited by
644
References
31
Citations by year
2026: 18 · 2025: 23 · 2024: 13 · 2023: 30 · 2022: 35 · 2021: 23 · 2020: 49 · 2019: 26 · 2018: 34 · 2017: 36 · 2016: 29 · 2015: 42 · 2014: 37 · 2013: 42 · 2012: 24
FWCI
23.50
Type
journal article
Language
en
Open access
Licence
cc-by-nc-nd
Locations
  • Journal of Consulting and Clinical Psychology (publishedVersion)
  • PubMed (publishedVersion)
  • KOPS (University of Konstanz) (submittedVersion, cc-by-nc-nd)
  • Medecins Sans Frontieres Field Research (Medecins Sans Frontieres) (submittedVersion)
  • PUB – Publications at Bielefeld University (Bielefeld University) (submittedVersion)
Funders
Deutsche Forschungsgemeinschaft
Topics
  • Social Sciences › Psychology › Clinical Psychology › Posttraumatic Stress Disorder Research
  • Social Sciences › Psychology › Clinical Psychology › Migration, Health and Trauma
  • Social Sciences › Psychology › Clinical Psychology › Psychoanalysis and Psychopathology Research
Keywords
narrative exposure therapy, post-traumatic stress disorder, refugees, Sudanese refugees, supportive counseling, psychoeducation, cognitive behavioral therapy, refugee settlement, treatment efficacy, long-term outcomes
MeSH terms
Adult, Counseling, Emigration and Immigration, Female, Health Education, Humans, Male, Psychotherapy, Surveys and Questionnaires, Refugees, Safety, Social Support, Stress Disorders, Post-Traumatic, Sudan, Uganda, Cognitive Behavioral Therapy, Narration, Diagnostic and Statistical Manual of Mental Disorders

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