The Effectiveness of Therapeutic and Psychological Intervention Programs in PTC-GAZA

Abstract

The wars on Gaza (2008, 2012 & 2014) have left thousands of children and adults exposed to traumatic events (UNICEF, 2017). This study seeks to study and compare the usefulness of three different intervention programs, namely Therapeutic, Psycho-social support and Focusing. These interventions have been developed based on a holistic and integrated approach aimed at empowering resilience among Palestinian patients with Posttraumatic Stress Disorder (PTSD). PTSD was assessed through a validated scale developed by Altawil (2016). The aforementioned interventions were found to be successful: a) In the Family Therapy Programme (FTP), PTSD diagnosis reduced from 82% before intervention to 20% after intervention; b) In the Community Wellness Focusing Programme (CWF), PTSD diagnosis reduced from 97% before intervention to 19% after intervention; c) In the Psycho-Social Support Programme (SANID), PTSD diagnosis reduced from 50% before intervention to only 14% after intervention. Establishing the impact of interventions can be difficult without good tools for evaluation or assessment. Therefore, PTSD scales must consider culture, specific needs and the context of trauma exposure using both quantitative and qualitative assessment tools. Future tools should examine On-going Traumatic Stress Disorder (OTSD) so that it reflects on-going conflict and trauma in war-torn environments worldwide.

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Acknowledgements

Acknowledgment and great thanks go to Dr. Pieter Nel who was the principal supervisor on the original research at the University of Hertfordshire (UK) from October 2004 till September 2008. We extend our great thanks to my colleagues at PTC-Gaza, who have worked voluntarily and with complete dedication in order for the dream to be realized. Our big thanks is conveyed to my colleagues in PTC-UK, especially David Harrold, Jerry Conway, and Mary Jennings. Along with contacts in Ireland, Netherlands, Germany, USA and Egypt, PTC-UK was set up to support PTC-Gaza. Finally, our unforgettable thanks to Interpal, Muslim Aid, the International Focusing Institute (New York) and Irish Quakers in Ireland and Britain for their great support and their funds to PTC-Gaza and PTC-UK since 2007. Finally, thanks to Denis Hawes and Sheila Stapleton for their editing support.

Funding

This study was supported by a grant from Palestine Trauma Centre (UK), Interpal and Muslim Aid in London to Mohamed Altawil, Principal Investigator.

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Authors

Corresponding author

Correspondence to Mohamad A. S. Altawil.

Ethics declarations

Disclosure of Interest

The study was commissioned and conducted by PTC. The project was supervised by Dr. Altawil with no financial benefits. Both Dr. El Asam and Ms. Khadaroo have co-authored this article on a voluntary basis, both of whom have received no financial benefits for their contribution.

Ethical Approval

This research was conducted in accordance with the ethical standards of the responsible committee on human experimentation [institutional and national] and with the Helsinki Declaration of 1975, as revised in 2000.

Informed Consent

Informed consent was obtained from all the participants prior to data collection. All participants were assured of confidentiality, anonymity and had the right to withdraw from the study at any given point.

Appendix

Appendix

PTSD Scale-Review (II)

[PTSD-SRII]

For Older Children and Adults in conflict/war zones

(Ages 10 and above)

(Altawil 2008, 2016 & DSM-V 2013)

This evaluation was developed as a solid and exact scale for the post traumatic syndrome disorder symptoms in the Palestinian environment, and this scale was approved in Dr. Mohammed Altawil’s PhD study at the Psychological Therapy Division of the University of Hertfordshire, United Kingdom in 2008, and published in a scientific research journal (Altawil 2008, 2016). This is a PTSD scale from zero to ten: zero means lack of any sort of problem or suffering whether psychological, cognitive, physical or functional. The more the number increases towards 10 the worse the disorder level (psychological symptom).

‘PTSD-SRII’ to be administered by clinicians and clinical researchers who have a working knowledge of PTSD but can also be administered by appropriately trained paraprofessionals.

It was also published in the Diagnostic and Statistical Manual of Mental Disorders; 5th edition (DSM-V 2013), and was revised in both languages (English and Arabic) in the previous edition, according to the instruction enlisted in the fifth American Manual. Nineteen paragraphs were deleted from the previous edition of Altawil 2008, and thirty-three items from fifty-two validated phrases were approved in the Manual of Post-Traumatic Stress Disorders (DSM-V 2013). The PTSD diagnostic indicators were summarised according to the American Manual into thirty-three items with five categories of symptoms and disorders as follows.

List of the most effective chocking/traumatic events:

Please ask client to list the more severe shocking/traumatic events have they experienced in the war/conflict zone and occupied territory. Please start with the most severe shocking event that most affected them at the present time.

figurea

First (B): Obsessive-Compulsive Symptoms in remembering the traumatizing event or anything related to it:

Did you suffer from any of the following psychological symptoms within the last month? [At least one symptom must be present].

Absent Mild Moderate Severe Extreme
0 1 2 3 4 5 6 7 8 9 10
Statements Score
B1) Inability to forget the traumatizing event  
B2) Sleeping difficulties.  
B3) Suffering nightmares.  
B4) Fear of remembering the traumatizing event or anything related to it, for instance the sound of airplanes or ambulances.  
B5) Suffering from physical pain after the traumatising event, for instance headache, back pain, hand pain, stomach pain, or any other physical pain?  

Second (C): Avoidance Symptoms from anything related to the traumatising event:

Did you suffer from any of the following symptoms? [At least one symptom must be present].

