La prévalence du trouble de l’état de stress post-traumatique (ESPT) parmi les populations réfugiées victimes de torture et de traumatismes de guerre est une des plus élevées en psychotraumatologie. Cependant, parmi les études ayant permis de recommander la thérapie comportementale et cognitive centrée sur le trauma (TCC-CT) comme première ligne de traitement de l’ESPT, peu ont concerné cette population. Face à ce constat, l’objectif de cet article est de rechercher dans la littérature scientifique internationale l’existence de protocoles TCC-CT spécifiquement adaptés à cette population et de déterminer si leurs études d’évaluation soutiennent une efficacité thérapeutique. Trois adaptations de la TCC-CT émergent depuis une dizaine d’année : la Somatic Focused Cognitive Behavioral Therapy, la Narrative Exposure Therapy et l’Interapy. Malgré le faible nombre d’études contrôlées et randomisées réalisées pour évaluer ces approches et la présence de biais méthodologiques dans celles existantes (faible taille d’échantillon, manque d’évaluation en double-insu, focalisation sur certaines communautés, etc.), les études montrent des résultats positifs et encourageants. D’autres études sont tout de même nécessaires pour confirmer ces résultats préliminaires et comparer l’efficacité thérapeutique des différentes approches entre-elles.

The prevalence of post-traumatic stress disorder (PTSD) among refugees subjected to war and torture is highest in psychotraumatology (Steel et al., 2009 [10Steel Z., Chey T., Silove D., Marnane C., Bryant R.A., van Ommeren M. Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis JAMA 2009 ;  302 (5) : 537-549 [cross-ref]

Cliquez ici pour aller à la section Références]). International guidelines recommend Trauma Focused-Cognitive Behavioral Therapy (TF-CBT) as the first line treatment for this pathology (Bisson et al., 2007 [12Bisson J., Ehlers A., Matthews R., Pilling S., Richards D., Turner S. Psychological treatments for chronic post-traumatic stress disorder. Systematic review and meta-analysis Br J Psychiatry J Ment Sci 2007 ;  190 : 97-104 [cross-ref]

Cliquez ici pour aller à la section Références]; Bisson and Andrew, 2005 [13Bisson J., Andrew M. Psychological treatment of post-traumatic stress disorder (PTSD) Cochrane Database Syst Rev Online 2005 ; CD003388.

Cliquez ici pour aller à la section Références], 2009 [14Bisson J., Andrew M. Psychological treatment of post-traumatic stress disorder (PTSD) (Review) Cochrane Database of Systematic Reviews [Internet] Chichester, UK: John Wiley & Sons, Ltd (2009). 

Cliquez ici pour aller à la section Références]; Foa et al., 2005 [15Foa E.B., Keane T.M., Friedman M.J., Cohen J.A. Practice guidelines from the International Society for Traumatic Stress Studies  New York: Guilford Press (2005). 

Cliquez ici pour aller à la section Références]; National Institute for Clinical Excellence, 2005 [16National Institue for Clinical Excellence Post-traumatic stress disorder (PTSD): the management of PTSD in adults and children in primary and secondary care  London: National Institute for Clinical Excellence (2005). 

Cliquez ici pour aller à la section Références]). The objective of this article is to explore international literature to identify applications and adaptations of TF-CBT for this specific population. To date, three literature reviews have analyzed research assessing psychotherapy with traumatized refugees (Crumlish and O’Rourke, 2010 [21Crumlish N., O’Rourke K. A systematic review of treatments for post-traumatic stress disorder among refugees and asylum-seekers J Nerv Ment Dis 2010 ;  198 (4) : 237-251 [cross-ref]

Cliquez ici pour aller à la section Références]; McFarlane and Kaplan, 2012 [22McFarlane C.A., Kaplan I. Evidence-based psychological interventions for adult survivors of torture and trauma: a 30-year review Transcult Psychiatry 2012 ;  49 (3–4) : 539-567

Cliquez ici pour aller à la section Références]; Nicholl and Thompson, 2004 [20Nicholl C., Thompson A. The psychological treatment of Post Traumatic Stress Disorder (PTSD) in adult refugees: a review of the current state of psychological therapies J Ment Health 2004 ;  13 (4) : 351-362 [cross-ref]

