Although war-trauma victims are at a higher risk of developing PTSD, there is no consensus on the effective treatments for this condition among civilians who experienced war/conflict-related trauma. This paper assessed the effectiveness of the various forms of cognitive-behavioral therapy (CBT) at lowering PTSD and depression severity. All published and unpublished randomized controlled trials studying the effectiveness of CBT at reducing PTSD and/or depression severity in the population of interest were searched. Out of 738 trials identified, 33 analysed a form of CBTs effectiveness, and ten were included in the paper. The subgroup analysis shows that cognitive processing therapy (CPT), culturally adapted CPT, and narrative exposure therapy (NET) contribute to the reduction of PTSD and depression severity in the population of interest. The effect size was also significant at a level of 0.01 with the exception of the effect of NET on depression score. The test of subgroup differences was also significant, suggesting CPT is more effective than NET in our population of interest. CPT as well as its culturallyadapted form and NET seem effective in helping war/conflict traumatised civilians cope with their PTSD symptoms. However, more studies are required if one wishes to recommend one of these therapies above the other.
Exposure therapy (ET) refers to a series of procedures designed to help individuals confront thoughts, and safe or low-risk stimuli, that are feared or avoided . Applied to the treatment of PTSD, most exposure therapy programs include imaginal exposure to the trauma memory and in vivo exposure to reminders of the trauma or triggers for trauma-related fear and avoidance . In 2002, Neuner's research team developed a new form of ET called Narrative Exposure Therapy (NET). NET is a standardized short-term approach in which the classical form of ET is adapted to meet the needs of traumatized survivors of war and torture . As most of the victims of organized violence have experienced many traumatic events, it is often impossible for them to identify the worst event before treatment. To overcome this difficulty, the team combined with ET, the testimony therapy's approach of Lira and Weinstein designed to treat traumatized survivors of the Pinochet regime in Chile . Instead of defining a single event as a target in therapy, the patient constructs a narration of his whole life from birth up to the present situation while focusing on the detailed report of the traumatic experiences . This treatment has shown low dropout rates in different studies. Many think that the main motivator of NET is the anticipation of receiving a written biography upon completion, that can help participants pass on their story to their children, while simultaneously educating them .
Stress Inoculation Training (SIT) is a multicomponent anxiety management treatment program that includes education, muscle relaxation training, breathing retraining, role playing, covert modeling, guided self-dialogue, and thought stopping . Cognitive therapy (CT) predicated the idea that it is one's interpretation of an event rather than the event itself that determines emotional reactions. It involves identifying erroneous or unhelpful cognitions, evaluating the evidence for and against these cognitions, and considering whether the cognitions are the result of cognitive biases or errors, in the service of developing more realistic or useful cognitions . Cognitive processing therapy (CPT) implements exposure to the trauma memory via writing a trauma narrative and repeatedly reading it, and is combined with CT focused on themes of safety, trust, power/control, esteem, and intimacy . A culturallyadapted form of CPT was developed in 2004 by a team of researchers from Massachusetts to fit the needs of traumatised Cambodian refugees with pharmacotherapy-resistant PTSD . Dialectical behavior therapy (DBT) is a comprehensive treatment developed for the treatment of individuals with borderline personality disorder. An important aspect of DBT is skills training in affect regulation and interpersonal regulation. Some trauma survivors may have deficits in these skill areas that render it difficult for them to tolerate or benefit from trauma-focused interventions such as ET .
The first subgroup analysis revealed that CPT, culturallyadapted CPT, and NET can significantly contribute to the PTSD severity reduction. However, the first two forms of CBT seem to have a higher effect on PTSD severity reduction than NET. We cannot exclude the possibility that those two forms of CBT might be the most adapted to the needs of patients of the population of interest. However, other reasons might have resulted in the superiority effect observed. First, it is possible that culturallyadapted CPT and CPT had a higher effect on PTSD severity reduction because they were all conducted in the participants' native language by people familiar with their culture. In fact, not all of the NET trials were conducted in the participants' native language, and the amount of trials available was too low to conduct a subgroup analysis that assesses the impact of interpreters on PTSD severity reduction. The observed difference might have also resulted from the variety of participants included in the NET trials compared to the other forms. In fact, the NET trials were conducted in different countries (Uganda, Germany, and Romania) with different settings and participants from different origins, while all the culturallyadapted CPT were conducted in Massachusetts with participants living in a more stable economic/politic context. It is possible that participants who are still living in the conflict-affected country are less inclined to fully benefit from the success of psychotherapy even when they need it. This idea derived from the comparison of the trial conducted by Bichescu et al.  to the ones conducted in Uganda [16, 30]. The former trial is the most effective, and this is likely due to the fact that the communist regime in Romania was over and most of the participants are living in a more peaceful environment than the refugees living in camps (most of them without decent lodging, food, or health services). Our hypothesis seems to be confirmed with the results of the trials that studied the effectiveness of NET among refugees in Germany, results which were in favour of the intervention.
The second subgroup analysis conducted revealed that culturallyadapted CPT and NET were effective in reducing the severity of depression in our population of interest. However, the effect size of NET therapy compared to control condition (Psychoeducation, Trauma Counselling or No treatment) was not significant. With regards to PTSD outcome, results show that culturallyadapted CPT is more effective than NET in depression severity reduction. The reasons described earlier might have also caused the results obtained.
In comparison to CPT, NET is a more contemporary method and more researched method of treatment in the population of interest (5 out of 10 trials compared it to another type of therapy). NET also seems to be the most adapted method to our population of interest because it is designed to suit their need and its effectiveness has been proven in different trials. Our meta-analysis also confirmed that it can help subjects of our population of interest in lowering the severity of their PTSD and depression symptoms. Even if NET does not appear to be the most effective treatment, the fact that it has been applied with success to participants from diverse origins (Romania, Somalia, Sudan, Turkey, Balkans, and Uganda) makes it easier to generalise its effectiveness among the population of interest. We also think that this form of CBT will probably benefit from integrating the variable of culture into the design of their sessions.
Physical and sexual violence committed against women during war time have always being condemned by institutions but more needs to be done to help the victims pick up the remaining pieces of life, regain confidence, and recover from their trauma. Unfortunately, there is limited and disparate information on what intervention is the most appropriate and effective for this category of victims. The primary objective of this systematic review is to assess whether the different forms of CBT can successfully help adult civilians (specifically women) who experienced war-or-conflict-related trauma (imprisonment, torture, sexual abuse, rape, kidnapping, or detainment against will) cope with the symptoms of PTSD and depression. Secondary, we identify which form of CBT is more efficient in reducing the severity of the previously cited outcomes. 2b1af7f3a8