How is trauma-focused therapy experienced by adults with PTSD? A systematic review of qualitative studies.

BACKGROUND: Trauma-focused therapies (TFTs) are first-line treatments for posttraumatic stress disorder (PTSD). However, TFTs are under-utilised, partly due to clinicians' and patients' fear that TFT is too challenging or harmful. We review the qualitative studies on how adults with PTSD experience TFTs to enhance the understanding of user perspectives, therapeutic processes, and outcomes. METHODS: PubMed, PsychINFO and PTSDPubs were searched between October 1st and November 30th, 2021. Study quality assessments were undertaken, and studies were analysed using a descriptive-interpretative approach. Nine studies were included. RESULTS: The analysis resulted in the identification of four key domains, representing a temporal sequence of TFT stages: Overcoming ambivalence towards TFT, Experience of treatment elements, Motivation for dropout/retention, and Perceived changes post-treatment. CONCLUSION: Although many participants reported high levels of distress and considered dropping out, only a minority did eventually drop out and most patients expressed that the hardships in therapy were necessary for PTSD improvement. Establishing a safe therapeutic environment and working with the ambivalence towards treatment was essential for retention. This review serves a dual purpose, to shed light on diverse TFT experiences found to be important for treatment satisfaction, and to elucidate common treatment patterns. The results can be used in preparing patients for therapy and in training TFT therapists. Studies had moderate to high quality, and more studies of experiences of TFT non-responders and dropouts in a non-veteran population are needed to further our understanding of the utility and limitations of TFTs.

The Danish Trauma Database for Refugees (DTD): A Multicenter Database Collaboration-Overcoming the Challenges and Enhancing Mental Health Treatment and Research for Refugees.

Mental health of trauma-affected refugees is an understudied area, resulting in inadequate and poorer treatment outcomes. To address this, more high-quality treatment studies that include predictive analyses, long-term evaluations, cultural adaptations, and take account for comorbidities, are needed. Moreover, given the complex intertwining of refugees' health with post-migration stressors and other social factors, it is crucial to examine the social determinants of refugee mental health. The Danish Trauma Database for Refugees (DTD) is a multicenter research database uniting six national centers that provide outpatient treatment for trauma-affected refugees. Through the database, we collect clinical and sociodemographic data from approximately 1200 refugees annually and will merge the database with Danish population register data. The purpose of the DTD is two-fold; clinical and research. The DTD offers data-driven guidance for routine clinical treatment planning of the individual patient, as well as exceptional research opportunities for testing treatment interventions in clinical settings, with larger sample sizes, and more representative heterogeneity of the population. Complex analyses of risk and protective factors, barriers, access to treatment, and societal and transgenerational aspects of trauma are possible with the DTD. This conceptual paper introduces the DTD, the historical background, the development process and implementation strategy, and the associated challenges with developing and running a multicenter database. Most importantly, it highlights the clinical and research potential of the DTD for advancing the understanding and treatment of trauma-affected refugees.

Cross-cultural validity and psychometric properties of the International Trauma Questionnaire in a clinical refugee sample.

Background: The ICD-11 post-traumatic stress disorder (PTSD) and complex PTSD diagnoses have been examined in several studies using the International Trauma Questionnaire (ITQ). The cross-cultural validity of the ITQ has not previously been studied using item responses theory methods focused on the issue of equal item functioning and thus comparability of scores across language groups.Objective: To investigate the cross-cultural validity of the ITQ scales considering specifically local independence of items and differential item functioning (DIF) in a cross-cultural sample of refugees.Method: Data from 490 treatment-seeking refugees were included, covering Danish, Arabic, and Bosnian languages and different levels of interpreter-assisted administration. Rasch and graphical log-linear Rasch models were used.Results: There was strong local dependence among items from the same symptom clusters in the PTSD and disorders in self-organization (DSO) scales, except between affective dysregulation items. Weak local dependence was discovered between an item from the affective dysregulation cluster and an item from the disturbed relationship cluster. There was no evidence of DIF related to language or interpreter assistance. There was evidence of DIF for two PTSD items relative to gender and time since the traumatic event. The targeting of the scales to the study population was not optimal. Reliability varied from 0.55 to 0.78 for subgroups.Conclusions: The PTSD and the DSO scales have stable psychometric properties across the Danish, Arabic, and Bosnian language versions and different levels of assisted administration. Scores are comparable across these groups. However, DIF relative to gender and time since trauma introduces considerable measurement bias. DIF-adjusted summed scale scores or estimated person parameters should be used to avoid measurement bias. Future research should investigate whether scales including more and/or alternative items that require higher levels of PTSD and DSO to be endorsed will improve targeting and measurement precision for refugee populations.

