Influence of participation in a reintegration program

Because most of the therapy attendees had participated in a reintegration program as well, it is necessary to investigate the potential influence of the reintegration program on the outcome variables. Table 5.1 shows the distribution of program participation over the three treatment conditions.

Comparisons of participants who neither received a therapy intervention nor took part in a reintegration program with those participants involved in both therapy and the

reintegra-Long9term!effects!of!psychotherapy!in!a!context!of!continuous!community!and!gang!

violence:!changes!in!aggressive!attitude!in!high9risk!South!African!adolescents!

94!

tion program or either only therapy or the reintegration program were conducted. The results showed that those involved in both programs showed a significant difference in criminal be-havior over time (Wilcoxon’s signed-rank test: z = -3.01, p < 0.01) in comparison to those taking part in none of the offered programs (Mann-Whitney U-Test: z = -2.89, p < 0.01). Wil-coxon’s signed-rank test reveals that this difference is due to an increase in criminal behavior in those attending both therapy and reintegration programs (z = -3.01, p < 0.05), whereas the number of offense types did not change in the group not attending any program. The only pre-therapy score difference between the two groups was age: non-participants were younger than those who participated in both (z = -2.44, p < 0.05).

5.5 Discussion

The reduction in PTSD symptom levels that was observed in the FORNET group at the first follow-up (about 8 months post-therapy) was still significant about one and a half years after therapy. These outcomes indicate that FORNET is not only a feasible intervention for young men at risk (of both trauma exposure and violence perpetration) but also achieves positive long-term results in terms of post-traumatic stress reduction, even for individuals who contin-ue to live in unsafe conditions. The lasting reduction in PTSD over time in the FORNET group is in line with findings from previous FORNET studies (Hermenau et al., 2013b;

Köbach et al., 2015b). Notably, the latest follow-ups in those studies were 12 months post-treatment; this study is the first to investigate therapy outcomes as late as 20 months after treatment.

In the FORNET group, the young men’s attraction to violence did not alter in the first months post-therapy, but changed significantly over a longer period of time. One possible explanation might be that a change in attitude (in this case, attraction to cruelty) takes more time than changes in a fear-network (and the associated post-traumatic stress symptoms). In

Long9term!effects!of!psychotherapy!in!a!context!of!continuous!community!and!gang!

violence:!changes!in!aggressive!attitude!in!high9risk!South!African!adolescents!

contrast to Hermenau's and colleagues' (2013b) study, where the reduction in appetitive ag-gression was most likely due to a change in context (from an area plagued by conflict to a safe area) and the rehabilitation program received, in this study, the change in appetitive aggres-sion was proven to be possible in a context of ongoing violence.

Violence perpetration was not reduced in any of the treatment conditions, even in the long-term perspective. The reduction in criminal behavior that was achieved in the Burundian FORNET study (Crombach & Elbert, 2015) might have been supported by the change in the environment of those participants – a change that did not occur for the South African partici-pants of this study. Those adolescents that took part in the therapy as well as the rehabilitation program seem to show more criminal behavior than those not participating in any group. Al-so, participants seemed to be of younger age than non-participants. Both observations might lead to the explanation that non-participants were mainly still engaged in school-life or had jobs, which might have been the reason they could not participate in any of the programs of-fered at the same time that could mean that this protected them from being involved in gangs or drugs and thus would result in less criminal acts. Another explanation could be that those participating in both programs met and socialized with peers that share the same aggression-oriented attitude and thus continued to reside in a social context that generally accepts or even values criminal behavior (Wikström, 2006).

5.5.1 Limitations

This study is limited by its small sample size. The use of non-parametric (robust) statistical tests can compensate for this limitation; however, the study’s power is reduced as a result.

Consequently, there is the possibility that any results established might be an analytical arti-fact. The small sample size also restricts the generalizability of the study outcome to the male population of South African townships.

Long9term!effects!of!psychotherapy!in!a!context!of!continuous!community!and!gang!

violence:!changes!in!aggressive!attitude!in!high9risk!South!African!adolescents!

96!

A further limitation of therapy studies is related to the incidence of dropouts. Our dropout rate of 29% falls in the middle of dropout rates in studies with comparable samples (e.g., Golden et al., 2006: 38%; Bickle, 2013: 18%). However, dropouts occurred in all three treatment conditions and were non-systematic in nature. Due to dropouts and absenteeism at the follow-up sessions, the previously separate waiting lists “camp” (n = 6) and “no camp” (n

= 20) had to be combined into one waiting list in order to achieve a sample size that would be large enough for the conduction of the statistical analysis. Therefore, the influence of camp participation alone could not be determined.

This investigation concentrated on the long-term effects of therapy outcomes, with a second follow-up after an average of 17 months posttreatment. The advantage of long time intervals for follow-ups is that information can be obtained about the potential duration of therapy effects. The disadvantage is that other factors may come into play, and it becomes more difficult to evaluate the acute efficacy of the therapy.

5.5.2 Conclusion

The main conclusions to be drawn from this research trial with high-risk South African youth are a) the possible long-term success of trauma-focused interventions in a context of ongoing threat (one and a half years after treatment, PTSD severity levels were still significantly lower than before therapy, despite continuing traumatization) and b) the successful reduction of ap-petitive aggression in a context of persistent community violence. This answers the question of whether the treatment of post-traumatic stress is feasible in areas of ongoing threat and whether and how treatment can be realized for high-risk adults who are involved in gang structures and drugs. Future research must focus on the preconditions necessary for the pre-vention of recidivism, in particular the roles that employment and school attendance play in this triangular relationship.

Long9term!effects!of!psychotherapy!in!a!context!of!continuous!community!and!gang!

violence:!changes!in!aggressive!attitude!in!high9risk!South!African!adolescents!

5.6 Acknowledgements

This research was supported by the European Research Council (ERC). Clinical trials regis-tration ID: NCT02012738. We are deeply grateful to all the participants, interpreters, inter-viewers, supervisors, and cooperating institutions that have supported our research project.

! !

! 98!! !