Crombach, Anselm
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Impact and cultural acceptance of the Narrative Exposure Therapy in the aftermath of a natural disaster in Burundi
Background: In the aftermath of natural disasters, affected populations are at risk of suffering from trauma-related mental health disorders such as posttraumatic stress disorder (PTSD) or depression. Particularly in poor post-conflict regions, these mental disorders have the potential to impair the ability of individuals to move on with their lives. We aimed to evaluate the feasibility, cultural acceptance, and effect of a trauma-focused psychotherapy, Narrative Exposure Therapy (NET), in the aftermath of a flood disaster in Burundi.
Methods: Fifty-one individuals who were living in emergency camps overseen by the Burundian Red Cross in the aftermath of a flood disaster, and who had lost homes and close relatives, were invited to participate in semi- structured diagnostic interviews. Trained Burundian psychology students conducted these interviews, and six sessions of NET were offered to the 15 individuals most affected by trauma-related symptoms. An additional group of psychology students, blind to the treatment conditions, conducted three and 9 months follow-ups with them including also 25 participants who had reported significant but less severe trauma-related symptoms, assessing mental health symptoms, acceptance of NET, stigmatization due to trauma symptoms, and participants’ economic well-being.
Results: Between baseline and 9-months post-intervention assessment, symptoms of PTSD (Hedges’ g = 3.44) and depression (Hedges’ g = 1.88) improved significantly within participants who received NET and within those who received no treatment (Hedges’ gPTSD = 2.55; Hedges’ gdepression = 0.72). Furthermore, those who received NET felt less stigmatized by their participation in the intervention than by the trauma-related mental health symptoms they experienced. Overall, participants reported that they would be willing to forego as much as 1 month’s worth of income in exchange for receiving trauma-focused interventions in the months following the disaster.
Conclusions: Individuals severely affected by trauma-related mental health symptoms might benefit significantly from NET in the aftermath of natural disasters, while less affected individuals seem to recover spontaneously. Despite significant challenges conducting NET in emergency camps in the aftermath of natural disaster in a post-conflict country, such interventions are feasible, appreciated and might have long-lasting impacts on the lives of survivors if conducted with due respect to participants’ privacy.
Is the Implicit Association Test for Aggressive Attitudes a Measure for Attraction to Violence or Traumatization?
Traumatic exposure is particularly devastating for those who, at a young age, have become combatants or experienced massive adversity after abduction by armed movements. We investigated the impact of traumatic stressors on psychopathology among war-affected young men of Northern Uganda, including former child soldiers. Adaptation to violent environments and coping with trauma-related symptoms often result in an increasing appetite for violence. We analyze implicit attitudes toward violence, assessed by an Implicit Association Test (IAT), among 64 male participants. Implicit attitudes varied as a function of the number of experienced traumatic event types and committed offense types. As the number of traumatic experiences and violence exposure increased, more appetitive aggression was reported, whereas the IAT indicated increasingly negative implicit attitudes toward aggression. The IAT was also the strongest predictor of cortisol levels. Diffusion-model analysis was the best way to demonstrate IAT validity. Implicit measures revealed the trauma-related changes of cognitive structures.
Treating and Preventing Psychological Trauma of Children and Adolescents in Post-Conflict Settings
Several factors endanger the psychological well-being of children and adolescents growing up in post-conflict settings. The risk of experiencing traumatic events at early stages of their development renders them more vulnerable for developing mental disorders. Furthermore, they have to deal with ongoing socioeconomic insecurity, loss of close relatives, disrupted family systems, and the disruptive consequences of their caregivers’ mental health status on child-rearing practices. In this chapter we identify the particular risk factors for children and adolescents growing up in post-conflict settings. We highlight the need for and provide an overview of existing and developing evidence-based interventions aimed at preventing and treating trauma-related disorders in children and adolescents in these potentially insecure and volatile environments. Specifically, we present the research-based interventions Parent Management Training Oregon model adapted to family systems in post-conflict settings and Interaction Competences with Children for Caregivers in institutional facilities, both aimed at promoting caring and violence-free child-rearing practices. The initial results of both interventions indicate their feasibility of implementation, including first hints of effectiveness, cultural acceptance, and adaptability to specific post-conflict settings. Finally, we introduce Narrative Exposure Therapy for Forensic Offender Rehabilitation as a promising treatment approach to reduce trauma-related symptoms and the risk of aggressive behavior in street children and child soldiers. Throughout the chapter we highlight the feasibility of scientifically evaluating interventions in post-conflict settings and emphasize the need for evidence-based prevention and treatment approaches.
