Unravelling the spirits' message: a study of help-seeking steps and explanatory models among patients suffering from spirit possession in Uganda.

As in many cultures, also in Uganda spirit possession is a common idiom of distress associated with traumatic experiences. In the DSM-IV and -5, possession trance disorders can be classified as dissociative disorders. Dissociation in Western countries is associated with complicated, time-consuming and costly therapies. Patients with spirit possession in SW Uganda, however, often report partial or full recovery after treatment by traditional healers. The aim of this study is to explore how the development of symptoms concomitant help-seeking steps, and explanatory models (EM) eventually contributed to healing of patients with spirit possession in SW Uganda. Illness narratives of 119 patients with spirit possession referred by traditional healers were analysed using a mixed-method approach. Treatments of two-thirds of the patients were unsuccessful when first seeking help in the medical sector. Their initially physical symptoms subsequently developed into dissociative possession symptoms. After an average of two help-seeking steps, patients reached a healing place where 99% of them found satisfactory EM and effective healing. During healing sessions, possessing agents were summoned to identify themselves and underlying problems were addressed. Often-mentioned explanations were the following: neglect of rituals and of responsibilities towards relatives and inheritance, the call to become a healer, witchcraft, grief, and land conflicts. The results demonstrate that traditional healing processes of spirit possession can play a role in restoring connections with the supra-, inter-, intra-, and extra-human worlds. It does not always seem necessary to address individual traumatic experiences per se, which is in line with other research in this field. The study leads to additional perspectives on treatment of trauma-related dissociation in Western countries and on developing effective mental health services in low -and middle-income countries.

From despair to hope: a longitudinal study of illness perceptions and coping in a psycho-educational group intervention for women with breast cancer.

OBJECTIVES: This study examined the cross-sectional and longitudinal relationships of illness perceptions, coping, and distress in women with breast cancer. Illness perceptions and coping at baseline and changes in these variables over time served as possible predictors of distress at two follow-up points. DESIGN AND METHODS: Fifty-seven women with breast cancer who participated in a psychosocial aftercare programme completed a questionnaire before the start of the intervention, directly after the end of the intervention, and 1 year after the start of the intervention. Study variables were assessed with the Illness Perception Questionnaire-Revised (illness perceptions), the COPE (coping), and the Hopkins Symptom Check List (distress). RESULTS: Results showed that 43% of variance in distress at baseline was explained by participants' illness perceptions. Cyclical timeline perceptions were the strongest predictor of distress at baseline. Longitudinal data revealed that after the end of the intervention, the intensity of general distress and breast cancer-related emotions had decreased significantly. Partial correlations showed that baseline illness perceptions were unrelated to distress at follow-up. However, changes in illness perceptions (perceptions about the cyclical and chronic timeline and symptoms associated with breast cancer) showed significant associations with distress at both follow-up assessments. Associations of follow-up distress with coping styles were less consistent. CONCLUSIONS: Our results suggest that changes in illness perceptions are related to an improvement or worsening of patients' emotional well-being over time. These findings hold promise for the development of interventions that specifically target patients' representations of their illness.

Are symptoms of spirit possessed patients covered by the DSM-IV or DSM-5 criteria for possession trance disorder? A mixed-method explorative study in Uganda.

INTRODUCTION AND AIMS: As in many cultures, spirit possession is a common idiom of distress in Uganda. The DSM-IV contains experimental research criteria for dissociative and possession trance disorder (DTD and PTD), which are under review for the DSM-5. In the current proposed categories of the DSM-5, PTD is subsumed under dissociative identity disorder (DID) and DTD under dissociative disorders not elsewhere classified. Evaluation of these criteria is currently urgently required. This study explores the match between local symptoms of spirit possession in Uganda and experimental research criteria for PTD in the DSM-IV and proposed criteria for DID in the DSM-5. METHODS: A mixed-method approach was used combining qualitative and quantitative research methods. Local symptoms were explored of 119 spirit possessed patients, using illness narratives and a cultural dissociative symptoms' checklist. Possible meaningful clusters of symptoms were inventoried through multiple correspondence analysis. Finally, local symptoms were compared with experimental criteria for PTD in the DSM-IV and proposed criteria for DID in the DSM-5. RESULTS AND CONCLUSION: Illness narratives revealed different phases of spirit possession, with passive-influence experiences preceding the actual possession states. Multiple correspondence analysis of symptoms revealed two dimensions: 'passive' and 'active' symptoms. Local symptoms, such as changes in consciousness, shaking movements, and talking in a voice attributed to spirits, match with DSM-IV-PTD and DSM-5-DID criteria. Passive-influence experiences, such as feeling influenced or held by powers from outside, strange dreams, and hearing voices, deserve to be more explicitly described in the proposed criteria for DID in the DSM-5. The suggested incorporation of PTD in DID in the DSM-5 and the envisioned separation of DTD and PTD in two distinctive categories have disputable aspects.

