Impact of Testimony Psychotherapy on PTSD and Depression
Our findings indicate that testimony psychotherapy decreased both PTSD diagnosis and severity in a group of refugees to the United States who were survivors of state-sponsored violence in Bosnia-Herzegovina. This finding is generally consistent with those of Cienfuegos and Monelli (
1). Our use of standardized instruments, follow-up assessments, and statistical analysis provides additional substantiation of their findings.
Our clinical and research experience indicates that when one thinks of testimony psychotherapy’s possible clinical impact, the changes in PTSD symptom severity, which occurred across all three symptom clusters, would appear to have at least as much clinical significance as the presence or absence of the diagnosis of PTSD. We found that testimony psychotherapy also led to a reduction of depressive symptoms that often accompany PTSD in this population. For the subjects in our study, there were no apparent negative effects of giving testimony.
These findings run contrary to the opinion that we have often encountered among survivors, refugee resettlement workers, and health care providers: that it is not helpful to tell the trauma story. Our findings provide some evidence to support the claim that telling the trauma story through testimony psychotherapy can reduce symptoms and improve survivors’ psychosocial functioning. When successful, telling their stories can enable survivors to advance on the path to recovery, accepting new responsibilities and regaining satisfactory functioning in their families, their workplaces, and their new surroundings.
Use of Testimony Psychotherapy
The testimony method of psychotherapy is one of numerous interventions that mental health professionals have for working with survivors of state-sponsored violence. It may be the sole intervention with a survivor, or as is often the case in the psychiatric treatment of trauma, it may be used adjunctively with other methods of psychotherapy, with pharmacotherapy, or with other forms of psychosocial assistance. These treatments can be used before, during, or after testimony psychotherapy.
There is still much to learn about the indications for the use of testimony. Our experience working with Bosnian survivors has demonstrated that individuals with severe clinical forms of PTSD (e.g., high severity of traumatic stress or dissociative symptoms) tend to benefit from initial psychopharmacological treatment. Testimony psychotherapy can be introduced subsequent to reduction of symptoms to a more moderate level.
There are several psychological, somatic, and social conditions that may render testimony psychotherapy ineffective for the individual survivor: severe impairment of thinking and judgment due to a psychotic or affective disorder, severe cognitive deficits due to an organic brain syndrome, substance abuse, preexisting personality disorders that interfere with the establishment of a good working relationship, and serious somatic disorders. On the other hand, there are many survivors who are highly disinclined to seek or accept psychiatric treatment from a clinician but who would participate in testimony psychotherapy in the community.
When survivors are told about testimony psychotherapy, they learn about the history of testimony work with survivors of human rights violations in Chile, the Holocaust, and Bosnia-Herzegovina. It is explained to the survivors that there is a reasonable chance that the procedure will help them to diminish their traumatic stress symptoms. It is also explained 1) that part of the aim of testimony is to counter nationalism and violence and to promote peace, solidarity, and human rights and 2) that these efforts may involve sharing their testimony. The survivor’s understanding and accepting this approach are key factors in the development of a working alliance with the therapist that allows the testimony work to begin. The therapist must thoroughly address any concerns that the survivor has about confidentiality or safety before proceeding with testimony.
Factors Hypothesized to Contribute to the Testimony Method’s Clinical Efficacy
On the basis of our work and the existing literature (
1–
5), we can further describe some of the special aspects that testimony psychotherapy provides that may account for the clinical improvements in survivors of political violence. These factors can be thought of as relational, integrative, ritual, and social.
Testimony psychotherapy is relational. Two individuals, a survivor and a listener, enter into a relationship that centers on the task of documenting and communicating the survivor’s story. As in other psychotherapies, the relationship must be safe, trusting, and caring. In testimony, the listener must have adequate knowledge of the historical events through which the survivor lived. The story belongs, first and foremost, to the survivor; in some ways, however, the story belongs to the relationship. In most cases, were it not for the relationship, the story would not be told and documented at all, because most persons who give testimony are not members of the cultural or professional elite who are likely to write their own testimony. The testimony is relational in another sense: the listener plays a major role in facilitating the unfolding of the narrative and reframing the story. In our experience, the story that comes out of testimony is different from the stories that come out of survivors’ solitary attempts to render their experiences into stories, regardless of their narrative abilities.
