Dissemination of Psychotherapy for Trauma Spectrum Disorders in Postconflict Settings : A Randomized Controlled Trial in Rwanda

Abstract

Background: Dissemination of psychotherapeutic modules to local counselors seems a key requirement for coping with mental health disasters in conflict regions. We tested a train-the-trainer (TTT) dissemination model for the treatment of posttraumatic stress disorder (PTSD). Methods: We randomly assigned widowed or orphaned survivors of the 1994 Rwandan genocide with a PTSD diagnosis to narrative exposure therapy (NET) treatment (NET-1, n = 38) or to a 6-month waiting list (WL) condition to be followed by treatment (WL/NET-2, n = 38). Expert therapists trained a first dissemination generation of local Rwandan psychologists in NET complemented by 2 sessions of interpersonal psychotherapy modules. Under the supervision of the experts, these Rwandan psychologists (a) provided NET to the NET-1 participants and (b) subsequently trained and supervised a second generation of local psychologists. This second dissemination generation provided treatment to the WL/NET-2 group. The primary outcome measure was the Clinician-Administered PTSD Scale total score before therapy and at 3- and 12-month follow-ups. Results: At the 3-month follow-up, the NET-1 participants suffered significantly and substantially less from PTSD symptoms than the participants in the WL group. The treatment gains of NET-1 were maintained and increased at follow-up, with a within-group effect size of Cohen's d = 1.47 at the 12-month follow-up. After treatment by the second dissemination generation of therapists, the WL/NET-2 participants improved to an extent similar to that of the NET-1 group at follow-ups, with an effect size of Cohen's d = 1.37 at the 12-month follow-up. Conclusions: A TTT model of PTSD treatment dissemination can be effective in resource-poor postconflict societies.