Download Psychopathology and Well-Being in Civilian Survivors of War

Clinical Psychology and Psychotherapy
Clin. Psychol. Psychother. 17, 79–86 (2010)
Published online 29 December 2009 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/cpp.673
Psychopathology and Well-Being in
Civilian Survivors of War Seeking
Treatment: A Follow-Up Study
Nexhmedin Morina,1* Feride Rushiti,2 Mimoza Salihu2
and Julian D. Ford3
1
University of Amsterdam, the Netherlands
Kosova Rehabilitation Centre for Torture Victims, Kosova
3
School of Medicine, University of Connecticut, USA
2
The goal of the current study was to examine types of exposure to
traumatic events and affective and anxiety disorders of 81 civilian war
survivors seeking treatment for war-related stress almost one decade
following the war in the area of former conflict. Furthermore, the study
investigated changes in symptoms of mental health and in well-being
amongst these individuals during a treatment period of 6 months.
The results indicated that civilian war survivors seeking treatment
reported multiple war-related traumatic events and high levels of psychiatric morbidity. Individuals assessed at follow-up (n = 67) reported
no change in post-traumatic stress symptoms or psychological wellbeing, but improvement in symptoms of depression, overall psychiatric distress and quality of life. The only significant difference between
participants classified as achieving clinically significant improvement
as compared with those who did not achieve such change was in less
symptom severity of depression, post-traumatic stress, general distress
and higher psychological well-being at the time of first assessment.
Neither the assessment of initial diagnoses nor war or post-war trauma
types emerged as significantly different amongst the two groups. Copyright © 2009 John Wiley & Sons, Ltd.
Key Practitioner Message:
• Civilian survivors of war seeking treatment report high levels of
psychiatric morbidity.
• Treatment for survivors of war may require adaptations to evidencebased treatments based on their culture and life circumstances in order
to recover from PTSD and experience general emotional relief.
Keywords: Civilian War Trauma, PTSD, Depression, Anxiety, Treatment, Well-Being
Millions of individuals and whole communities worldwide have suffered and/or continue
to suffer from prolonged war-related traumatic
stressors. According to recent estimates, 28 wars
* Correspondence to: Nexhmedin Morina, Department of
Clinical Psychology, University of Amsterdam, Roetersstraat
15, 1018 WB Amsterdam, the Netherlands.
E-mail: [email protected]
Copyright © 2009 John Wiley & Sons, Ltd.
and 14 armed conflicts were taking place around
the world in the year of 2005 (Schreiber, 2006). A
large number of studies have reported high levels
of psychopathological distress amongst civilian
survivors of war (see Johnson & Thompson, 2008),
including those in Kosovo where the current study
took place (Cardozo, Kaiser, Gotway, & Agani,
2003; Kashdan, Morina, & Priebe, 2009). Mental
health opportunities for those affected by war are
80
rather scarce given the fact that the overwhelming majority of those individuals live outside the
Western countries (Brundtland, 2000) where mental
health services had not been on the agenda anyway
or were destroyed during the war. Due to the accumulated knowledge about the long-term effects of
war-related events (e.g., Amir & Lev-Wiesel, 2003),
in the recent years there has been an increase in the
attempts to help post-war societies.
However, these projects seem to be very shortlived. For instance, there have been reports that
in the first year following the war in Kosovo,
such projects made up to 60% of the budgets of
health and social services and only 2 years later
this percentage was lower than 10% (Mental Disability Rights International, 2002). Yet, in particular
cases, such help from the wealthier countries might
facilitate the establishment of local mental health
projects. One such project with relevance to the
current study is the Kosova Rehabilitation Centre
for Torture Victims (KRCT). Established in 2000,
the KRCT has been the only professional rehabilitation centre in Kosovo dealing with torture
victims and traumatized persons suffering from
post-traumatic stress disorder (PTSD) and other
related disorders. The services of the KRCT cover
psychotherapy, psychiatric treatment, physical
treatment and socio-legal support.
There is need for research on the mental health
of civilian war survivors who seek treatment at
centres established for the treatment of this population, such as the KRCT. Therefore, the current
study examined the mental health of survivors of
war who seek treatment for mental health problems related to war. The study was carried out in
Kosovo that underwent a 10-year political repression and a subsequent full-scale war beginning in
1998 and ending by North Atlantic Treaty Organization air strikes in mid-1999.
The first aim of the study was to examine types
of exposure to traumatic events and the prevalence
rates of mental disorders amongst civilian war survivors seeking treatment. Our second objective was
to examine the changes in symptoms of depression, post-traumatic stress, and well-being of clients
seeking treatment over a period of 6 months.
METHOD
Sample and Procedure
The data for this study were collected in the KRCT
in 2007 and 2008 (i.e., 8 and 9 years after the war).
The interviews were conducted by the staff of
Copyright © 2009 John Wiley & Sons, Ltd.
N. Morina et al.
the KRCT and no inter-rater reliability was measured. Altogether, 120 clients registered to receive
cognitive behaviour therapy (CBT) treatment
were invited to participate, following a protocol
approved by the human rights and advocacy committee of the KRCT. Thirty of the contacted individuals refused to participate in the study, either
reporting not having time for the interview (N =
17) or not wanting to talk about the war again
(N = 13). Due to missing data nine participants
were excluded, resulting in a participation rate
of 68%. The non-participants did not differ from
participants in gender or age.
The average age of the participants (N = 81) was
44.2 (SD = 11.5), and ranged from 20 to 69 years.
The sample consisted of 69.1% women. The majority of the participants (82.7%) were married, 4.9%
were single and 9.9% were widowed. The unemployment rate was 75%. A majority (60.5%) of them
were from rural areas. All clients were seeking
treatment for what they regarded as consequences
of war-related experiences.
The psychotherapeutic treatment provided at the
KRCT is CBT. Prolonged exposure and cognitive
techniques are used to treat post-traumatic symptoms. The trauma-focused CBT incorporates psychoeducation, imaginal and in vivo exposure to reduce
avoidance of memories of the traumatic experiences
and associated distress, and reappraisal of traumarelated cognitions. With clients with depressive
symptoms or other relevant symptoms additional
CBT techniques are used (e.g., behavioural activation, reappraisal of depressive cognitions).
Psychotherapy sessions at the KRCT initially
were scheduled for regular appointments on a
weekly basis. However, regular scheduling failed
for a mixture of reasons. People in Kosovo were
not used to fixed multiple appointments and often
either did not attend or did not show up on time.
Furthermore, financial difficulties prevented some
clients from being able to pay for the travel costs or
required them to miss appointments due to having
to be at work. Thus, the psychotherapy actually
was delivered at irregular intervals. None of the
clients in the current study completed the whole
treatment package at follow-up. The irregularity
and incompleteness of attendance is likely to have
diminished the effectiveness of the CBT, including
interfering with the therapists’ ability to assist their
clients in meaningfully transitioning from the preparatory phase to the trauma-focused phase, and
finally to the closure phase of treatment for traumatic stress disorders (Ford, Courtois, Steele, Hart,
& Nijenhuis, 2005).
Clin. Psychol. Psychother. 17, 79–86 (2010)
DOI: 10.1002/cpp
Psychopathology and Well-Being in Civilian War Survivors
Measures
Traumatic events were measured using an adjusted
checklist for war-related events that is based on
the first part of the Harvard Trauma Questionnaire (Mollica et al., 1992). This checklist assesses
18 potentially war-related traumatic events and
has been used before in the Kosovar population
(Cardozo et al., 2003; Morina, 2007).
The MINI International Neuropsychiatric Interview
(MINI; Sheehan et al., 1997; Albanian version:
Morina, 2006) is a structured diagnostic interview
based on Diagnostic and Statistical Manual of
Mental Disorders-IV (DSM-IV) and International
Classification of Diseases-10 (ICD-10) criteria, which
require a fixed number of symptoms, a minimum
duration of symptoms and clear evidence of impairment in social or daily functioning. Major depressive episode (MDE) and anxiety disorders (panic
disorder, social phobia, agoraphobia, generalized
anxiety disorder, PTSD, obsessive–compulsive disorder) were assessed with the MINI in the current
study. The clinician-rated format of the MINI has
demonstrated good reliability and validity in comparison with the Structured Clinical Interview for
the DSM and Composite International Diagnostic
Interview (Sheehan et al., 1998).
