La thérapie comportementale et cognitive auprès des populations réfugiées victimes de torture et de guerre : revue de la littérature

The prevalence of post-traumatic stress disorder (PTSD) among refugees subjected to war and torture is highest in psychotraumatology (Steel et al., 2009 [10]). International guidelines recommend Trauma Focused-Cognitive Behavioral Therapy (TF-CBT) as the first line treatment for this pathology (Bisson et al., 2007 [12]; Bisson and Andrew, 2005 [13], 2009 [14]; Foa et al., 2005 [15]; National Institute for Clinical Excellence, 2005 [16]). The objective of this article is to explore international literature to identify applications and adaptations of TF-CBT for this specific population. To date, three literature reviews have analyzed research assessing psychotherapy with traumatized refugees (Crumlish and O'Rourke, 2010 [21]; McFarlane and Kaplan, 2012 [22]; Nicholl and Thompson, 2004 [20]). Focusing only on randomized controlled trials assessing TF-CBT protocols, one study was found that compared it to exposure therapy and two adaptations: Somatic Focused-Cognitive Behavioral Therapy and Narrative Exposure Therapy. Another emerging adaptation was found independently: Interapy (Internet-Based Cognitive and Behavioral Therapy). Paunovic and Ost (2001) [23] compared TF-CBT to exposure therapy in a sample of 16 traumatized refugees from Bosnia. Despite a significant decrease in PTSD and major depressive episode (MDE) for both protocols, no difference was found in terms of efficacy. Given the small sample sizes, a replication on a larger cohort is necessary to confirm these preliminary results. Somatic Focused-Cognitive Behavioral Therapy (SF-CBT) was developed for Cambodian refugees arriving in the United States after the Kmer-Rouge genocide (Hinton et al., 2006 [26]; Otto et al., 2003 [28]; Otto and Hinton, 2006 [27]). The authors adapted TF-CBT to a 10-step protocol focusing primarily on meditation. In the three validation studies (Hinton et al., 2004 [24], 2005 [25]; Hinton et al., 2009 [29]), comparing SF-CBT (n = 38) to wait-list control groups (n = 38), a greater reduction was found for PTSD and MDE in the active treatment groups. Nevertheless, more studies should be done on larger samples, with other refugee populations and against other active treatments to generalize the conclusion of therapeutic efficiency. Narrative Exposure Therapy (NET) was developed as a short-term standardized TF-CBT treatment easily implemented in refugee camps (Schauer et al., 2005 [33]). NET combines CBT exposure principles to the methodology of testimony therapy. Patients are invited to chronologically narrate their life story while the therapist transcribes it. Each time a traumatic event is described, a prolonged imagery exposure technique is used and repeated until the habituation of the triggered emotional response is achieved. Six studies assessed therapeutic efficacy of this approach (Bichescu et al., 2007 [34]; Halvorsen and Stenmark, 2010 [35]; Hensel-Dittmann et al., 2011 [37]; Neuner et al., 2008 [30], 2009 [31]; Neuner et al., 2004 [32]). NET was compared to supportive counseling, psychoeducation, trauma counseling, no-treatment, treatment as usual, and stress inoculation training and each comparison showed a significant and greater decrease on PTSD measures than the control group. Although it did not appear in any literature review, Interapy, or Internet Based Cognitive and Behavioral Therapy, was identified as an emerging and interesting approach to help traumatized war and torture survivors living in areas where no mental health resources exist (Knaevelsrud et al., 2007 [38]). Interapy is an Internet adaptation of TF-CBT in which the therapist and patient communicate exclusively through email. The patient receives therapist guidelines by emails that consist of different written exposure assignments. Only one preliminary study (Wagner et al., 2012 [44]) assessed the evolution of PTSD, MDE, anxiety and quality of life before and after the five-week Interapy treatment in a sample of 40 Iraqi traumatized individuals. Despite the high number of dropouts and the lack of a control group, this study showed encouraging results on all variables. In conclusion, despite the small number of randomized controlled trials and the methodological bias existing in those that exist (small sample size, lack of double-blind assessment, focus on specific communities, etc.), TF-CBT, SF-CBT, NET and Interapy have shown positive and encouraging results in treating PTSD in the refugee torture victim population. More research is, however, needed to confirm these results and determine optimal efficacy.