Intergenerational violence in Burundi : experienced childhood maltreatment increases the risk of abusive child rearing and intimate partner violence
Background: Experiencing abuse during childhood affects the psychological well-being of individuals throughout their lives and may even influence their offspring by enhancing the likelihood of an intergenerational transmission of violence. Understanding the effects of childhood maltreatment on child-rearing practices and intimate partner violence might be of particular importance to overcome the consequences of violent conflicts in African societies.
Objective: Using Burundi as an example, we aimed to explore the associations between childhood maltreatment, intimate partner violence, perceived partner intimidation, gender and the probability of violently acting out against one's own children or romantic partner.
Methods: Amongst a sample of 141 men and 141 women in the capital of Burundi, we identified those who had biological children and those who lived or had lived in relationships. Using culturally appropriate instruments, we enquired about their exposure to childhood maltreatment and partner violence as well as their inclinations to act out violently.
Results: We found that childhood maltreatment and perceived partner intimidation were strong predictors for the perpetration of violence against children. Moreover, we found that women were more likely to use violence against children if they experienced partner violence and less likely to resort to violence if they felt intimidated. Men were more likely to perpetrate violence against their partner. Childhood maltreatment was again a strong predictor. The more women experienced partner violence, the more they fought back.
Conclusions: Childhood maltreatment is a strong predictor for domestic violence and has to be addressed to interrupt the cycle of violence in post-conflict countries.
Predicting domestic and community violence by soldiers living in a conflict region
Objective:
Past research revealed war trauma and posttraumatic stress disorder (PTSD) symptoms as potential predictors for domestic and community violence in crisis regions and among soldiers in different armed conflicts. The impact of family violence and other adversities experienced in childhood as well as of a combat-enhanced appeal for aggressive behavior (appetitive aggression) remains to be specified.
Method:
In the present study, the authors separately predicted violence against children, intimate partner violence and community violence in 381 Burundian soldiers returning from foreign deployment and living in a post- conflict region. Using path analysis, they aimed to disentangle the independent contributions and pathways of the following variables: Exposure to war trauma and childhood familial violence, PTSD and depression symptom severity, and appetitive aggression.
Results:
Childhood familial violence had an independent effect on all contexts of violence and was the only significant predictor for violence against the soldiers’ own children. Intimate partner violence was additionally predicted by depression symptom severity, while community violence was additionally predicted by PTSD symptom severity and appetitive aggression.
Conclusions:
Besides war-related mental ill-health and appetitive aggression, violent experiences during childhood development must not be overlooked as a factor fueling the cycle of violence in conflict regions.
Succumbing to the Call of Violence : Sex-Linked Development of Appetitive Aggression in Relation to Familial and Organized Violence
Appetitive aggression is the attraction to violent behavior, which can peak in the experience of a combat high. In various war and conflict scenarios, members of armed groups have reported developing a desire to hunt and even kill humans. More recently, we reported that the phenomenon has also been observed in female ex-combatants with varying participation in warfare. Despite recent investigations on risk factors for appetitive aggression, sex-specific pathways in the development of appetitive aggression have not yet been delineated. This study investigated moderation effects of sex on previously identified risk factors for appetitive aggression by means of regression analyses in a sample of individuals with varying degrees of warfare participation (overall sample, n = 602). First examining a sample characterized by backgrounds heterogeneous in both sociodemographic data and war experiences, the analysis was then replicated in a subsample of fighters active during the civil war (combatant sample, n = 109). In both samples, regression analyses revealed significant moderation effects of sex. Childhood maltreatment and traumatic events had positive associations on the development of appetitive aggression for males but a negative (childhood maltreatment) or no (traumatic events) association for females. Perpetrated events were more strongly correlated with appetitive aggression for females than for males. This pattern was pronounced for the combatant sample. These results are in favor of sex-linked pathways. In both sexes, appetitive aggression may have evolved as a biologically prepared response to cruel environments but might develop along different trajectories. The current study highlights the need for addressing appetitive aggression in order to support peace-building processes and emphasizes sex specific starting-points.
