Prolonged exposure for adolescents

Some PTSD treatment guidelines recommend the use of trauma focused treatment that includes an exposure element [18–21]. Prolonged exposure therapy is a trauma focused treatment initially designed for adults [22–24]. It has been shown to be effective within a community setting [25] and meets the requirements for dissemination of PTSD interventions in LMICs, as suggested by some researchers in the field [26]. Similarly, the adolescent adaptation of this intervention, prolonged exposure treatment for adolescents (PE-A) has been successfully implemented in community settings in the USA [27], Israel [28], and in an exploratory pilot study in South Africa [6]. Treatment comprises of eight modules that expound on the treatment rationale, breathing retraining, common reactions to trauma, in-vivo exposure using in-vivo hierarchy, and imaginal exposure (emotional processing of the traumatic memory through retelling) [6].

Although a highly efficacious treatment for PTSD [24], prolonged exposure therapy is underutilized [29]. Apart from a shortage of adequately trained professionals, treatments that include an element of exposure are sometimes perceived as unsafe or “cruel” [30]. In addition, criticism is often raised about manualized treatments detracting from the therapeutic relationship [29, 31].

Supportive counselling

Supportive counselling (SC), based on Rogerian principles and the traumagenic model [32], has been shown to lead to improvements in PTSD and depression symptoms in adolescents in the USA [27] and South Africa [6]. This treatment was chosen as a comparator treatment (to PE-A) as it is an active treatment with demonstrated success that does not have a trauma focus. SC sessions center around developing a trusting, empowering, and validating therapeutic relationship and adolescents decide on the agenda for the sessions. Nurses provide active listening, empathy, and encouragement to express feelings and reinforced self-efficacy. Non-directive problem solving and keeping a diary are skills taught to participants.

This nested, qualitative (empiricist framework) study compares the experiences and perceived efficacy of two PTSD interventions by treatment users (adolescents with PTSD) and treatment providers (supervised nurses). This is the third of 3 qualitative studies, the first describing the impediments and catalysts to task-shifting of the treatments experienced by school liaisons and the treating nurses [33], and the second describing stigma-related experiences of adolescent participants accessing psychotherapy for PTSD in their school-based setting [34].

Setting

For the RCT, trauma-exposed adolescents (aged 13 to 18) with PTSD were recruited at their respective schools from lower income high schools around Cape Town (South Africa) by presenting the treatment study and explaining the diagnosis of PTSD to students. Interventionists were registered nurses from outside of the community where the schools were situated, who were studying towards a diploma in psychiatry at Stellenbosch University. They were randomly assigned within a permuted block design to provide both treatments to prevent therapist confound. They were trained and supervised in both PE-A and SC protocols [3]. Nurses attended three days of training in PE-A from two authors (JR and EY) both of whom are experienced in implementing and training of the protocol. Training included theoretical and practical components such as reviewing of case studies and role plays. One author (JR) experienced in SC principles provided a one day training and supervised a further 16 hours of peer roleplay of the treatment components. Field workers included 2 recruiters and 2 independent assessors blind to the treatments.

Participants

This qualitative study is nested within the main RCT study [35]; Pan African Clinical Trials Registry: PACTR201511001345372). Due to limited resources, only adolescents and interventionists who were entered inot the RCT in the first year (2014) were asked to participate. In 2014, 53 adolescents were screened for eligibility for the RCT by independent evaluators, using a structured interview, and 12 met inclusion criteria and were randomised to receive either PE-A or SC. These adolescents were purposively recruited by telephone during 2015, after having completed all post-treatment up and follow-assessments. All adolescents who had participated in the trial during the course of 2014 were invited, regardless of treatment arm or completion status, in an attempt to draw on a broad range of experiences. Ten adolescents agreed to participate in face-to-face, in-depth, interviews. Of the 10 participants, 8 also took part in follow-up focus groups. Two focus groups (4 in each group) were conducted, with each focusing on the type of intervention the adolescents received (PE-A or SC). Six nurses, previously psychotherapy-naïve, volunteered for the RCT and received training in both PE-A and SC and provided both treatments at 4 lower income high schools in Cape Town during 2014. The 6 nurses were purposively recruited by telephone during 2015 for this qualitative study. Three of the nurses consented to participate in individual interviews.