The severity of depressive symptoms was assessed
with the Beck Depression Inventory (BDI; Beck, Steer,
& Brown, 1996), which is a 21-item self-report
inventory with each item scored from 0–3. Scores
0–13 have been shown to reflect minimal depression, 14–19 mild, 20–28 moderate and 29–63 severe
depression. Adequate correlations with several
clinical assessment ratings of depression have been
reported (Beck et al., 1996). The Albanian version of
the BDI (Morina, Rudari, Bleichhardt, & Prigerson,
2009) reached an internal consistency of 0.86.
PTSD was assessed with the Post-traumatic Stress
Diagnostic Scale (PDS; Foa, Cashman, Jaycox, &
Perry, 1997). The PDS assesses the 17 PTSD symptoms specified in the DSM-IV. The items are scored
on a 4-point Likert-type scale ranging from 0 (never)
to 3 (five times per week or more/nearly always).
In addition to the presence–absence of PTSD, the
PDS also measures the overall severity of PTSD
symptoms. The PDS has shown good psychometric
properties (Foa et al., 1997). In the current study,
the internal consistency of the Albanian version
of PDS (Morina, Böhme, Morina, & Asmundson,
submitted) was 0.94.
The Brief Symptom Inventory (BSI; Derogatis &
Melisaratos, 1993; Albanian version: Morina, 2007)
is a 53-item scale of psychological symptoms and
Copyright © 2009 John Wiley & Sons, Ltd.
81
psychopathology experienced during the prior
week. A general severity index is calculated by
summing all scores. All scales range from 0 (‘not at
all’) to 4 (‘extremely’). The internal consistency of
the Global Severity Index of the BSI in the current
sample was 0.93.
The brief version of the Psychological Well-Being
Scale (PWBS; Ryff & Keyes, 1995) was used to assess
six areas of psychological well-being: autonomy,
environmental mastery, purpose, positive relations
with others, positive self development and selfacceptance. The scale aims at capturing multiple
aspects of positive psychological functioning, not
just a simple assessment of happiness or life satisfaction. The dimensions of the PWBS have been
identified as important in mental health, clinical and
life-span developmental theories (Ryff & Singer,
1996). Responses are made on a 6-point scale (1–6),
with higher scores indicating greater well-being.
The brief version correlates acceptably (0.70–0.89)
with the 84-item full scale. In this study, only
the total score for overall well-being was used. The
internal consistency of the PWBS translated by the
first author for this study was 0.77.
The Manchester Short Assessment of Quality of Life
(MANSA, Priebe, Huxley, Knight, & Evans, 1999;
Albanian version: Morina, 2007) was used to assess
subjective quality of life. The MANSA contains 12
questions to assess global life satisfaction and facets
including: social relationships, family relationships,
work, leisure, sex life, financial situation, living
situation, personal safety, and physical and mental
health. The scales measuring subjective quality of life
range from 1 (‘couldn’t be worse’) to 7 (‘couldn’t be
better’). There are also four objective items measuring whether individuals have a ‘close friend’, seen a
friend over the past week, been arrested and been a
victim of a violent crime. The MANSA is able to differentiate clinical outpatients from healthy control
groups and shows strong positive correlations with
larger comprehensive measures of life satisfaction
and quality of life (e.g., d’Ardenne, Capuzzo, Fakhoury, Jankovic-Gavrilovic, & Priebe, 2005; Priebe et
al., 1999). For the current study, only the 12 items
measuring general and facet levels of quality of life
were used (α = 0.89).
RESULTS
Traumatic Events
All participants reported multiple war-related
potentially traumatic events. With the exception
of sexual abuse, all measured events were reported
Clin. Psychol. Psychother. 17, 79–86 (2010)
DOI: 10.1002/cpp
82
N. Morina et al.
Table 1. Self-reported war-related potentially traumatic
experiences
Table 2.