A first cross-cultural validity study of the ITQ using IRT.PTSD and DSO subscales functioned invariantly across Danish, Arabic, and Bosnian, and also across degrees of interpreter assistance. Two PTSD items did not function invariantly across gender and time since trauma.The Danish, Arabic, and Bosnian ITQ can be used for screening treatment-seeking refugees, taking into account the item bias in the PTSD subscale, and suboptimal targeting and reliability, which require extensions or modification of items.

Psychotherapy readiness domains as predictors of psychotherapy outcome in trauma-affected refugees.

INTRODUCTION: Little is known about predictors of psychotherapy outcome in trauma-affected refugees. Knowledge on outcome predictors can help clinicians identify patients prior to treatment who are not likely to benefit from standardized psychotherapy and take additional measures to adjust treatment to the individual patient. Given the dynamic nature of psychotherapy readiness domains, they represent potential targets to be worked with in therapy in order to improve outcomes. METHODS: Psychotherapy readiness domains (locus of control, cognitive functioning, motivation for therapy, and personality functioning) were examined as potential predictors of psychotherapy outcome in trauma-affected refugees. Secondary analyses were conducted on data from a pragmatic randomized controlled trial. Study participants (N = 190) were refugees with PTSD who received flexible manual-based Cognitive Behavioral Therapy (CBT) at a psychiatric outpatient clinic in Denmark. Psychotherapy readiness domains were assessed via semi-structured interviews at the beginning of psychotherapy. Outcome variables were pre-post change in PTSD symptomology and global level of functioning. RESULTS: Multiple regression analyses revealed that higher motivation for psychotherapy predicted improvement in PTSD symptomology and global level of functioning. Moreover, higher cognitive functioning predicted improvement in global level of functioning. LIMITATIONS: The predictor rating scales need further psychometric evaluations in cross-cultural contexts. CONCLUSIONS: These findings highlight the importance of considering motivation in psychotherapy offered to trauma-affected refugees. Further research is needed to identify potential barriers to motivation in this diverse patient population and to determine whether motivational interventions can lead to improved treatment outcomes.

Adverse childhood experiences among children of parents who are refugees affected by trauma in Denmark: a register-based cohort study.

BACKGROUND: Children in families who are refugees might experience more adversities than their peers. Adverse childhood experiences (ACEs) are well known risk factors for poorer adulthood health and adjustment. The risk of ACEs for children with a parent who is a refugee affected by trauma is unknown. We aimed to estimate the hazard of individual and cumulative ACEs using a unique sample of children with parents who are refugees affected by and seeking treatment for trauma and population level data. METHODS: This was a register-based cohort study carried out in Denmark. All children aged 0-15 years, residing in Denmark between Jan 1, 1990, and Dec 31, 2016, were followed up from birth or migration into the country to their 15th birthday. We linked data from the Danish Civil Registration System, the Danish National Patient Register, the Danish Psychiatric Central Research Register, the Employment Classification Module, the Register of Causes of Death, and the Income Statistics Register to investigate ten ACE categories (parental: natural and unnatural death, serious mental illness, substance use disorder, somatic illness, and disability; child: residential instability, family disruption, poverty, and stressors) and the cumulative number of ACE categories for children with a parent from a refugee-sending country and children with a parent who is a refugee in treatment for trauma. The main outcome was the hazard ratio (HR) of the individual and cumulative ACEs among children with a parent from a refugee-sending country and children with a parent who is a refugee affected by trauma, compared with the general population of children in Denmark, both adjusted and unadjusted for parental country of origin. FINDINGS: 2 688 794 children were included in the study, 252 310 of whom had parents from refugee-sending countries. 11 603 children had parents affected by trauma and seeking treatment, of whom 1163 (10%) migrated to Denmark before their second birthday and 10 440 (90%) were born in Denmark. Compared with the general population of children in Denmark, the hazard for most ACEs was significantly higher for both children with parents from a refugee-sending country and children with parents who are refugees affected by trauma. For children with a parent from a refugee-sending country, the highest HR was related to the child living in relative poverty for 3 years (3·62 [95% CI 3·52-3·73]). After adjusting for parental country of origin, the hazards for five ACEs were significantly greater for children of parents who are refugees affected by trauma compared with the remaining children of parents from the same countries. The highest HR for this child group was for parental serious mental illness (1·98 [1·85-2·12]). The hazard for experiencing multiple ACEs was significantly higher for both child groups compared with the general population. INTERPRETATION: Our findings suggest that children with parents from refugee-sending countries have a higher rate of several ACEs compared with the general population. Furthermore, having a parent who is a refugee affected by trauma and seeking treatment seems to be an independent risk factor for poorer health and adjustment in adulthood. This study informs decision makers and caregivers that there might be much added value in addressing needs within the whole family, as opposed to only attending to the parent who is seeking treatment. FUNDING: The Lundbeck Foundation.

