Academic journal article Journal of Cognitive Psychotherapy

Intervening on Persistent Posttraumatic Stress Disorder: Rumination-Focused Cognitive and Behavioral Therapy in a Population of Young Survivors of the 1994 Genocide in Rwanda

Academic journal article Journal of Cognitive Psychotherapy

Intervening on Persistent Posttraumatic Stress Disorder: Rumination-Focused Cognitive and Behavioral Therapy in a Population of Young Survivors of the 1994 Genocide in Rwanda

Article excerpt

This study assessed the outcome of a brief rumination-focused cognitive and behavioral intervention in treating posttraumatic stress disorder (PTSD) symptoms among Rwandan adolescent survivors of the 1994 genocide. All participants (54.5% female, N = 22) aged between 15 and 18 years (M = 16.55, SD = 0.96) met criteria for PTSD as assessed by the PTSD self-rating scale (UCLA PTSD index). Measures included questionnaires assessing PTSD, depression, and somatization. Data were obtained at four points: (1) 11 years after the genocide (baseline), (2) 13 years after the genocide (pretreatment), (3) posttreatment (2 weeks after the treatment), and (4) follow-up (2 months after the treatment). PTSD symptoms increased between baseline and pretreatment. The intervention was associated with a reduction in PTSD symptoms, with gains maintained at follow-up.

Keywords: children; adolescents; genocide; PTSD; intervention; Rwanda

In their cognitive model of posttraumatic symptomatology, Ehlers and Clark (2000) distinguish three types of subjective factors accounting for the persistence of posttraumatic stress disorder (PTSD). First, negative evaluations ("added meanings") of the trauma and/or its consequences or aftereffects (intrusions, hyperarousal) drive the impression of continuous threat. These evaluations maintain the intrusions together with the physical sensations of malaise, which in turn trigger mechanisms of rumination (Behar, Zuellig, & Borkovec, 2005; Borkovec, Newman, & Castonguay, 2003). Second, the nature of the memory of the trauma (difficulty in cognitive integration of the trauma) explains the establishment and persistence of intrusions, which later create sensitive triggers for the rumination. Third, apprehensive evaluations motivate a set of behaviors (e.g., avoidance) and dysfunctional cognitive strategies (e.g., thought suppression, rumination) intended at reducing the feeling of current threat. However, instead of reducing symptoms, these factors actually maintain the disorder by preventing changes in the apprehensive evaluations and in trauma memory.

Ehlers and Clark's (2000) model has been recently extended in a metacognitive model (Wells & Sembi, 2004). The latter model particularly stresses metacognitive processes, mainly anxious rumination, that hinder the normal process of adaptation to trauma. It postulates that the alleviation of anxious ruminations and of interpretative and attentional biases on one hand, and the strengthening of metacognitive flexibility on the other hand, should foster more adaptive cognition and alleviate symptoms. Clinical findings indeed suggest that rumination-focused interventions may reduce and alleviate PTSD symptoms (Ehlers & Clark, 2000). More generally, clinical evidence (Segal, Williams, & Teasdale, 2006) suggests that the more successfully clients can disengage from rumination and avoidance, the more effective they can be in regulating their feelings and resolving their problem.

This article presents a study conducted in Rwanda with a sample of young survivors of the 1994 genocide. It assessed the effects of rumination-focused cognitive behavioral therapy (RFCBT) in treating persistent PTSD and associated disorders such as depression and somatization. Previous data collected 12 years after the genocide (Sezibera & Philippot, 2009) revealed a high prevalence of PTSD symptoms in a large sample of this population (N = 232; PTSD prevalence: 71.6%). Consistent with existing findings (Michael, Halligan, Clark, & Ehlers, 2007), our later data indicated that ruminative coping strategy was the best predictor of PTSD symptoms (β = 0.47, t = 7.80, p < 0.001), though other coping strategies, including problem solving, cognitive restructuring, expressing emotions, and seeking social support, were not significant predictors. Likewise, PTSD was strongly associated with depression (r [225] = .59, p < .001) and somatization (r [225] = . …

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