(n = 81)
Prevalence estimates of mental disorders
War-related potentially traumatic experiences
Modules
Initial examination
%
Combat situation
Lack of shelter
Forced evacuation under violent threat
Lack of food or water
Ill health without access to medical care
Forced separation from family members
Being close to death
Murder of stranger or strangers
Repetitive house search by armed forces
Murder of family or friends
Death of family or friends
Kidnapped
Serious injury
Torture
Physical abuse by combatant(s)
Imprisonment
Sexual abuse
%
98.0
96.3
95.9
91.5
90.2
81.8
80.0
77.8
76.7
76.7
65.7
65.7
59.4
58.3
57.5
50.0
41.0
by at least 50% of the participants (see Table 1).
Twenty-one participants (25.9%) also reported
post-war potential traumatic events. The post-war
potentially traumatic events reported by more the
one participant were death of family members
(n = 6), suicide of family members (n = 4), domestic violence (n = 3) and serious illness of family
members (n = 2).
Prevalence of Depression, Anxiety Disorders
and Somatization
Estimates of the prevalence of the affective and
anxiety disorders are presented in Table 2. Only
one participant did not meet criteria for any disorder. Nine participants (11.1%) met criteria for
one disorder, 13 (16.0%) for two disorders and the
remaining participants (71.6%) had three or more
disorders. The most frequently occurring combinations of two disorders were current MDE and
PTSD (58.0%), PTSD and Generalized Anxiety
Disorder (GAD) (48.1%) and current MDE and
GAD (45.7%). The over representation of current
MDE, PTSD and GAD was also expressed in
the finding that 42.0% of the participants met
the criteria for all three disorders. The relationship between MDE and PTSD was significant,
χ2 = 4.31, df = 1, p < 0.05. Of the participants with
MDE, 78.3% had co-morbid PTSD, whereas 52.9%
of those without MDE met criteria for PTSD. Alternatively, 83.9% of the participants with PTSD had
co-morbid MDE, whereas 61.9% of those without
PTSD had MDE. The association between GAD
Copyright © 2009 John Wiley & Sons, Ltd.
MDE current
MDE recurrent
Dysthymia
PTSD
Generalized anxiety disorder
Agoraphobia
Social phobia
Panic disorder current
Panic disorder lifetime
Obsessive–compulsive disorder
Somatization disorder
77.8
30.9
12.3
69.1
54.3
19.8
25.9
39.5
58.0
32.1
14.8
MDE = major depressive episode. PTSD = post-traumatic stress
disorder.
and PTSD was also significant, χ2 = 16.91, df = 1,
p < 0.001. Of the participants with GAD, 90.7% had
co-morbid PTSD, whereas 48.6% of those without
GAD met criteria for PTSD. Alternatively, 69.6% of
the participants with PTSD had co-morbid GAD,
whereas 18.2% of those without PTSD had GAD.
The relationship between MDE and GAD
yielded non-significant results, as did the associations between somatization disorder and the three
most prevalent disorders (current MDE, PTSD
and GAD) (i.e., all ps > 0.05). The co-morbidity
between somatization disorder and the three most
prevalent disorders was as follows: somatization
disorder and MDE = 6.2%, somatization disorder
and PTSD = 12.3% and somatization disorder and
GAD = 1.1%.
CHANGE OVER TIME WHILE
RECEIVING TREATMENT
Sixty-seven patients out of the original sample of
81 were re-interviewed after the 6 months followup period. The 14 patients did not participate for
the following reasons: immigration (n = 5), addresses were not correct (n = 4), married and moved
away (n = 3) and rejected re-interviewing without
further explanation (n = 2). Thus, altogether, 67
participated in the follow-up assessment after 6
months (80%, i.e., 67/84). Furthermore, due to
missing values the data of three participants were
excluded from the analysis, resulting in a final of 64
participants. The 17 clients who did not participate
in the follow-up did not differ significantly from
the individuals who participated in the follow-up
with respect to age, gender or mental health at
baseline.