Predictors of treatment outcomes for trauma-affected refugees - results from two randomised trials.

INTRODUCTION: Treatment effects in trials with trauma-affected refugees vary considerably between studies, but the variability in outcome between individual patients is often overlooked. Consequently, we know little about why some patients benefit more from treatment than others. The aim of the study was therefore to identify predictors of treatment outcome for refugees with Posttraumatic Stress Disorder (PTSD). METHODS: Data was derived from two randomised trials including 321 refugees, who had all participated in a 6-7 months bio-psycho-social treatment programme. Outcome measures were the Harvard Trauma Questionnaire (PTSD, self-rating), Hopkins Symptom Checklist-25 (depression and anxiety, self-rating) and Hamilton Depression and Anxiety rating scales (observer-ratings). Using hierarchical regressions models, associations were analysed between pre- to post treatment score changes (dependent variable) and a range of variables including sociodemographics, pre-migration trauma, post-migratory stressors, baseline symptom scores and level of functioning. RESULTS: A high baseline score (=more symptoms) and a high level of functioning were found to be associated with improvement on all ratings. Additionally, the following variables were associated with symptom improvement on at least one outcome measure: short time in host country, full time occupation, young age and status as family reunified (in contrast to refugee status). Being Muslim was inversely correlated with improvement. LIMITATIONS: Translated self-ratings were used, which could impact reliability. CONCLUSION: These results call for screening and early interventions for arriving refugees. For clinical populations, level of functioning should be included in assessments of refugees, to possibly begin stratifying samples to different interventions based on their likelihood of responding.

PTSD with secondary psychotic features among trauma-affected refugees: The role of torture and depression.

This cross-sectional study examined the prevalence of PTSD with secondary psychotic symptoms (PTSD-SP), its comorbidities, and its association with torture and depression in treatment-seeking refugees. Data were pooled from the Danish Database on Refugees with Trauma (DART). The sample represents approximately 90% of trauma-affected refugee-patients (N = 627) attending a Danish psychiatric outpatient clinic from 2008 to 2013. PTSD, secondary psychotic symptoms, and comorbidities were assessed with structured and routine clinical interviews. The association of PTSD-SP with torture and depression was investigated using hierarchical logistic regression. The prevalence of PTSD-SP in treatment-seeking refugees with PTSD was 30%. Among these, 44% fulfilled the criteria for Enduring Personality Change After Catastrophic Experience (EPCACE). Psychotic symptoms comprised hallucinations and persecutory delusions, often reflecting trauma-related themes. Comorbidity with depression was high (79%). Neither torture, nor other war-trauma (ex-combatant, imprisonment, civilian war trauma) predicted PTSD-SP, but comorbid depression did. Depression only explained a small amount of the total PTSD-SP variance. Results indicate that PTSD-SP is common in treatment-seeking refugees. However, its etiology is poorly understood. This highlights the need for further research to improve diagnosis and treatment for this patient group.

Replicability and Generalizability of Posttraumatic Stress Disorder (PTSD) Networks: A Cross-Cultural Multisite Study of PTSD Symptoms in Four Trauma Patient Samples.

The growing literature conceptualizing mental disorders like posttraumatic stress disorder (PTSD) as networks of interacting symptoms faces three key challenges. Prior studies predominantly used (a) small samples with low power for precise estimation, (b) nonclinical samples, and (c) single samples. This renders network structures in clinical data, and the extent to which networks replicate across data sets, unknown. To overcome these limitations, the present cross-cultural multisite study estimated regularized partial correlation networks of 16 PTSD symptoms across four data sets of traumatized patients receiving treatment for PTSD (total N = 2,782). Despite differences in culture, trauma type, and severity of the samples, considerable similarities emerged, with moderate to high correlations between symptom profiles (0.43-0.82), network structures (0.62-0.74), and centrality estimates (0.63-0.75). We discuss the importance of future replicability efforts to improve clinical psychological science and provide code, model output, and correlation matrices to make the results of this article fully reproducible.

Evidence of complex posttraumatic stress disorder (CPTSD) across populations with prolonged trauma of varying interpersonal intensity and ages of exposure.

The ICD-11 proposes different types of prolonged trauma as risk factors for complex PTSD (CPTSD). However, CPTSD's construct validity has only been examined in childhood abuse, and single trauma exposure samples. Thus, the extent to which CPTSD applies to other repeatedly traumatized populations is unknown. This study examined ICD-11's PTSD and CPTSD across populations with prolonged trauma of varying interpersonal intensity and ages of exposure, including: 1) childhood sexual abuse, 2) adulthood trauma of severe interpersonal intensity (refugees and ex-prisoners of war), and 3) adulthood trauma of mild interpersonal intensity (military veterans, and mental health workers). In support of the proposal, latent class analysis (N = 820) identified, a 4-class solution representing "PTSD", "CPTSD", and "non-pathological" classes, but also an "Anxiety symptoms" class, and an alternative 5-class solution, with a "Dissociative PTSD-subtype" class. ICD-11's CPTSD was not exclusively associated with childhood abuse, but also with exposure to adulthood trauma of severe interpersonal intensity. Furthermore, all types of prolonged trauma were equally associated with the "Anxiety symptoms" class. Finally, of all the classes, the "CPTSD" class was associated with the highest frequency of work-related functional impairment, indicating an association between the severity of prolonged trauma exposure and the level of posttraumatic residues.

Rasch Validation and Cross-Validation of the Health of Nation Outcome Scales for Monitoring of Psychiatric Disability in Traumatized Refugees in Western Psychiatric Care.

There are no validated measures of psychiatric disability for traumatized refugees in Western psychiatric care. This is a serious shortcoming as it precludes monitoring of global treatment outcomes in this group, as well as appropriate matching of treatment needs to the disability levels. Using Rasch analysis, we evaluated the psychometrics of the Health of Nation Outcome Scales (HoNOS) in pretreatment data of consecutive refugee patients (N = 448) from a Danish psychiatric clinic. Then, we carried out a cross-validation of the pretreatment HoNOS model on posttreatment data from the same group. A revised 10-item HoNOS fit the Rasch model at pretreatment and also showed excellent fit within the cross-validation data. Culture, gender, and need for translation did not exert serious bias on the measure's performance. The results establish good monitoring properties of the 10-item HoNOS as the first validated measure of psychiatric disability for traumatized refugees in Western psychiatric care.

Assessment of dissociation in Bosnian treatment-seeking refugees in Denmark.

BACKGROUND: Dissociative experiences are common in traumatized individuals, and can sometimes be mistaken for psychosis. It is difficult to identify pathological dissociation in the treatment of traumatized refugees, because there is a lack of systematic clinical descriptions of dissociative phenomena in refugees. Furthermore, we are currently unaware of how dissociation measures perform in this clinical group. AIMS: To describe the phenomenology of dissociative symptoms in Bosnian treatment-seeking refugees in Denmark. METHOD: As a part of a larger study, dissociation was assessed systematically in 86 Bosnian treatment-seeking refugees using a semi-structured clinical interview (Structured Interview for Disorders of Extreme Stress-dissociation subscale; SIDES-D) and a self-report scale (Dissociative Experiences Scale; DES). RESULTS: The SIDES-D indicated twice as high prevalence of pathological dissociation as the DES. According to the DES, 30% of the refugees had pathological dissociation 15 years after their resettlement. On the SIDES-D, depersonalization and derealization experiences were the most common. Also, questions about depersonalization and derealization at times elicited reporting of visual and perceptual hallucinations, which were unrelated to traumatic re-experiencing. Questions about personality alteration elicited spontaneous reports of a phenomenon of "split" pre- and post-war identity in the refugee group. Whether this in fact is a dissociative phenomenon, characteristic of severe traumatization in adulthood, needs further examination. CONCLUSIONS: Knowledge of dissociative symptoms in traumatized refugees is important in clinical settings to prevent misclassification and to better target psychotherapeutic interventions. Much development in the measurement of dissociation in refugees is needed.

