Treating post‐traumatic stress disorder by resource activation in Cambodia

There is a need for effective, low‐threshold psychotherapeutic treatments in post‐conflict settings1. However, systematic outcome research on site is still extremely rare. To address this problem we integrated rigorous research procedures into a humanitarian program, the so called Mekong Project, and conducted a randomized controlled trial for the treatment of post‐traumatic stress disorder (PTSD) in Cambodia. In short, the Mekong Project aims at establishing independent psychotherapeutic services in several Southeast Asian countries via the systematic training of local health professionals and offering free of charge psychological help to traumatized civilians.

Cambodia is one of the least developed countries in Asia, facing many challenges (e.g., poor standards of health and education, rural exodus, and political instability). Mental health morbidity in Cambodia is high. It has been found that 53.4% of the Cambodian population suffer from a mental disorder, with anxiety and PTSD being the most frequent (40.0% and 28.4% respectively)2. Thus, although some stability has returned to the country during the past decades, there are urgent mental health care needs, including the need for individualized psychiatric services.

Our aim was to test the efficacy of a non‐confrontational psychotherapeutic treatment for PTSD. The therapy includes two main treatment principles described in treatment manuals: resource‐oriented trauma therapy and resource installation with eye movement desensitization and reprocessing (EMDR) (short: ROTATE). ROTATE aims at strengthening resilience and coping capacities by activating positive personal resources, and largely draws on psychodynamic principles of the therapeutic relationship. It includes a variety of imaginative resource‐activating methods3, 4 as well as resource development and installation, an EMDR technique aiming at systematically developing and anchoring resources using alternating bilateral stimulation5. ROTATE has several advantages: a) it can be safely applied even to complex trauma conditions, with no major side effects being observed so far; b) instead of solely focusing on PTSD symptoms, it also considers the mental comorbidities typically found in these clients, notably depression and anxiety; c) it is especially suitable for clients from non‐Western countries, as traditional healing resources like mindfulness strategies can be integrated in an overall framework of resource activation; d) its basic elements can easily be taught, even to paraprofessionals.

Our trial was carried out in cooperation with the Royal University of Phnom Penh and was located in Phnom Penh City and the nearby Kandal Province. Help‐seeking outpatients screening positively for PTSD (PTSD Check List ≥ 446) were eligible for inclusion. We allowed for comorbid mental health disorders except for psychosis, organic brain disorder, cognitive impairment, dementia, acute suicidality, and acute need for treatment.

Overall, 800 patients were screened for eligibility, of whom 86 (mean age 27 years, 61% female) fulfilled the selection criteria and were randomly assigned to either 5 weekly sessions of ROTATE (N=53) or a 5‐week waiting list control group (N=33). Symptoms were measured before and after the intervention (or waiting period). Assessments were performed via personal interview by an investigator blind to treatment allocation. All patients in the control group were offered treatment after the end of the waiting period. The primary outcome was PTSD symptom change on the Indochinese version of the Harvard Trauma Questionnaire (HTQ)7. The PTSD scale of the HTQ includes 16 items reflecting the DSM‐IV criteria for PTSD. Secondary outcomes included depression, anxiety and social functioning. All applied instruments have been validated for the Cambodian population7. The therapy was provided by six Cambodian psychologists who had completed a 3‐year course in trauma therapy as part of the Mekong Project.

Based on previous findings of psychological therapies for PTSD8, we expected ROTATE to be superior to waiting list with a between group effect size of at least d=0.65 on the primary outcome. To detect this difference with a power of 0.80 at α=0.05, 2‐sided test, 2 × 40 patients were required. Unfortunately, the concept of randomization, especially being randomized to a waiting list, was very difficult for some clients. As a consequence, randomization failed in 38 patients, leading to an unbalanced allocation ratio (1.6:1), with an overrepresentation of patients randomized to treatment. The trial stopped when the necessary sample size to achieve a power of 0.80 was reached. Data were analyzed by general linear regression models, controlling for baseline symptom severity. The drop‐out rate during the intervention was very low (N=2, one in each group), thus only completer data were analyzed (N=84).

Most frequent types of trauma were traffic accidents (24%), domestic violence (23%) and sexual abuse (16%). Patients receiving ROTATE showed significant reductions in PTSD symptoms compared to the waiting list (baseline adjusted means post‐treatment: 1.39, 95% CI: 1.23‐1.54 for ROTATE, and 2.86, 95% CI: 2.66‐3.06 for waiting list, p<0.00001). The between‐group effect size was large (d=2.59). The within‐group effect size was also large for ROTATE (d=4.43), while it was moderate in the control group (d=0.52). No harms were reported.

We conclude that a treatment focusing on stabilization rather than confrontation, by establishing a secure patient‐therapist relationship, applying stabilization techniques, and putting an emphasis on a patient's own resources, significantly reduced symptoms of PTSD in comparison to a waiting list.

The strengths of our study are the following: a) it was conducted on site by local psychologists, which meant that communication between therapists and patients was natural and no interpreters were needed; b) therapists and patients had similar cultural backgrounds, so that culture specific interpretations of symptoms could be taken into account, a factor that has been identified as vital in the therapeutic work with Cambodian patients9; c) local psychologists were trained in ROTATE, which is expected to facilitate patient access to a psychological treatment in a country struggling with insufficient mental health care.

Conducting a randomized controlled trial in a developing country is challenging. Nevertheless, we were able to show that the implementation of such a trial was possible and that this specific form of trauma therapy was well accepted by therapists and patients. Our results are preliminary but promising. Further research is required to corroborate the findings.

Christiane Steinert1, Peter J. Bumke2, Rosa L. Hollekamp1, Astrid Larisch1, Falk Leichsenring1, Helga Mattheß3, Sek Sisokhom4, Ute Sodemann2, Markus Stingl1, Ret Thearom4, Hana Vojtová5, Wolfgang Wöller6, Johannes Kruse1,7
1Clinic for Psychosomatic Medicine and Psychotherapy, University of Giessen, Giessen, Germany; 2Trauma Aid Germany, Berlin, Germany; 3Psychotraumatology Institute Europe, Duisburg, Germany; 4Department of Psychology, Royal University of Phnom Penh, Phnom Penh, Cambodia; 5Slovak Institute for Psychotraumatology and EMDR, Trencin, Slovakia, and Center for Neuropsychiatric Research of Traumatic Stress, Charles University, Prague, Czech Republic; 6Hospital for Psychosomatic Medicine and Psychotherapy, Rhein‐Klinik, Bad Honnef, Germany; 7Clinic for Psychosomatic Medicine and Psychotherapy, University of Marburg, Marburg, Germany

This study was carried out as part of an ODA Project (Official Development Assistance, Project 2010.1572.6, Program for Trauma Treatment in Thailand, Burma, Cambodia and Indonesia, Mekong Projekt) and was financially supported by the German Federal Ministry for Economic Cooperation and Development and the German branch of EMDR‐Europe. The authors thank all involved patients for their participation in the study. The therapists responsible for treating the patients were O. Plaktin, S. Samchet, Y. Sotheary, P. Bunna, T. Nary, and E. Nil.