Testimony psychotherapy is integrative. It provides an opportunity for the survivor to assimilate dissociated fragments of traumatic memory and to associate affective and cognitive aspects of the experience. Through abreaction of different emotions in the context of a trusting relationship, there is an opportunity for catharsis, but clearly for something more. By covering the life course of individual survivors, testimony opens the way for a life history review and for integration of traumatic memories of ethnic cleansing into the longitudinal saga of the life history. Testimony provides a time for an individual to look back over and reconsider his or her previous attitudes concerning, for example, ethnic identity, forgiveness, and violence. The listener may help to reframe the survivors’ stories away from ethnic hatreds and toward a perspective that values universal human rights above all else.
Testimony psychotherapy is ritual in a number of senses. In one sense, the ritual of giving testimony is synonymous with the oral tradition in the cultures of the Balkans (
30). In another sense, testimony involves the creation of a ritual space, as described by Agger and Jensen (
4). Although our testimonies were not done in the physical setting of a “blue room,” as Agger describes her work with exiles in Denmark, we were able to create a similar “social-psychological space” in refugees’ homes and in the refugee community center. In part, that involved thinking about testimony as consisting of three ritual acts. The first ritual is the signing of the informed consent for participation in the project. It marks the point in the relationship when the survivor and the listener make an explicit agreement to embark on the project of documenting the trauma story. The second ritual is when the testimony is signed by the survivor, marking the end of the receiving process. The third ritual is when the survivor’s testimony is presented to others, either directly by the survivor or indirectly through the text.
What may most distinguish testimony from other forms of psychotherapy is its social aspect. Its explicit aims are to move the trauma story outside of the narrowing prisms of individual psychopathology and the psychotherapeutic dyad and to reframe the survivor’s story in the social and historical context where the etiologic factor of state-sponsored violence originally took place. For the survivor, this may be a necessary factor that permits the “entry into meaning” (
31), whereby the stories that one tells can address painful and shameful memories and take a strong step in the direction of reconstruction for the self, identity, and sense of connectedness, in relation to the collectives to which one belongs.
Testimony shares with cognitive behavioral approaches many aspects of the relational, integrative, and ritual factors. It seems likely that even though their respective theories draw more attention to differences then to similarities, there are some areas of overlap between testimony and cognitive behavioral therapy, such as interpersonal context, imaginal exposure, narrativization, life history review. It is our impression, however, that most of the refugees in this group would not have agreed to participate in receiving a clinical psychiatric intervention that was divorced from social context and meaning. Thus, the fact that testimony deals with the social dimension while cognitive behavioral therapies do not becomes important as an organizing concept for undertaking the activity in the absence of help-seeking behavior that would otherwise lead to mental health services. One implication is that the group that may be best able to benefit from testimony is precisely a group of survivors who would not be found in a clinic population. Further research in the treatment of PTSD with testimony and cognitive behavior interventions may try to isolate these factors to understand better their possible impact.
Limitations of This Study and Implications for Future Studies
This was a preliminary study that had a number of limitations. As in other treatment studies of trauma, it focused upon a distinct subject group, which should militate against generalization of findings to other groups. However, the attempt to address the unique aspects of a given group and to see the treatment intervention in a broad context that addresses ethnocultural and sociohistorical factors is consistent with recent recommendations for research (
9). This study is also limited because the validity of our study instruments may be affected by linguistic and ethnocultural differences, presenting daunting challenges for the cross-cultural PTSD researcher (
32).
Our subject group was composed of individuals who volunteered to give testimony. A larger study with a more representative group, comparison groups (i.e., supportive psychotherapy only versus no intervention), and blind raters is needed to demonstrate and characterize more definitively the clinical effectiveness of testimony therapy. Because we do not believe that testimony therapy should work for all traumatized refugees at all times, we would not consider such broad effectiveness an appropriate aim of investigation. Further studies, however, could help to identify the best conditions for testimony work, in consideration of factors such as age, gender, level of education, types of traumatic events reported, time since trauma, time since arrival in the United States, previous treatments, PTSD and psychiatric comorbidity, past and present use of medications, and follow-up treatments. It would also be valuable to do a comparative investigation of the use of testimony across different recovery environments, such as the United States, Croatia, and Bosnia-Herzegovina.
Last, if clinical research investigations into testimony were conducted along with interdisciplinary ethnographic inquiries, we might better understand the psychological, social, and cultural phenomena at play when survivors tell their stories.