Comparison of psychiatric disability on the health of nation outcome scales (HoNOS) in resettled traumatized refugee outpatients and Danish inpatients.

BACKGROUND: Currently, the mental health issues of traumatized refugees are mainly documented in terms of posttraumatic stress disorder, depression, and anxiety. Importantly, there are no reports of the level of psychiatric disability in treatment seeking traumatized refugees resettled in the West. Insufficient acknowledgment of the collective load of bio-psycho-social problems in this patient group hinders effective psychiatric and social service utilization outside the specialized clinics for traumatized refugees. METHODS: The level of psychiatric disability in traumatized refugees from Danish specialized clinics (N = 448) is documented using routine monitoring data from pre- and post-treatment on the Health of Nation Outcome Scales (HoNOS). Furthermore, the HoNOS ratings are compared with routine monitoring data from Danish inpatients with different diagnoses (N = 10.911). RESULTS: The routinely collected data indicated that despite their outpatient status, traumatized refugees had higher levels of psychiatric disability at pre-treatment compared to most inpatients. Moreover, the traumatized refugees had a HoNOS profile characterized by an overall high problem level in various psychiatric and social domains. The rate of pre- to post-treatment improvement on the HoNOS was smaller for the traumatized refugees than it was for the psychiatric inpatients. CONCLUSIONS: The level, and the versatile profile, of psychiatric disability on the HoNOS point to complex bio-psycho-social problems in resettled treatment seeking traumatized refugees. Thus, a broader assessment of symptoms and better cooperation between psychiatric, health care, and social systems is necessary in order to meet the treatment needs of this group.

Impact of traumatic events on posttraumatic stress disorder among Danish survivors of sexual abuse in childhood.

Childhood sexual abuse can be extremely traumatic and lead to lifelong symptomatology. The present study examined the impact of several demographic, abuse, and psychosocial variables on posttraumatic stress disorder severity among a consecutive sample of treatment-seeking, adult child sexual abuse survivors (N = 480). The child sexual abuse sample was characterized by severe trauma exposure, insecure attachment, and significant traumatization, with an estimated 77% suffering from posttraumatic stress disorder, more than twice the level of the comparison group. Regression analyses revealed risk factors associated with the development of posttraumatic stress disorder in which the strongest predictors being additional traumas, negative affectivity, and somatization. The findings add to existing research confirming the stressful nature of child sexual abuse and the variables that contribute to the development and severity of posttraumatic stress disorder.

Personality dysfunction and complex posttraumatic stress disorder among chronically traumatized Bosnian refugees.

A proposal for the inclusion of complex posttraumatic stress disorder (CPTSD) in the upcoming ICD-11 has been put forward. Using self-report, we investigated the resemblance between disorders of extreme stress not otherwise specified (DESNOS) and both axis I and II syndromes among 116 treatment-seeking Bosnian refugees. In this sample, the prevalence of DESNOS overlapped to a large degree with the prevalence of schizotypal and paranoid personality disorders (PDs). There was, however, also a large prevalence of axis I syndromes in the group. Thus, DESNOS in the refugees can be categorized as an axis I or II disorder depending on the chronicity and the severity of functional impairment. DESNOS and PD-like states were even observed among the refugees with no history of childhood maltreatment. No large differences were observed between DESNOS and PD regarding sex. The symptom constellation of CPTSD in the ICD-11 is partially supported. However, CPTSD might resemble PD to a considerable degree.

Predicting chronic posttraumatic stress disorder in bereaved relatives: a 6-month follow-up study.

The objectives of the present study were to examine the prevalence of posttraumatic stress disorder (PTSD) and to identify predicative risk factors for PTSD in bereaved people after a terminal illness. Fifty-four persons (mean age 60 years) participated in the study. Demographic, peritraumatic, and psychosocial factors were assessed in order to identify variables that affected PTSD severity. Six months after the loss, 21.6 % of the subjects had PTSD, an 8.6 % decrease from PTSD measured one month after the loss. Intake of medicine after the loss, place of death, not having a close intimate, negative affectivity, and the A2 criterion predicted 65 % of PTSD severity. A considerable number of the bereaved were still at great risk for developing PTSD six months after loss.

Social support, coping and posttraumatic stress symptoms in young refugees.

