Discussion of therapy outcomes

This study successfully proved the feasibility of trauma therapy in a context of ongoing com-munity and gang violence despite doubts amongst some practitioners and researchers (e.g.

Diamond et al., 2010; Kaminer et al., 2016; Roach, 2013), who assume that exposure therapy could be unhelpful in these contexts or lead to high dropout rates during therapy. The fact is that PTSD symptoms dropped over time in those receiving FORNET, compared to a waiting list. These findings are in line with other studies that tested trauma-focused interventions in areas of ongoing threat (Adessky & Freedman, 2005; Berger et al., 2007; Bryant et al., 2011;

Cigrang et al., 2005; Cohen et al., 2011; Murray et al., 2010; Shalev et al., 2012). What could be expected is that PTSD symptoms go up quickly again to the level of pre-assessment or higher after an initial decrease through therapy since the traumatization continued (the levels of trauma exposure in the study participants were not significantly different before and after therapy). In fact, independent of the continuity of the trauma occurring, 1.5 years later PTSD levels were still significantly lower in the FORNET group compared to pre-therapy values.

This result is in line with other long-term follow ups that were testing other trauma-focused therapy approaches (CPT/PE/CT: Bryant et al., 2003; CBT: Durham et al., 2005; CPT/PE:

General!Discussion!

102!

Resick et al., 2012 and Wachen et al., 2014; CT/IE: Tarrier & Summerfield, 2004). As Adessky and Freedman (2005) and Bryant et al. (2011) assume, the treatment of trauma might help individuals that have to reside sometimes for their entire lives in violent environments with the handling of traumatic incidents in a way that those do not influence their psychologi-cal health to an extent that they did before. This could be the case with, for example, the for-mer restructuring of typical mind patterns trauma victims show ("the world is a bad place",

"you can't trust anyone anymore", "it is my fault, that this happened to me", and so forth) and from which the clients now profit, and also from having developed ways that help resolve feelings of guilt and shame.

Difficulties that we in fact were facing in this trial were that therapy in an office set-ting could not be established. We can only assume what the reasons might have been: lacking therapy motivation; peer pressure to take part in the gang activities instead; the demands of daily life; necessity to "earn" money, for example, by robbing people; continuing drug use;

territorial obstacles where members of certain gangs are not allowed in or to cross areas that

"belong to" rival gangs and if they get caught doing so, they risk being assaulted by rival gang members. Since the establishment of therapy in a camp setting was feasible without high dropout numbers and the camp environment ruled out most of the above mentioned obstacles, it is likely that these factors are important to be considered in order to build a safe and func-tional therapeutic environment.

The drop in the severity of PTSD symptoms in this study was in line with the outcome of the FORNET study in the DRC (Köbach et al., 2015b). The likely reason why the FORNET studies from Hermenau and colleagues (2013b) and Crombach and Elbert (2015) did not achieve a significant decrease in PTSD symptoms could be the lacking cutoff for PTSD symptom severity. Despite the high level of exposure to trauma, there was an astonish-ingly high number of participants that had zero PTSD symptoms, for example, 19% in the

General!Discussion!

study of Crombach and Elbert (2015), and while about 10% in Crombach and Elbert's inter-vention trial had the full picture of PTSD, in this study's interinter-vention trial 55% of participants fulfilled the criteria for PTSD. This finding would support the gained insight of Shalev and colleagues (2012) that clients with subthreshold levels of PTSD have no added benefit from trauma-focused therapy.

Besides a long-term decrease in posttraumatic stress, FORNET proved to be success-ful in reducing the attraction to violence that the young men developed 15 to 20 months post treatment. This reduction has not been there on the first follow-up (8 months on average), which could indicate that changes of attitudes need a longer time-frame than changes of a fear-network in a context of ongoing violence, where an aggression-oriented mindset proofs to be adaptive (Weierstall et al., 2013c). In the FORNET trials of Köbach and colleagues (2015b) and Crombach and Elbert (2015) there were also no changes in appetitive aggression and the latest follow up was 12 months post treatment. Eventually the change in appetitive aggression took place, but could only have been measured at a later point of time. This would indicate that a change in the aggressive attitude can only be expected about 12 to 15 months post treatment. Contrary to this assumption though, a change in attraction to violence hap-pened in the FORNET study by Hermenau and colleagues (2013b) after only 6 months, how-ever, the change happened in the FORNET as well as in the control group. The result of the latter study might indicate that a change of appetitive aggression initiated by the therapy only becomes effective after about 1 to 1.5 years and that the general change in appetitive aggres-sion in the study of Hermenau et al. (2013b) was presumably initiated by other factors. The authors explained the change via a change in context, that is participants moving from being combatants to ex-combatants, as well as the reintegration program that every ex-combatant took part in that supported this role change. These changes in environment made the former adaptation to a violent context eventually unnecessary, so ex-combatants easily underwent the