Absent Mild Moderate Severe Extreme
0 1 2 3 4 5 6 7 8 9 10
Statements Score
C6) Avoiding talking about the trauma you went through.  
C7) Avoiding visiting the places or doing things that remind you of the traumatising event.  
C8) Avoiding touching or playing with anything out of fear of suspicious objects.  

Third (D): Negative changes in the psychological and cognitive status (mood). Did you suffer from any of the following symptoms within the last month?

[At least two symptoms must be present].

Absent Mild Moderate Severe Extreme
0 1 2 3 4 5 6 7 8 9 10
Statements Score
D9) Difficulty in remembering/forgetting (dispersion).  
D10) Loss of desire in living.  
D11) Not appreciating the value of anything in life.  
D12) Frustration and pessimism.  
D13) Pessimism and fear of the future.  
D14) Feeling guilty about the traumatising event.  
D15) Fear of the reoccurrence of the traumatising event, for instance renewal of war.  
D16) Difficulty enjoying things after the traumatising event.  
D17) Fear of staying alone.  
D18) Emotions and mood swings.  
D19) Feeling lack of security and safety.  

Fourth (E): Irritability symptoms, and disruption of psychosocial balance

Did you suffer from any of the following symptoms within the last month? [At least two symptoms must be present].

Absent Mild Moderate Severe Extreme
0 1 2 3 4 5 6 7 8 9 10
Statements Score
E20) Problems and inappropriate actions with family members.  
E21) Problems and inappropriate actions at school or work.  
E22) Desire to assault people or their properties after the traumatising event.  
E23) Feeling angry quickly.  
E24) Inability to properly focus on studying or doing any task at work .  
E25) Fear of any sudden sound or movement.  

Fifth (G): Personal or professional functional accomplishment

Did you suffer from deficiency in the following functional aspects within the last month? [At least one symptom must be available].

Absent Mild Moderate Severe Extreme
0 1 2 3 4 5 6 7 8 9 10
Statements Score
G26) Difficulty in continuously doing things.  
G27) Difficulty in completing duties on the personal level.  
G28) Difficulty in completing duties on the professional level (student/employee).  
G29) Relationship problems with family members.  
G30) Relationship problems with friends, relatives, or community members.  
G31) Lack of trust in people.  
G32) Weak participation in social events.  
G33) Distraction, lack of focus in study or job etc.  

Important remarks in the diagnosis/psychological assessment

Based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the psychologist can diagnose the client with post-traumatic stress disorders only if at least six/seven symptoms from the five categories are present, provided that the suffering from the symptoms have reached the level of 4 or more according to the scale described earlier:

Absent Mild Moderate Severe Extreme
0 1 2 3 4 5 6 7 8 9 10

Severity Rating

0 Absent: The respondent denied the problem or the respondent’s report doesn’t fit the DSM-5 symptom criterion.
1,2,3 Mild: The respondent described a problem that is consistent with the symptom criterion but isn’t severe enough to be considered clinically significant. The problem doesn’t satisfy the DSM-5 symptom criterion and thus doesn’t count toward a PTSD diagnosis.
4,5,6 Moderate: The respondent described a clinically significant problem. The problem satisfies the DSM-5 symptom criterion and thus counts toward a PTSD diagnosis. The problem would be a target for intervention.
7,8 Severe: The respondent described a problem that is above edge. The problem is difficult to manage and at times overwhelming, and would be a prominent target for intervention.
9,10 Extreme: The respondent described a dramatic symptom, far above edge. The problem is persistent, unmanageable, and overwhelming, and would be a high-priority target for intervention.

Symptoms of Post-Traumatic Stress Disorders:

  • First Category (B): Obsessive symptoms in remembering the traumatizing event.

    [At least one symptom must be present with a suffering level of four or more].

  • Second Category (C): Avoidance symptoms from anything related to the traumatising event.

    [At least one symptom must be present with a suffering level of four or more].

  • Third Category (D): Negative changes in the psychological and cognitive status (Mood)

    [At least two symptoms must be present with a suffering level of four or more].

  • Forth Category (E): Irritability symptoms, and disruption of psychosocial balance

    [At least two symptoms must be present with a suffering level of four or more].

  • Fifth Category (G): Disruption in a personal or professional functional accomplishment event.

    [At least one symptom must be present with a suffering level of four or more].

Self-Scoring Assessment

For self-scoring, put the number of symptoms of each category in the box below if the score is 2 and above.

First Category (B) Score = > 2
At least one symptom must be present here.
Second Category (C) Score = > 2
At least one symptom must be present here.
Third Category (D) Score = > 2 At least two symptoms must be present here. Fourth Category (E) Score = > 2
At least two symptoms must be present here.
Fifth Category (G) Score = > 2
At least one symptom must be present here.
Assessment Result
  1. Note: Regarding the fifth category (G), it is not necessary for the symptom to be present in this category if the required symptoms in the first, second, third, and fourth categories are present. Therefore, the psychologist can diagnose the client/case as PTSD

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Altawil, M.A.S., El Asam, A. & Khadaroo, A. The Effectiveness of Therapeutic and Psychological Intervention Programs in PTC-GAZA. Journ Child Adol Trauma 11, 473–486 (2018). https://doi.org/10.1007/s40653-018-0213-0

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Keywords

  • PTSD
  • Trauma
  • Intervention
  • Resilience
  • Family therapy
  • Psycho-social support
  • Focusing
  • War