Young refugees from the former Yugoslavia commonly testify to having been exposed to multiple, traumatic experiences, which may contribute to the development of serious mental health problems such as posttraumatic stress disorder (PTSD), anxiety, and depression. Using selfreport scales the present study investigated the prevalence of PTSD as well as factors associated with PTSD in a group of 119 Bosnian refugee youths (mean age 18.5). The group was special in that they had no right to seek asylum in the host country for the first couple of years of their stay. It is suspected that this circumstance had an effect on their wellbeing. Between 35-43% of the youth were found to be in the clinical range for a PTSD diagnosis. Female gender, problem-focused, and avoidant coping strategies, were significant predictors of PTSD. The protective effects of social support were, however, not observed for this group. There is a need for more studies, which address the factors that mediate and moderate effects of social support and effectiveness of different coping strategies in refugee youth dealing with different circumstances of the refugee experience.

Psychosocial treatment of posttraumatic stress disorder in adult refugees: a systematic review of prospective treatment outcome studies and a critique.

BACKGROUND: Refugees with posttraumatic stress disorder (PTSD) often present with complicated traumatic symptoms, prolonged and repeated exposure to traumatic events, acculturation, and social problems. A consensus about suitability of psychosocial treatments for refugees does not exist. Never the less there is a need to review the state of knowledge about effective treatments for traumatized refugees, to help guide the practitioners in their choice of treatment methods. METHODS: A systematic review of treatment outcome studies was carried out. RESULTS: Twenty-five studies were reviewed. The majority were treatment studies of different forms of cognitive-behavioral therapy (CBT). The rest were reports of outcomes of alternative treatments and a small group of studies of multidisciplinary treatments. LIMITATIONS: The amount of grey literature not covered by the review could not be estimated precisely. Included studies are methodologically diverse and consist of different refugee populations. This makes a broad interpretation of the treatment results only tentative. CONCLUSIONS: Very large effect sizes were obtained in some of the CBT studies, indicating a broad suitability of CBT in the treatment of core symptoms of PTSD in adult refugees. Empirical evidence also points to the possibility that the maladaptive traumatic reactions in refugees can take shape of more complex reactions than those strictly specified in the diagnostic category of PTSD. Effectiveness of CBT treatments has as yet not been tested on the whole range of symptoms in these complex cases. There are few studies of treatments alternative to CBT and they are less methodologically rigorous than the CBT studies.

PTSD-8: A Short PTSD Inventory.

Traumatic events pose great challenges on mental health services in scarcity of specialist trauma clinicians and services. Simple short screening instruments for detecting adverse psychological responses are needed. Several brief screening instruments have been developed. However, some are limited, especially in relation to reflecting the posttraumatic stress disorder (PTSD) diagnosis. Recently, several studies have challenged pre-existing ideas about PTSD's latent structure. Factor analytic research currently supports two four factor models. One particular model contains a dysphoria factor which has been associated with depression and anxiety. The symptoms in this factor have been hailed as less specific to PTSD. The scope of this article is therefore to present a short screening instrument, based on this research; Posttraumatic Stress Disorder (PTSD) - 8 items. The PTSD-8 is shown to have good psychometric properties in three independent samples of whiplash patients (n=1710), rape victims (n=305), and disaster victims (n=516). Good test-rest reliability is also shown in a pilot study of young adults from families with alcohol problems (n=56).

An explorative outcome study of CBT-based multidisciplinary treatment in a diverse group of refugees from a Danish treatment centre for rehabilitation of traumatized refugees.

A group of highly traumatized refugees n = 26 with diverse cultural backgrounds in a Danish Clinic for Traumatized Refugees (CTR) was assessed for symptoms of post-traumatic stress disorder and other aspects of general functioning. Patients were assessed at intake, after the end of treatment and six months later. The results point to very high symptom levels and a large need for treatment in this population. Psychiatric symptoms and their correlates were assessed with the Harvard Trauma Questionnaire (HTQ), the Trauma Symptom Checklist-23 (TSC-23), the Global Assessment of Function (GAF), and the Crisis Support Scale (CSS). The Trail Making Test A & B (TMT) was used as a screening instrument for acquired brain damage, with promising results. Indications of effectiveness from 16-18 weeks of multidisciplinary treatment (physiotherapy, pharmacotherapy, psychotherapy, and social counseling) were supported with small to medium effect sizes on most outcome measures. The results are discussed in terms of clinical implications and future treatment, assessment, and research needs.