General!Discussion!

104!

adaptation to a less violent context.

The only other FORNET study that measured the level of perpetrated violence before and after therapy was the FORNET trial of Crombach and Elbert (2015) where the result was a decrease in perpetrated violence, despite a lack of a reduction in attraction to violence, which is not in line with our study, where a decrease in offenses could not be measured nei-ther at the first, nor the second follow-up and this despite a change in appetitive aggression over time. A possible explanation for the difference in outcomes of the studies could again be the lack of change in the living circumstances and the continuous violence that our South Af-rican participants were and are living with.

TFAC (respectively CBT) did not initiate a change in aggressive attitude nor in ag-gressive behavior in our study. This finding is not in line with any of the other TFAC studies where some success was always achieved: Landenberger and Lipsey (2005) found in their meta-analysis of different CBT approaches that TFAC was equally helpful in reducing recidi-vism. Golden and colleagues (2006) indeed didn't find a difference between groups of TFAC completers and the waiting list concerning recidivism, but there was a change in the TFAC group over time in terms of probation violations as well as in their interpersonal problem solving skills. The TFAC group of Lowenkamp and colleagues (2009) showed lower levels of recidivism than the comparison group even two years post the intervention and Bickle (2013) showed that even in the context of a prison it was possible to achieve an improvement in so-cial problem-solving skills as well as in criminal attitude. It is possible that the participants of the TFAC intervention in our study improved on their problem solving and communication skills, but potential changes did not reflect in their pro-criminal attitude nor in their criminal behavior. The lack of success in our study might be due to alterations that were made to the scope of the program, namely, instead of 22 sessions in eleven weeks we condensed the man-ual to longer sessions that were conducted in seven days over a course of three weeks. This

General!Discussion!

left the participants less time for reflection, processing and transferring the new knowledge into new behavior patterns. Also it is unknown in which context the participants of the other TFAC studies were living in: if they mainly came from areas of continuous gang and commu-nity violence or could return to a more helpful environment with less ongoing violence.

The reasons individuals vary in their levels of criminal activity are related to a number of circumstantial, situational, personal, interpersonal, familial, cultural and economic factors (Andrews, 1989). Andrews & Bonta (1998) listed the major contributors and established risk factors according to the magnitude of their correlation with criminal behavior in the following order: 1. pro-criminal attitude; 2. pro-criminal peers/associates; 3. personality factors; 4. his-tory of antisocial behavior evident at an early age; 5. dysfunctional family environment, low level of personal educational, vocational, or financial achievement. It is likely that most of those risk factors apply in respect to the participants of our study, which gives an indication as to why it might be possible to change the pro-criminal attitude or the personal skills of the young men, but still not achieve any change in the number of criminal acts committed.

The combination of reintegration program as well as therapy, irrespective of whether it was FORNET or TFAC, had a negative influence on violence perpetration in that it led to an increase of criminal offenses compared to those receiving no intervention at all. This finding could be explained, firstly, by a third variable, namely school or job engagement, which could have a protective effect on criminal behavior. Those adolescents that have the daily structure through job or school attendance might be less involved in potential criminal or gang activi-ties (Pyrooz & Decker, 2011). Additionally, those that have an employment might face less financial strains and thus not feel the urge to have to earn money on illegal ways (Males &

Brown, 2014). Last but not least, for those receiving both interventions, the group may pro-vide an environment in which increased cohesion and identification with other criminals may occur (Golden et al., 2006; Wormith, 1984). As indicated above, pro-criminal peers are one of

General!Discussion!

106!

the main influential factors for future criminal acts.