Research instruments

The first author (who was not involved in the RCT) and a research assistant conducted recorded interviews and focus groups during 2015 as follows:

The first author conducted individual face- to- face semi-structured interviews (40–90 minutes) in English or Afrikaans. The discussion schedule focused onparticipants’ previous experiences with counselling, receiving treatment in the school setting, the counselling relationship, usefulness of the intervention, volunteering for the study, and recommendations for future interventions. Adolescents were also encouraged to participate in an English focus group (60 minutes) with the primary purpose of achieving data saturation. The interviewer was blinded to treatment arm for the individual interviews but unblinded for the focus group discussions, which were treatment specific. Interviews took place at the adolescents’ school or at Stellenbosch University’s Health Sciences Campus according to what best suited participants, while focus groups took place at the Health Sciences Campus with a co-facilitator (female fieldworker familiar to participants from Afrikaans middle schools).

Nurse participants did not arrive for the focus groups, so individual semi-structured interviews (60–90 minutes) were conducted. One interview was conducted via Skype as the nurse had returned to her hometown upon completion of her studies. No follow up interviews were conducted, however, nurse transcripts were emailed to participants to confirm the accuracy of the transcripts.

Analysis

Fifteen audio recordings were transcribed by the first author and a research assistant (3 nurse interviews, 10 adolescent interviews, 1 adolescent SC focus group, 1 adolescent PE-A focus group). The first 2 authors read through the transcripts to identify emerging themes. The first author did thematic content analysis using Atlas.ti software to assist with coding the transcripts. After analysis, the second author re-read the transcripts and included any contradicting and/or outstanding data.

This article focuses on two richly described themes: (1) perceptions of the intervention and (2) usefulness of the intervention. Other themes identified have been described elsewhere [33, 34].

Ethics

Stellenbosch University Human Research Ethics Committee approved the study (N12/06/031) and the Western Cape Education Department gave permission for the study to be conducted at the schools. Nurses and parents provided written informed consent and adolescents provided assent. Transcripts were de-identified and stored with the audio- recordings in a locked research office. Participants received reimbursement for their time and transport costs (up to ZAR 75 = US$ 5.45 for adolescents who participated in both the focus group and individual interview and ZAR 50 = US$ 3.36 grocery voucher for the nurses).

Participants

The two adolescents who declined participation were both female and from the SC arm aged 16 (Afrikaans) and 17 (English). Two of the three female nurses who declined participation were Afrikaans speaking, the other was English. Table 1 provides demographic details (with pseudonyms) for consenting participants. For easy reference, pseudonyms are gender specific and start with “N” (nurse), “S” (SC adolescent) or “P” (PE-A adolescent). The last letter indicates if the participant was English, Afrikaans, or Xhosa speaking (ending on letter “e”, “a”, or other respectively).

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Table 1. Participant pseudonyms and demographics.

https://doi.org/10.1371/journal.pone.0199816.t001

Experience with treatment

Note that participants used the term ‘counselling’ to describe both treatment interventions. In an effort to authentically represent responses, the term is used here as said but should not to be confused as a reference to SC only.

Counselling was different from what participants expected. ‘Precious’ anticipated it would be similar to counselling seen on TV and ‘Seuna’ expected the counselling to work faster, like going to the doctor and receiving a tablet. ‘Princess’ and ‘Siyoli’ reported initial uncertainty about confidentiality. Nevertheless, participants experienced great relief in the relationships they forged with nurse counsellors and fieldworkers alike, saying that the fieldworker “always had a smile for me” (‘Seuna’). Similarly ‘Patrick’ said: “[The counsellor] is one of the people who is important in my life. And also [the fieldworker]… They play a very, very huge role in my life.”