Dealing with man-made trauma: the relationship between coping style, posttraumatic stress, and quality of life in resettled, traumatized refugees in the Netherlands.

This study investigated the relationship between coping style, posttraumatic stress disorder (PTSD) symptoms, and quality of life in traumatized refugees (N = 335). Participants had resettled in the Netherlands on average 13 years prior and were referred to a Dutch clinic for the treatment of posttraumatic psychopathology resulting from persecution, war, and violence. The majority (85%) of the research sample met diagnostic criteria for PTSD. Path analysis suggested a model in which PTSD symptoms (ß = -.61, p < .001), social support seeking (ß = .12, p < .05), and emotion-focused coping (ß = .13, p < .01) have a direct effect on quality of life. The role of avoidant and problem-focused coping could be interpreted in 2 ways. Either these coping styles are influenced by PTSD severity and have no effect on quality of life, or these coping styles influence PTSD severity and therefore have an indirect effect on quality of life. Intervention strategies aimed at modifying coping strategies and decreasing PTSD symptoms could be important in improving the quality of life of traumatized refugees.

Illness perceptions and quality of life in Japanese and Dutch patients with non-small-cell lung cancer.

This study examined quality of life (QOL) and illness perceptions in Dutch and Japanese patients with non-small-cell lung cancer, thereby extending the body of knowledge on cultural differences and psychosocial aspects of this illness. 24 Dutch and 22 Japanese patients with non-small-cell lung cancer filled out questionnaires on three occasions: immediately before chemotherapy, 1 week later, and 8 weeks after the initial chemotherapy. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) assessed QOL, and the Brief Illness Perception Questionnaire (B-IPQ) illness perceptions. Scores on several QOL measures indicated (a) major impact of first chemotherapy sessions, and (b) some tendency to returning to baseline measures at 8 weeks. Differences between Japanese and Dutch samples were found on five EORTC QLQ-C30 dimensions: global health status, emotional functioning, social functioning, constipation, and financial difficulties, with the Dutch patients reporting more favorable scores. Regarding illness perceptions, Japanese patients had higher means on perceived treatment control and personal control, expressing a higher sense of belief in the success of medical treatment than Dutch patients. In both Japanese and Dutch patients, impact of chemotherapy on QOL was evident. Some differences in illness perceptions and QOL between the two samples were observed, with implications for integral medical management. Both samples reported illness perceptions that reflect the major consequences of non-small-cell lung cancer. Incorporating symptom reports, illness perceptions, and QOL into medical management may have positive consequences for patients with non-small-cell lung cancer.

EMDR versus stabilisation in traumatised asylum seekers and refugees: results of a pilot study.

BACKGROUND: Traumatised asylum seekers and refugees are clinically considered a complex population. Discussion exists on whether with this population treatment guidelines for post-traumatic stress disorder (PTSD) should be followed and Trauma-Focused Cognitive-Behavioural Therapy (TF-CBT) or Eye Movement Desensitisation and Reprocessing (EMDR) should be applied, or whether a phased model starting with stabilisation is preferable. Some clinicians fear that trauma-focused interventions may lead to unmanageable distress or may be ineffective. While cognitive-behavioural interventions have been found to be effective with traumatised refugees, no studies concerning the efficacy of EMDR with this population have been conducted as yet. OBJECTIVE: In preparation for a randomised trial comparing EMDR and stabilisation with traumatised refugees, a pilot study with 20 participants was conducted. The objective was to examine feasibility of participation in a randomised trial for this complex population and to examine acceptability and preliminary efficacy of EMDR. DESIGN: Participants were randomly allocated to 11 sessions of either EMDR or stabilisation. Symptoms of PTSD (SCID-I, HTQ), depression and anxiety (HSCL-25), and quality of life (WHOQOL-BREF) were assessed at pre- and post-treatment and 3-month follow-up. RESULTS: Participation of traumatised refugees in the study was found feasible, although issues associated with complex traumatisation led to a high pre-treatment attrition and challenges in assessments. Acceptability of EMDR was found equal to that of stabilisation with a high drop-out for both conditions. No participants dropped out of the EMDR condition because of unmanageable distress. While improvement for EMDR participants was small, EMDR was found to be no less efficacious than stabilisation. Different symptom courses between the two conditions, with EMDR showing some improvement and stabilisation showing some deterioration between pre-treatment and post-treatment, justify the conduct of a full trial. CONCLUSION: With some adaptations in study design, inclusion of a greater sample is justifiable to determine which treatment is more suitable for this complex population.

Agricultural cycle and the prevalence of posttraumatic stress disorder: a longitudinal community study in postwar Mozambique.

The influence of physical activity on the prevalence and remission of war-related mental disturbances has never been systematically evaluated. This study examined the influence of participation in the agricultural cycle on the posttraumatic stress disorder (PTSD) prevalence and correlated symptoms longitudinally in post civil war Mozambique. Prevalence rates were examined in the end and the outset of the agricultural cycle in a community population (N = 240). The agricultural cycle, which is characterized by fluctuations in physical activities, social connectedness, and the sense of purpose in life influences the PTSD prevalence and correlated symptoms. By studying the influence of the agricultural cycle on PTSD prevalence, severe PTSD cases that fail to respond to the agricultural cycle can be identified, and subsequently evaluated regarding the need for specialized care.