Clin. Psychol. Psychother. 17, 79–86 (2010)
DOI: 10.1002/cpp
Psychopathology and Well-Being in Civilian War Survivors
83
Table 3. Levels of depression, post-traumatic stress reactions, quality of life
and well-being
Outcome
Initial examination
M (SD)
Follow-up
M (SD)
Statistics
t
p
BDI
PDS
BSI
MANSA
PWBS
28.25 (9.76)
24.32 (12.34)
33.51 (15.96)
40.51 (11.67)
64.42 (10.85)
22.72 (16.29)
24.38 (12.94)
29.13 (15.96)
49.10 (13.18)
66.47 (10.45)
2.38
0.07
2.15
−5.49
−1.09
0.021
0.943
0.036
0.000
0.281
BDI = Beck Depression Inventory. BSI = Brief Symptom Inventory. MANSA = Manchester Short Assessment of Quality of Life. PDS = Posttraumatic Stress Diagnostic Scale.
PWBS = Psychological Well Being Scale. SD = standard deviation.
The 67 clients who participated in the follow-up
had an average of seven sessions of psychotherapy. However, the range of the number of sessions ranged from 1 to 36 as the therapeutic work at
the KRCT is not based on regular intervals.
Table 3 summarizes differences in symptoms
of depression and post-traumatic stress as well
as in quality of life and psychological well-being
between the first and the second assessment. At
follow-up, the clients had markedly lower symptoms of depression as measured with the BDI as
well as symptoms of psychiatric distress as measured with the BSI. However, there was no change
in symptoms of post-traumatic stress as measured with the PDS. With regard to well-being, the
follow-up results of quality of life as measured with
the MANSA showed significant improvement over
time. Yet, there was no change in psychological
well-being as measured with the PWBS.
Twenty-four (i.e., 35.8%) participants were classified as having achieved clinically significant
change based upon improvement on the BDI or BSI
to within one standard deviation of non-clinical
Mean scores and positive change on the MANSA.
Participants who achieved clinically significant
improvement did not significantly differ in their
initial report of having experienced different types
of war-time potentially traumatic events or in the
number of types of war-time potentially traumatic events reported. There was also no significant
difference with respect to reporting post-war
potentially traumatic events. The two groups of
participants also did not differ with regard to
the presence of any diagnosis measured in this
study or the number of the co-morbid diagnoses.
Finally, the two groups also did not differ in age
or gender.
There was, however, a significant difference
between the two groups on the initial severity of
symptoms of depression as measured with the
Copyright © 2009 John Wiley & Sons, Ltd.
BDI, post-traumatic symptoms as measured with
the PDS, symptoms of general distress as measured with the BSI and psychological well-being as
measured with the PWBS (see Table 4). Participants
classified as achieving clinically significant improvement had reported significantly less severe symptoms of depression, post-traumatic stress, and
general distress, and higher levels of psychological
well-being at the time of first assessment. A comparison of the absolute amount of change on the
symptom, quality of life and personal well-being
measures showed that participants who achieved
clinically significant change did differ from those
who did not achieve clinically significant change
on symptoms of depression as measured with the
BDI, post-traumatic symptoms as measured with
the PDS, symptoms of general distress as measured with the BSI and quality of life as measure with
the MANSA. However, there was no significant
difference between the two groups with regard to
the psychological well-being as measured with the
PWBS.
DISCUSSION
The present study investigated the mental health
and well-being amongst treatment-seeking survivors of war. Participants reported extremely high
prevalence rates for the various types of potentially
traumatic war events, including almost universal
endorsement of exposure to combat, and more
than 90% reporting forced evacuation and deprivations of shelter, food and health care that placed
them at risk for serious physical complications.
Potentially traumatic loss—due to the murder of or
separation from family, and witnessing or being at
imminent risk of death or intentional harm—were
reported by more than three quarters of respondents. Between half and two-thirds of respondents
Clin. Psychol. Psychother. 17, 79–86 (2010)
DOI: 10.1002/cpp
84
Table 4.