Advantages and disadvantages of SC

Nurses mentioned a number of advantages of the SC intervention, including working without a time restriction: “[the child] can share, even if it is just for 5 or 10 minutes” (‘Natalia’), and giving the child “power” and the counsellor “freedom” to work on any issue (‘Natasha’). This was echoed by ‘Sara’ who found the counselling helpful in addressing the death of her father and academic stress.

One disadvantage of this flexibility is described by ‘Natasha’:

“You did not know each day what this one’s reaction will be or what response you will get out of this one… Or you must find the right words to get the reaction or just get the one to say something. It made me kind of anxious.”

In the SC focus group, adolescents described what they did in counselling sessions: play games (e.g. dominoes or cards), write poetry, or draw. Although the games were not central to the treatment strategy (but rather a communicative aid), they were repeatedly highlighted by participants. ‘Sonja’ experienced counselling as more “fun” than expected, and assumed that the games were a distraction technique to “take your mind out of [pause] what happened.”

‘Seuna’ and ‘Sonja’ noted the burden of the paperwork they needed to complete (e.g. symptom self-report assessments). ‘Seuna’ compared it to an exam at school which left his brain tired. However, both participants suggested that they were willing to invest in some unpleasant tasks to get better.‘Sonja’ emphasized her eagerness to engage in the focus group because she felt it would be a forum to share her experiences and to get some sense of normalization.

Advantages and disadvantages of PE-A

Nurses provided mixed reports on delivering PE-A. On the one hand, it was “easier to do” (‘Natasha’) because the intervention manual described each task every step of the way, but due to the perceived manual complexity it was “kind of hard to master” (‘Natalia’). It required a lot more preparation to become familiar with each session’s content, including attempts to “ask the questions from memory” (‘Natalia’) to avoid the children thinking that “you are not listening to them” (‘Noleen’) because of reading questions to them from a manual.

Compared to adolescents who received SC, adolescents who received PE-A provided more descriptive explanations of what took place in their sessions, reflecting on many components central to PE-A, including the use of metaphors, breathing retraining, imaginal exposure, and in-vivo exposure.

Experience of the therapeutic relationship

Regardless of treatment modality, participants listed the counselling relationship as the number one most important component of their experience. They described the counsellors as accepting, maternal, and trustworthy. Many participants highlighted that they would contact the fieldworkers and counsellors in the future should a friend be in need of some help.

“Someone you can trust” (‘Princess’)

‘Susanna’ decided to trust the counsellor because of “the way she spoke and … that she understood everything I said,” while ‘Patrick’ said it was because “she will give me facts” and “she would tell me more about what I don’t understand.” It was important that the counsellor showed interest (‘Princess’, ‘Siyoli’) as demonstrated in the nurse counsellors’ voluntary (unpaid) service. This trust enabled participants to be honest even when they were “not honest with my mother” (‘Paula’).

Navigating therapeutic boundaries

Nurses described how their relationships with the children developed, sometimes leading to boundary considerations. Both ‘Noleen’ and ‘Natalia’ found birthdays exceptionally challenging, wondering if they could not just give a chocolate as a present but “we were not allowed to do that… you must rather not do it” (‘Natalia’). ‘Natasha’ described that simply wishing “them good luck with the exam it meant a lot to them. Just that little extra attention that they received.”

Participants had access to the counsellors’ cellphone numbers. A while after ‘Natasha’ had completed providing the PE-A treatment, one of the participants sent her a text message indicating suicidal intent. ‘Natasha’ was able to refer the participant to receive appropriate help. This was not the only difficulty in terminating the therapeutic relationship as ‘Noleen’ described:

I might be the only person that can do something… That awareness and that understanding ja, it just, it helped me … to be in the process and forget about my own um… other things that I was supposed to do … As much as some of the children had difficulty terminating with me and I also had difficulty terminating with them …. Because it was like, I’m here, I came and then I disappear. And you also find that there are people in their life who were there and then disappeared. So I was like, “what, what system is there?” You know, I would often ask about that. This child from me where is she or he going to go.