The psychological mindedness assessment procedure - validation study of a Dutch version.

OBJECTIVE: The Psychological Mindedness Assessment Procedure [PMAP; McCallum, M. & Piper, W. E. (1990)] operationalizes psychological mindedness as a participant's understanding of the problem presented by two videotaped enacted patients. To possibly enhance predictive power for psychotherapy outcome, we added two video scenarios with emotionally high-impact. This article describes psychometric properties of the Dutch translation of the PMAP and the extended version, the PMAP-plus. DESIGN: A therapy-analogue study with non-clinical participants (N = 100). METHODS: In individual sessions, participants watched the four video-scenarios and responded to the PMAP-question 'What seems to be troubling this woman?'. Emotional reactions were measured using the Positive And Negative Affect Schedule [PANAS; Watson, D., Clark, L. E. & Tellegen, A. (1988)]. RESULTS: The PMAP and the PMAP-plus had good interrater reliability. As expected, PMAP-levels were lower for the newly added high-emotional scenarios. Validity was further supported by a negative relation of PMAP-scores with the Negative Affect subscale. CONCLUSIONS: The Dutch translation of the PMAP and the added scenarios of the PMAP-plus are reliable instruments. The predictive power for psychotherapy outcome needs to be investigated in a patient group. The variation in presented clinical problems could also make it a useful instrument to assess psychological mindedness in psychotherapists.

How therapists cope with clients' traumatic experiences.

An initial finding of high emotional stress in trauma therapists working in a specialized trauma institute led to three empirical studies on trauma-related therapist reactions. The purpose of these studies was to investigate the relation between high emotional burden and burnout, and the trauma-specific processes described by the concepts "secondary traumatic stress", "vicarious traumatization" and "traumatic countertransference". The initial qualitative/quantitative study examined how a group of specialized trauma therapists (N=63) coped with clients' traumatic experiences. The results on trauma-related reactions were inconclusive. This motivated a qualitative study of expert psychotherapists (N=11). Interviews with expert trauma therapists and other expert therapists were focused on reactions to the confrontation with traumatic experiences and differences between both groups of experts. Results indicated a specific reaction pattern to traumatic situations, but revealed no other differences between trauma specialists and other experts. To further examine trauma-specificity of this reaction pattern, a third study was conducted with psychology students (N=100) using an experimental design. The results suggest the existence of a trauma-specific reaction pattern, characterized by shock, anxiety and the experience of being carried away by strong emotions. The relation of trauma reactions with traumatic situations is endorsed by results on differential reactions to traumatic and interactionally difficult situations, although results suggest that other kinds of situations with high emotional impact may also evoke trauma-reactions. In the discussion the results are considered in relation to the limitations of the studies are followed recommendations for further research. Our results thus far support the high emotional impact of confrontation with traumatic material, but nuances psychopathological or other long-term negative changes that are suggested by the terms secondary or vicarious traumatization.

When the war was over, little changed: women's posttraumatic suffering after the war in Mozambique.

This article explores the psychosocial effects of women's prolonged exposure to civil war in the center of Mozambique. Using a combination of quantitative and qualitative methods, 91 women were assessed for posttraumatic stress symptoms and psychosocial indicators of ill health. The results indicate that for the majority of the women in this study, traumatic experiences are sequential processes. Their ill health ranges from symptoms of posttraumatic stress to episodes of spirit possession (gamba), affecting women's capacities to conceive and raise children, and marginalizing their social position. A careful analysis of the specific problems and needs of women in postwar contexts is recommended, along with a systematic examination of the effectiveness of the available resources that may play a role in boosting trauma recovery in this group of women.

Testimony method to ameliorate post-traumatic stress symptoms. Community-based intervention study with Mozambican civil war survivors.

BACKGROUND: The effectiveness of the testimony method has not been established in rural communities with survivors of prolonged civil war. AIMS: To examine the effectiveness and feasibility of a testimony method to ameliorate post-traumatic stress symptoms. METHOD: Participants (n=206) belonged to former war zones in Mozambique. They were divided into a case (n=137) and a non-case group (n=69). The case group was randomly divided into an intervention (n=66) and a control group (n=71). Symptoms were measured during baseline assessment, post-intervention and at an 11-month follow-up. RESULTS: Post-intervention measurements demonstrated significant symptom reduction in both the intervention and the control group. No significant differences were found between the intervention and the control group. Follow-up measurements showed sustained lower levels of symptoms in both groups, and some indications of a positive intervention effect in women. CONCLUSIONS: A remarkable drop in symptoms could not be linked directly to the intervention. Feasibility of the intervention was good, but controlling the intervention in a small rural community appeared to be a difficult task to accomplish.