N. Morina et al.
Levels of depression, post-traumatic stress reactions, quality of life and well-being
Participants labelled as
non-significantly improved
(n = 43)
Statistics
t
p
25.47 (9.66)
21.75 (10.97)
25.14 (14.74)
40.71 (10.98)
65.47 (11.32)
32.42 (8.52)
29.00 (13.55)
37.33 (15.59)
40.13 (13.11)
62.30 (9.76)
−2.86
−2.29
−2.83
0.19
1.07
0.006
0.026
0.007
0.849
0.289
Time 2–Time 1 change scores
BDI
−18.26 (9.26)
PDS
−6.00 (17.23)
BSI
−8.59 (18.54)
MANSA
15.71 (12.61)
PWBS
4.85 (10.45)
3.74 (16.00)
3.61 (15.71)
12.50 (16.01)
6.92 (13.97)
0.41 (15.17)
5.89
2.15
4.25
−2.39
1.16
<0.001
0.036
<0.001
0.020
0.251
Participants classified as
significantly improved
(n = 24)*
Time 1 scores
BDI
PDS
BSI
MANSA
PWBS
* Classified as having achieved clinically significant change based upon improvement on the BDI or BSI to within one standard
deviation of non-clinical Mean scores and positive change on the MANSA.
BDI = Beck Depression Inventory. BSI = Brief Symptom Inventory. MANSA = Manchester Short Assessment of Quality of Life.
PDS = Posttraumatic Stress Diagnostic Scale. PWBS = Psychological Well Being Scale.
reported torture, imprisonment, physical abuse by
combatants or other physical injury. Thus, consistent with other studies’ findings concerning civilians exposed to war (Johnson & Thompson, 2008)
and particularly those who seek mental health
treatment (Michultka, Blanchard, & Kalous, 1998;
Miller et al., 2002), the sample was almost entirely comprised of persons who had been displaced
from their homes due to threat of death or violence,
and their tendency to report experiencing multiple
forms of other war-related potentially traumatic
experiences.
Almost a decade after the war, these adults who
were seeking treatment due to their war-related
experiences still suffered from substantial psychological distress. This finding is consistent with
prior reports of psychiatric morbidity (Johnson &
Thompson, 2008; Roberts, Damundu, Lomoro, &
Sondorp, 2009) and quality of life (Besser & Neria,
2009) amongst civilians exposed to other wars. As
expected, the estimated prevalence rates of depression, anxiety disorders and somatization observed
in the present study were higher than those found
in studies of the Kosovar population with non-clinical samples. For instance, Cardozo et al. (2003)
and Morina and Ford (2008) found a prevalence
rate of PTSD of 25%. Also, Morina and Ford (2008)
found a prevalence rate of depression of 31% in
the general population. The specific association of
war events with PTSD symptoms and post-war
‘exile-related’ stressors with depression symptoms
reported by Miller and colleagues (2002) was not
found in the present study.
Copyright © 2009 John Wiley & Sons, Ltd.
Those clients who were assessed at follow-up
reported no change in post-traumatic stress symptoms. Yet, there was significant improvement in
symptoms of depression and symptoms of general
distress. Additionally, the clients also reported
significant increase of their quality of life. The
latter finding, however, could not be replicated
with respect to psychological well-being where no
statistically significant improvement overall was
reported. Altogether, the results indicate that CBT
treatment offered to the participants of the current
study had some positive impact on generalized
emotional distress and overall quality of life but
limited effect on post-traumatic stress symptoms
and sense of overall well-being. Findings regarding clinically significant change further suggest
that treatment enabled clients to achieve symptom
levels within the normal range if their symptoms
were less severe initially. Further analyses demonstrated that the clinically significant group had
significantly higher levels of absolute symptom
reduction than the other clients. This suggests that
CBT as delivered to these clients was not sufficient
to meet the needs of more severely distressed war
survivors, and that adapted approaches to CBT
(Cook, Schnurr, & Foa, 2004) or alternate approaches
to therapy (Miller, 1999) may be needed for war
survivors with more severe long-term symptoms.
On the other hand, the subgroup that achieved
clinically significant change did not differ from
the remaining participants on their initial levels of
quality of life. This finding demonstrates that CBT
treatment was associated with marked improveClin. Psychol. Psychother. 17, 79–86 (2010)
DOI: 10.1002/cpp
Psychopathology and Well-Being in Civilian War Survivors
ment (a more than 20% increase) in quality of life
for a subset of civilian war survivors. The fact that
this subgroup had less severe initial symptoms
suggests that CBT is best able to enhance quality
of life for persons who are less severely distressed
than those who are more severely distressed.
Therefore, quality of life should be considered separately as a goal and outcome for civilian war survivors (Besser & Neria, 2009). For those with more
severe symptoms, either more intensive therapy to
resolve PTSD or alternate (e.g., community based;
Miller, 1999) interventions designed to specifically
enhance social support or personal efficacy may be
necessary in order to improve quality of life.
The current study, however, cannot determine
why the clients reported reduced symptoms of
depression at follow-up despite no such improvement related to symptoms of PTSD. With regard to
depression one might assume that the realization
of their own ability to work on symptoms of distress as well as the opportunity to share suffering
with the therapist might have led to the improvement of depressive symptoms and in perceived
quality of life. Recovery from war trauma has
been hypothesized to require not only resolution
of post-traumatic stress, but also a reduction in the
war-related loss or change of meaningful structure
and activity in daily life and social roles (Miller,
1999). Research is needed to determine whether
these interpersonal factors, which are known to
be fundamental contributors to depression and
recovery from depression, may mediate or serve as
mechanisms of change in CBT with war survivors.
Also, the hypothesized additional benefit of community based interventions designed explicitly to
restore a sense of personal efficacy and communal
involvement warrants evaluation (Miller, 1999).
In line with this argument, it is possible that the
symptoms of PTSD might require more consistent
focused psychotherapeutic involvement than was
achieved by most of the present study’s participants.
Both the cognitive/emotional processing and the
trauma narrative or therapeutic exposure aspects of
CBT for PTSD require consistent sustained therapy,
particularly with severely traumatized and chronically affected persons (Cook et al., 2004; Resick,
Nishith, & Griffin, 2003). The relatively infrequent
treatment attendance (i.e., on average, just over
once monthly) reported by participants, with a few
exceptions, would not be likely to be a sufficient
‘dose’ to enable them to resolve PTSD symptoms.
Chronic PTSD tends to be relatively stable and
unremitting unless an adequate dose of an evidence-based approach to treatment such as CBT is
Copyright © 2009 John Wiley & Sons, Ltd.
85
received (Resick et al., 2003). Given the common
reluctance to engage in clinic-based therapy by displaced persons, another important clinical research
question is whether potentially more acceptable
community based interventions could provide sufficient ongoing social support and experiences of
self-efficacy to counteract PTSD symptoms. This
is particularly important in settings such as the
present study in Kosovar society, in which there is
a lack of adherence to fixed appointments due to
cultural and financial reasons. It also is important
to determine if clinic-based treatment can be effective for PTSD and personal well-being if adherence
to fixed appointments is required but resources
are provided to enhance attendance (e.g., providing transportation, offsetting the cost of travel and
lost work, having therapists come to local sites to
deliver treatment and adapting treatment to cultural norms to reduce potential stigma).
The current study has several limitations. There
was no measurement of inter-rater reliability with
respect to the MINI. Furthermore, without pre-war
assessment of psychiatric disorders, one cannot
evaluate whether some of the clients had psychiatric disorders prior to the war. Nevertheless, study
findings suggest that civilian war survivors with
extensive histories of multiple exposure to warrelated and post-war traumatic stressors may still
be in need of—and in many cases, able to benefit
from—therapeutic treatment to address psychological symptoms and enhance their quality of life
a decade or more after the conclusion of war. Survivors of war seeking treatment many years after
the war may however require adaptations to evidence-based treatments based on their culture and
life circumstances in order to both recover from
PTSD and experience general emotional relief.
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