Cliquez ici pour aller à la section Références]). Focusing only on randomized controlled trials assessing TF-CBT protocols, one study was found that compared it to exposure therapy and two adaptations: Somatic Focused-Cognitive Behavioral Therapy and Narrative Exposure Therapy. Another emerging adaptation was found independently: Interapy (Internet-Based Cognitive and Behavioral Therapy). Paunovic and Ost (2001) [23Paunovic N., Ost L.G. Cognitive-behavior therapy vs. exposure therapy in the treatment of PTSD in refugees Behav Res Ther 2001 ;  39 (10) : 1183-1197

Cliquez ici pour aller à la section Références] compared TF-CBT to exposure therapy in a sample of 16 traumatized refugees from Bosnia. Despite a significant decrease in PTSD and major depressive episode (MDE) for both protocols, no difference was found in terms of efficacy. Given the small sample sizes, a replication on a larger cohort is necessary to confirm these preliminary results. Somatic Focused-Cognitive Behavioral Therapy (SF-CBT) was developed for Cambodian refugees arriving in the United States after the Kmer-Rouge genocide (Hinton et al., 2006 [26Hinton D.E., Pich V., Chhean D., Safren S.A., Pollack M.H. Somatic-focused therapy for traumatized refugees: treating posttraumatic stress disorder and comorbid neck-focused panic attacks among Cambodian refugees Psychotherapy 2006 ;  43 (4) : 491-505

Cliquez ici pour aller à la section Références]; Otto et al., 2003 [28Otto M.W., Hinton D.E., Korbly N.B., Chea A., Ba P., Gershuny B.S., et al. Treatment of pharmacotherapy-refractory posttraumatic stress disorder among Cambodian refugees: a pilot study of combination treatment with cognitive-behavior therapy vs sertraline alone Behav Res Ther 2003 ;  41 (11) : 1271-1276 [cross-ref]

Cliquez ici pour aller à la section Références]; Otto and Hinton, 2006 [27Otto M.W., Hinton D.E. Modifying exposure-based CBT for cambodian refugees with posttraumatic stress disorder Cogn Behav Pract 2006 ;  13 (4) : 261-270

Cliquez ici pour aller à la section Références]). The authors adapted TF-CBT to a 10-step protocol focusing primarily on meditation. In the three validation studies (Hinton et al., 2004 [24Hinton D.E., Pham T., Tran M., Safren S.A., Otto M.W., Pollack M.H. CBT for Vietnamese refugees with treatment-resistant PTSD and panic attacks: a pilot study J Trauma Stress 2004 ;  17 (5) : 429-433 [cross-ref]

Cliquez ici pour aller à la section Références], 2005 [25Hinton D.E., Chhean D., Pich V., Safren S.A., Hofmann S.G., Pollack M.H. A randomized controlled trial of cognitive-behavior therapy for Cambodian refugees with treatment-resistant PTSD and panic attacks: a cross-over design J Trauma Stress 2005 ;  18 (6) : 617-629 [cross-ref]

Cliquez ici pour aller à la section Références]; Hinton et al., 2009 [29Hinton D.E., Hofmann S.G., Pollack M.H., Otto M.W. Mechanisms of efficacy of CBT for Cambodian refugees with PTSD: improvement in emotion regulation and orthostatic blood pressure response CNS Neurosci Ther 2009 ;  15 (3) : 255-263

Cliquez ici pour aller à la section Références]), comparing SF-CBT (n=38) to wait-list control groups (n=38), a greater reduction was found for PTSD and MDE in the active treatment groups. Nevertheless, more studies should be done on larger samples, with other refugee populations and against other active treatments to generalize the conclusion of therapeutic efficiency. Narrative Exposure Therapy (NET) was developed as a short-term standardized TF-CBT treatment easily implemented in refugee camps (Schauer et al., 2005 [33Schauer M., Neuner F., Elbert T. Narrative exposure therapy: a short-term intervention for traumatic stress disorders after war, terror, or torture  Toronto: Hogrefe & Huber (2005). 68