Appetitive aggression and its relation to posttraumatic stress in Burundian ex-combatants
Former combatants have experienced many traumatic events and violence in their past. Symptoms of posttraumatic stress disorder (PTSD) are prevalent among them, but at the same time, many combatants do not suffer from PTSD. Appetitive aggression—the perception of violent acts as appealing and exciting—was found to reduce the risk of developing PTSD symptoms in several studies with combatants of different countries. However, this protective influence waned when traumatization of combatants got too severe. The aim of the present study was to replicate previous findings in a sample of Burundian ex-combatants. The relationship between appetitive aggression and PTSD symptom severity was investigated, and a negative correlation between these variables was expected. On the basis of previous studies, we expected to find this relationship only after excluding the most traumatized participants. Semistructured interviews were conducted with 392 Burundian ex-combatants to assess traumatic event types, self-committed violent acts, PTSD symptom severity (PTSD Symptom Scale Interview) and appetitive aggression (Appetitive Aggression Scale). Appetitive aggression was not correlated with PTSD symptoms severity in the total sample. After the most severely traumatized participants were excluded, appetitive aggression was negatively related to PTSD symptom severity. The findings of the present study confirmed previous findings on the relationship between appetitive aggression and PTSD. Appetitive aggression was shown to lower PTSD symptom severity but is no ultimate protection against PTSD.
The individual contribution of DSM 5 symptom clusters of PTSD, life events, and childhood adversity to frontal oscillatory brain asymmetry in a large sample of active combatants
Post-Traumatic Stress Disorder (PTSD) has been linked to deviations in lateralized frontal functional oscillatory activity. This is possibly because left and right DLPFC have differential roles in regulating both memory and stress response, which are both dysfunctional in PTSD. However, previous results are heterogeneous, and could be attributable to individual symptom clusters, traumatic or aggressive life events, early life stress, or the interaction of these factors. In a large sample of active combatants (N=401), we regressed these factors on frontal electroencephalography (EEG) asymmetry across 5 frequency bands (delta: 2-4Hz; theta: 4-8Hz; alpha: 8-12Hz; beta: 12-24Hz; gamma: 24-48Hz). Negative cognition and mood was associated with stronger relative left delta and theta band power. Traumatic life events showed stronger right alpha and beta band power. Traumatic life events in interaction with hyperarousal predicted stronger relative right left-right imbalance (theta, alpha, and beta bands), whereas childhood adversity, in interaction with negative cognition and mood, predicted stronger relative left left-right imbalance (delta, theta, alpha and beta bands). The contribution of lateralized DLPFC dysfunction to PTSD is thus dependent on the individual complexities of subsymptom clusters and life history, and future studies need to take these factors into account.
Feasibility and Effectiveness of Narrative Exposure Therapy and Cognitive Behavioral Therapy in a Context of Ongoing Violence in South Africa
Objective: In an observer-blinded intervention trial, we tested the reduction of posttraumatic stress symptoms, aggressive attitude, and behavior in young males living in a context of ongoing community and gang violence by means of (a) forensic offender rehabilitation narrative exposure therapy (FORNET), and (b) the cognitive-behavioral intervention "Thinking for a Change" (TFAC). A waiting list served as the control condition. Method: A total of 39 young men were included in the data analysis: 15 completed FORNET, 11 underwent cognitive-behavioral therapy (CBT), and 13 were on a waiting list for later treatment. The primary efficacy endpoints were the PTSD Symptom Scale-Interview (PSS-I) severity score, the Appetitive Aggression Scale (AAS) score, and the number of perpetrated violent event types 8 months (on average) after treatment. Results: Only in the sample receiving FORNET were posttraumatic stress disorder (PTSD) scores significantly reduced at the first follow-up (Cohen's d = -0.97) and significantly different from those of the control group (Cohen's d = -1.03). The changes in scores for appetitive aggression and perpetrated events were not significant for any of the treatment conditions. Conclusions: The study shows that trauma-focused treatment can reduce the psychological symptoms of posttraumatic stress even for individuals living under unsafe conditions in low-income urban communities. However, achieving changes in violent behavior within a context of ongoing violence may require more than the treatment of trauma-related suffering, confrontation with one's offenses, or cognitive-behavioral interventions.
Appetitive Aggression in Women : Comparing Male and Female War Combatants
Appetitive aggression refers to positive feelings being associated with the perpetration of violent behavior and has been shown to provide resilience against the development of PTSD in combatants returning from the battlefield. Until this point, appetitive aggression has been primarily researched in males. This study investigates appetitive aggression in females. Female and male combatants and civilians from Burundi were assessed for levels of appetitive aggression. In contrast to non-combatants, no sex difference in appetitive aggression could be detected for combatants. Furthermore, each of the female and male combatant groups displayed substantially higher levels of appetitive aggression than each of the male and female civilian control groups. This study demonstrates that in violent contexts, such as armed conflict, in which individuals perpetrate numerous aggressive acts against others, the likelihood for an experience of appetitive aggression increases- regardless of whether the individuals are male or female.