(‘Noleen’)

Experience of treatment effectiveness

Adolescents were asked to reflect on their lives before and after the intervention. During the PE-A focus group, there was a powerful non-verbal emotional shift best described as a transition from upbeat camaraderie to quiet reflection. ‘Precious’ described it as “You asked me what does it feel like to be this kind of person that I am today. And I remember where I come from.” ‘Natasha’ and ‘Natalia’ also reflected on the feedback they received from other participants and their teachers to motivate them and make the most benefit of the treatment.

Perception of the impact of PTSD symptomson functioning before and after the-interventions

The rich data reflecting adolescents’ perceptions of the benefits of the intervention is best summarized in light of the following powerful description by ‘Precious’ of her experience with PTSD. This quote formed the basis of findings illustrating whether participants overcame these symptoms.

Well, I was very difficult child. Difficult to deal with because I had that state of mind that nobody would understand me. Nobody would know me. So I was in that blocking space. So I didn’t talk to anyone, didn’t do anything. I started failing and I started having that state of mind that I don’t want anyone to know what I am going through or to think that I’ll be able to talk to anyone. I just wanted to be alone. I didn’t want to think about it. I didn’t want to know how to solve it. I just wanted it to go away. Put it at the back of my mind. But actually at the end it did happen. Because it always came back and always haunting me. I was failing. It was going to affect me and everybody else in my life because I was distant also to my family. It was a horrible time. I just wanted to be alone, wanted to be in my own space. No one could bother me or anything. Now talking to someone in that space: I didn’t want to. Even if someone would ask me, I just blow out in anger. Shout at them. So I didn’t want to get help.

(‘Precious’)

Treatment effectiveness vs transferability

‘Precious’ explained that she is still on a journey despite symptom improvement: “I’m still unleashing that self of mine. I am still busy with that person. But the counselling has really, really helped me.”

‘Sara’ described to others in the SC focus group that she sometimes does not “want to think about it. Then it come and then I do something that don’t remind me of that.” Thereafter, group members admitted that intrusive thoughts occasionally recurred after treatment, making them feel “horrible… unhappy” (‘Sonja’), “very sad” (‘Sara’), and “makes you cry” (‘Siyoli’).

Throughout the individual interview, ‘Sonja’ seemed objectively depressed. She described how classroom conversations about divorce, drugs, absent parents “puts things on [her]” which makes her cry. She uses distraction as a coping mechanism.

‘Siyoli’s’ individual interview suggested that it was not the counselling that enabled her to change, but rather the birth of her child which made her stay at home and try and rebuild a new life. She admitted that, “even now, it is very difficult but not the way it was very difficult… Sometimes come to my mind I must go, leave this baby here. Huh-uh. I must stay at home.”

Overall, adolescents in the SC group perceived distraction as a helpful technique which they continued to apply after treatment termination in the form of “play[ing] with children” (‘Sonja’ & ‘Sara’), “play[ing] with my baby” (‘Siyoli’), “play[ing] with my dog (‘Seuna’) or “cleaning the house” (‘Sara’).

From the nurses’ perspective, SC was more transferable than PE-A. ‘Natalia’ preferred SC because it was better suited to her personality while ‘Natasha’ often implemented the SC skills in her current occupation because of time restraints:

Patients heap up and there are 30 patients on a day that you need to see… there is no time to do the prolonged exposure, not really, but the supportive counselling you can do … Just so that they know there is somebody that listens, there is help, there is somebody you can go to for help. That already makes a big difference.”

‘Noleen’ was thrilled to transfer her newly acquired counselling skills at a private psychiatric facility to engage with an unruly intoxicated patient. “I just use my reflection skill, I just validate her and do all that and slowly the patient was still like, nagging and nagging, but the most important thing is that she was walking [laughing]” (‘Noleen’). She emphasized that if she was able to “memorize” the treatment and had the power to influence her superiors, she would insist on implementing PE-A in her workplace as she experienced it as the most effective treatment.