Cliquez ici pour aller à la section Références]). NET combines CBT exposure principles to the methodology of testimony therapy. Patients are invited to chronologically narrate their life story while the therapist transcribes it. Each time a traumatic event is described, a prolonged imagery exposure technique is used and repeated until the habituation of the triggered emotional response is achieved. Six studies assessed therapeutic efficacy of this approach (Bichescu et al., 2007 [34Bichescu D., Neuner F., Schauer M., Elbert T. Narrative exposure therapy for political imprisonment-related chronic posttraumatic stress disorder and depression Behav Res Ther 2007 ;  45 (9) : 2212-2220 [cross-ref]

Cliquez ici pour aller à la section Références]; Halvorsen and Stenmark, 2010 [35Halvorsen J.Ø., Stenmark H. Narrative exposure therapy for posttraumatic stress disorder in tortured refugees: a preliminary uncontrolled trial Scand J Psychol 2010 ;  51 (6) : 495-502

Cliquez ici pour aller à la section Références]; Hensel-Dittmann et al., 2011 [37Hensel-Dittmann D., Schauer M., Ruf M., Catani C., Odenwald M., Elbert T., et al. Treatment of traumatized victims of war and torture: a randomized controlled comparison of narrative exposure therapy and stress inoculation training Psychother Psychosom 2011 ;  80 (6) : 345-352

Cliquez ici pour aller à la section Références]; Neuner et al., 2008 [30Neuner F., Onyut P.L., Ertl V., Odenwald M., Schauer E., Elbert T. Treatment of posttraumatic stress disorder by trained lay counselors in an African refugee settlement: a randomized controlled trial J Consult Clin Psychol 2008 ;  76 (4) : 686-694 [cross-ref]

Cliquez ici pour aller à la section Références], 2009 [31Neuner F., Kurreck S., Ruf M., Odenwald M., Elbert T., Schauer M. Can asylum-seekers with posttraumatic stress disorder be successfully treated? A randomized controlled pilot study Cogn Behav Ther 2009 ;  39 (2) : 81-91

Cliquez ici pour aller à la section Références]; Neuner et al., 2004 [32Neuner F., Schauer M., Klaschik C., Karunakara U., Elbert T. A comparison of narrative exposure therapy, supportive counseling, and psychoeducation for treating posttraumatic stress disorder in an African refugee settlement J Consult Clin Psychol 2004 ;  72 (4) : 579-587 [cross-ref]

Cliquez ici pour aller à la section Références]). NET was compared to supportive counseling, psychoeducation, trauma counseling, no-treatment, treatment as usual, and stress inoculation training and each comparison showed a significant and greater decrease on PTSD measures than the control group. Although it did not appear in any literature review, Interapy, or Internet Based Cognitive and Behavioral Therapy, was identified as an emerging and interesting approach to help traumatized war and torture survivors living in areas where no mental health resources exist (Knaevelsrud et al., 2007 [38Knaevelsrud C., Wagner B., Karl A., Mueller J. New treatment approaches: integrating new media in the treatment of war and torture victims Torture 2007 ;  17 (2) : 67-78

Cliquez ici pour aller à la section Références]). Interapy is an Internet adaptation of TF-CBT in which the therapist and patient communicate exclusively through email. The patient receives therapist guidelines by emails that consist of different written exposure assignments. Only one preliminary study (Wagner et al., 2012 [44Wagner B., Schulz W., Knaevelsrud C. Efficacy of an internet-based intervention for posttraumatic stress disorder in Iraq: a pilot study Psychiatry Res 2012 ;  195 (1–2) : 85-88

Cliquez ici pour aller à la section Références]) assessed the evolution of PTSD, MDE, anxiety and quality of life before and after the five-week Interapy treatment in a sample of 40 Iraqi traumatized individuals. Despite the high number of dropouts and the lack of a control group, this study showed encouraging results on all variables. In conclusion, despite the small number of randomized controlled trials and the methodological bias existing in those that exist (small sample size, lack of double-blind assessment, focus on specific communities, etc.), TF-CBT, SF-CBT, NET and Interapy have shown positive and encouraging results in treating PTSD in the refugee torture victim population. More research is, however, needed to confirm these results and determine optimal efficacy.