Treatment of Trauma and Violence in the Townships of South Africa
Condition: Post-traumatic Stress Disorder (PTSD); Aggressive Behavior
MeSH terms: Stress Disorders, Traumatic; Stress Disorders, Post-Traumatic; Aggression
Study type: Interventional

Summary: 
      Escalating violence is omnipresent in South African townships and can be traced back to two
      core mechanisms: a trauma-related hyper-arousal and a positive rewarding perception of
      violence. In the past, there was no therapeutic intervention available addressing both,
      trauma and the so-called appetitive aggression. The University of Konstanz has developed a
      culturally sensitive and scientifically based short-term intervention for the treatment of
      traumatized patients, the Narrative Exposure Therapy (NET), that has proven its effectiveness
      in various randomized clinical studies in different war-affected populations. Recently, the
      NET has been adapted for the forensic offender rehabilitation (FORNET) by also addressing the
      perpetration of violence related to a self-rewarding perception of the exposure with
      violence. It has shown to be effective in reducing the number of committed offenses in a
      perpetrator sample in Burundi and to reduce PTSD symptoms in a perpetrator sample in the
      Democratic Republic of the Congo. In this study, we investigated the therapeutic efficiency
      of FORNET in a randomized clinical control trial with a sample of former offenders of the
      townships of Cape Town. In addition to the previous studies, we specifically addressed the
      context of ongoing stress and linked our findings to epigenetic markers of stress and
      violence. Participants were followed over a period of up to 25-months post-treatment. The
      FORNET was also disseminated to local staff of our collaboration partners from the South
      African Universities and an organization working in the townships to warrant sustainability
      of the therapeutic intervention.
    

Detailed description: 
      A group of 290 former young male offenders and young males at risk for perpetrating or
      becoming victims of crime (age 10-40) from Cape Town, recruited via a community based
      skill-training program has been interviewed in a first step. Participants with neurological
      or psychiatric disorders other than those resulting from exposure to traumatic stress, like
      chronic psychosis, were excluded from participation in the study but received referrals in
      the professional health care system, if necessary.

      We applied standardised clinical questionnaires in a semi-structured interview for the
      assessment of exposure to traumatic stress (Children Exposed to Community Violence (CEVC)),
      trauma symptomatology (PSS-I for diagnosis of post-traumatic stress disorder), aggression
      (Appetitive Aggression Scale (AAS); Buss & Perry Aggression Questionnaire), offense types
      checklist (from the AAS) and related drug abuse, psychosocial functioning (Work and Social
      Adjustment Scale, WSAS) and suicidality (M.I.N.I. 6.0.0., shortened version). Additionally,
      we used a questionnaire about social acknowledgement (Social Acknowledgement Questionnaire)
      and substance dependence (M.I.N.I. version 6.0.0).

      We set up a randomised clinical intervention trial for the treatment of former offenders that
      covers violence perpetration on the one hand and traumatization on the other. 90 participants
      were chosen by the highest aggression scale scores and a certain threshold of trauma
      symptoms. 17 participants received FORNET, while 14 matched participants received CBT and
      another 7 matched participants treatment as usual (Waiting List camp) in a camp. Matching
      took place according to the severity of trauma symptomatology, aggressive behavior and
      suicidality. 36 participants didn't receive intervention and weren't part of the camp
      (Waiting List no camp) but were included in the follow-ups. In order to compare the treatment
      effect with the two control groups and follow the long-term effects, post-treatment
      assessments with the initial survey were performed about 8, 18 and 25 months post-treatment.

      After the follow-ups, 17 FORNET participants and 11 CBT participants were included in the
      analysis. Two CBT clients had been excluded since they had not come to the follow-ups, one
      CBT client died a relatively sudden death due to a severe disease. The camp waiting list had
      been reduced to only six persons since one participant of the waiting list has been stabbed
      to death in a gang fight. Therefore a combined waiting list has been emerged from the two
      waiting lists ("camp" and "no camp"). 13 men from the "no camp"-waiting list were excluded
      since they have not been to the follow ups. From the residual 21 clients from this waiting
      list, 11 have been matched (together with the six participants from the "camp"-waiting list)
      with the participants from the FORNET and CBT group in terms of post traumatic stress symptom
      severity, level of appetitive aggression and suicidality. In the end 17 FORNET-, 11CBT- and
      17 waiting list-attendees have been included into the analysis, hence a total sample size of
      45 participants.

      The 2 subjects of the control group, that still fulfilled the criteria for the therapy study
      and were interested in it, received FORNET by trained ZA staff for ethical reasons and to
      examine whether it is possible to effectively disseminate FORNET.

      In addition to the subjective data, we will corroborate the results with the assessment of
      epigenetic consequences of appetitive aggression and trauma and investigate its significance
      and persistence in the long-term course of the study. We propose that specific DNA
      methylation patterns are important markers of environmentally driven mental health
      pathologies, such as chronic aggression/violence and traumatic stress in such a sample of
      perpetrators or young males at risk for perpetration. Further, we will test the stability of
      DNA methylation and its potential modification over a period of up to 25 months by
      behavioural intervention (FORNET).

      Saliva samples (2ml) were collected through a non-invasive method using Oragene-Discover
      (OGR- 500) Collection Kit (DNA genotek, Ontario, Canada). We will collect two DNA saliva
      samples and one RNA saliva sample. Methylation patterns will be assessed at the University of
      Stellenbosch (Prof. Soraya Seedat), focussing on markers of trauma and violence.
    

Intervention name(s): FORNET; CBT; Waiting List Control Group (camp); Waiting List Control Group (no camp)
Intervention type(s): Behavioral; Behavioral; Other; Other
Intervention description(s): 8 individual sessions:
1 lifeline
6 exposure sessions
1 outlook; 7 individual sessions, according to the "Integrated cognitive behavior change program" manual, Bush et al., 1997, National Institute of Corrections, US Dept. of Justice.; Participants, if still meeting the criteria and interested, will receive FORNET by local counsellors after the 8-months follow up.; Participants, if still meeting the criteria and interested, will receive FORNET by local counsellors after the 8-months follow up.
Intervention MeSH terms: 8-chloro-cyclic adenosine monophosphate
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment