At the time of writing, my home country, Ukraine, is almost at its 1,000th day of the Russo-Ukrainian war. Considering the strength required to cope with the ever-present threat is devastating; even when the day goes without attacks, ongoing stress and witnessing traumatic events take a toll on one’s mental health (Hyland et al., 2023; Kurapov et al., 2023; Osokina et al., 2023). Reflecting on this war, I realise that modern age circumstances call for complex treatments. However, in Ukraine, the increased need for mental health support faced a lack of resources to provide such help (Seleznova, et al., 2023). In addition to this economic issue, our understanding of the most appropriate and effective psychological support for those under ongoing threat (e.g., ongoing war) is limited (Ennis et al., 2021).
For post-traumatic stress disorder (PTSD), one of the recurring remarks in the DSM-V is about the occurrence of distress after the traumatic event. Consequently, relevant treatment tends to adopt the idea of a “threat” being something in the past or exaggerated due to distress (Ennis et al., 2021). However, a recent paper by Yim et al. (2024) highlights that our understanding of trauma in the context of the past may not be generalisable to cases when the threat is ongoing, such as in a war context. Circumstances like this pose a dilemma: should we focus the treatment on the processing of trauma, or concentrate on coping with the present? Also, it is unclear how psychological support can be best delivered considering the ethical (e.g., practitioners’ wellbeing) and feasibility issues (e.g., governmental regulations).
To examine our academic understanding of this topic, researchers in Oxford (Yim et al., 2024) reviewed the studies on populations under ongoing threat. They synthesised current interventions and highlighted promising avenues for future research.
Existing interventions for trauma may be limited or potentially harmful when applied to populations under ongoing threat (i.e., during a war).
Methods
This systematic review builds on the previous review by Ennis et al. (2021). Here, the researchers widened the scope of trauma-related outcomes to include depression, anxiety and quality of life, as well as the traditionally associated PTSD. Also, in this paper, there was a clear definition of an ongoing threat. The focus was on living in a dangerous situation with ongoing violence and/or intimate partner violence (with acknowledgement of other types of ongoing threat).
The search was carried out according to the PRISMA guidelines, utilising relevant databases. The researchers extracted data on authors and year of publication, geographical location, type and definition of ongoing threat, intervention, effectiveness and feasibility of the intervention (e.g., outcomes, practical challenges).
The inclusion criteria were as follows:
- Peer-reviewed articles with various methodologies (e.g., RCT, mixed-methods, case studies).
- Participants experienced ongoing threats as defined a priori.
- The ongoing threat circumstances pertained to the two types (dangerous situation, intimate partner violence).
- Written in English.
Publications that did not meet these criteria and adhere to good academic practice (e.g., predatory journals) were excluded.
The authors used the Mixed-Method Appraisal Tool to evaluate the studies. The findings from the selected papers were analysed using a narrative synthesis. The authors explored the relationships between the studies and appraised their quality. Yim and colleagues also considered cultural adaptations of the interventions, where applicable.
Results
A total of 18 papers were included in the analysis; these featured 15 trials and 1,867 participants “with elevated levels of trauma-related symptoms, who received psychological interventions while in an ongoing threat context” (p. 580, Yim et al., 2024). Most studies were conducted in Occupied Palestinian Territories and South Africa. The studies were mostly RCTs (n=11), plus non-randomised, non-controlled studies (n=2) and case series (n=2).
The shortest intervention was a one-off 30-minute session; the longest comprised 14 weekly 90-minute sessions. Specialised interventions constituted 46.7%, whilst the rest were non-specialist, e.g., provided by a lay counsellor.
Ongoing threats included: terrorist attacks, shootings, fire, physical and psychological abuse, political and armed violence, and ongoing intimate partner violence. Papers varied in their measurements of the experiences of threat and its consequences, which reflected the unique circumstances and needs of each study.
What were the intervention outcomes?
For populations in dangerous situations, CBT was shown to reduce depression, grief, anxiety, and somatisation (distress due to excessive attention to physical symptoms such as increased heart rate). However, this was not sustained at the follow-ups. Meanwhile, narrative exposure therapy showed some evidence of sustained benefits at 7-20-month follow-up, with mainly reduced PTSD outcomes. Interventions for children gained mixed results; significant improvement was found for PTSD but not for depressive, grief and anger symptoms. Finally, non-CBT interventions demonstrated a large reduction in distress and small to moderate increases in the quality of life scores.
Meanwhile, for cases of ongoing intimate partner violence, many interventions focused on solution-seeking and empowerment. However, the effects on daily functioning were non-significant, with only one study finding significant improvements in depression that were sustained at 6-month follow-up.
How were the interventions adapted to context and culture?
Eight studies modified interventions, with seven of them providing the details. The adaptations included using Thai meditation techniques and metaphors from the Qur’an. Some studies also re-framed the threat into a realistic threat to reflect the circumstances. Researchers also had to review the ethical issues in the given context, such as keeping the intervention secret from the partners of the individuals who experienced intimate partner violence. Overall, the included papers illustrated how the subject of ongoing threat requires cultural sensitivity, mindfulness of the context and additional care around ethical dilemmas.
The review found evidence that trauma-focused CBT and Narrative Exposure Therapy may be beneficial for populations under ongoing threat.
Conclusions
The authors concluded that there are promising results that psychologically informed interventions, especially the CBT-based ones, could benefit people’s mental health when under ongoing threat. However, these interventions are often limited due to practical circumstances. Nonetheless, the studies suggest that it is feasible to carry out such interventions with careful planning, consideration of the unique challenges and ethical issues. The authors conclude that:
…although the quantity and quality of studies does not yet let us draw firm conclusions, this does not negate the importance of the research question and of this review, which we hope other researchers will build on (p. 589).
The results require cautious interpretation due to the numerous methodological limitations and lack of cross-cultural generalisability.
Strengths and limitations
This systematic review has several strengths. Firstly, as the authors state in the aims, the paper extends the existing systematic review by Ennis et al. (2021) with a clear purpose in mind. Also, it stood out to me that Yim and colleagues improved the definition of ongoing trauma and meticulously excluded the studies that shifted the focus to past events. I appreciated their detailed section on the definitions, which also provided a strong justification for using particular search terminology. However, I would be curious to see further development of the taxonomy of ongoing threat; presently, the authors considered two kinds – but is this enough to capture ongoing threat? Recognising the variety of nuances, such as context, duration, intensity, etc. could give us a deeper understanding of what support would be most effective and feasible. Additional strengths include the authors’ transparency and straightforwardness in reporting following PRISMA guidelines, selecting papers, avoiding predatory journals, and discussing the methodological shortcomings of the present research.
The reviewed studies bear several important limitations due to the infancy of this research field and the practical challenges of conducting research in this area. For example, methodological limitations include cross-cultural measures validation, which may not accurately reflect a particular populations’ lived/ing experience. Also, some studies faced early termination or therapists’ dropout due to the circumstances (e.g., political unrest/war). Understandably, it is impossible to predict all practical barriers, but the present literature can serve as a guide to what issues researchers should account for, e.g., ensuring that wellbeing support is readily available to therapists.
Also, the review itself bears some shortcomings. It may not tell the full story as only the articles written in English were considered. We may be missing out on the papers published locally, potentially with an even more in-depth understanding of the circumstances and the challenges faced by individuals under ongoing threat. Lastly, the review did not account for all ongoing conflicts (e.g., the Russo-Ukrainian war), which is to say we should remain critical of the unique socio-political landscape of a population and not generalise between cultures/countries. As the authors suggest, we should aim to provide culturally-sensitive psychological interventions. I appreciate that this has been voiced by the authors; my lived experience of receiving help, be it professional or from my loved ones, I resonate with the need to be mindful of the specific circumstances that cause mental distress. It can be incredibly reassuring and validating to be recognised for your unique circumstances and cultural background.
We need a balanced view of the available evidence that consider the differenciated psychological needs across cultural contexts and the nature of ongoing threat.
Implications for research and practice
Clinical practice
The evidence to date suggests that there are some promising interventions for populations under ongoing threat, but the benefits may be short-term or of low practical significance. This systematic review should not be seen as a guide to “the best” intervention, but rather as an indication of potentially most beneficial interventions that require a larger evidence-base in this context (e.g., trauma-informed CBT).
Importantly, Yim and colleagues show that our understanding of trauma and past-focused interventions may be limited and should not be strictly followed when supporting individuals for whom the threat remains real and ongoing. One of the biggest takeaways from this review for clinical practice will be remaining mindful of the cultural context and service-users’ reality. No less importantly, this also means that clinicians and wellbeing practitioners supporting this population should be wary of personal distress.
Research implications
Whilst the present review did define ongoing threat, there is still a need for an operationalisable term that could be re-applied and used consistently. It will be important to include relevant constructs, such as feelings of hopelessness and emptiness (Yim et al., 2024), as well as creating the tools to assess the nature and level of ongoing threat sensitively and ethically. Of course, as the authors mention, these measures will need to be psychometrically validated, which can be one line of future research.
Additionally, I agree with the authors that it would be intriguing to investigate individual versus collective exposure to traumatic events; how does the trauma of ongoing threat manifest on a personal and how on a collective level? Perhaps, addressing the collective elements of trauma could be more beneficial in highly collectivist cultures. Overall, we should develop a balanced understanding of ongoing threat. This could be identifying common psychological needs (or hierarchy of needs), but also highlighting the distinct outcomes of different types of threats.
“Building culturally sensitive, evidence-based psychological interventions during ongoing threat can one day ease suffering, prevent re-traumatisation, and start earlier healing in marginalised populations.”
Statement of interests
I am a Ukrainian living and studying in the UK, with my family and friends being back at home, in Ukraine. No conflict of interest to declare in relation to the authors of the paper, funding, or being involved in this area of research.
Links
Primary paper
Yim, S. H., Lorenz, H., & Salkovskis, P. (2024). The effectiveness and feasibility of psychological interventions for populations under ongoing threat: A systematic review. Trauma, Violence, & Abuse, 25(1), 577-592.
Other references
Ennis, N., Sijercic, I., & Monson, C. M. (2021). Trauma-focused cognitive-behavioural therapies for posttraumatic stress disorder under ongoing threat: a systematic review. Clinical Psychology Review, 88, 102049.
Hyland, P., Vallières, F., Shevlin, M., Karatzias, T., Ben–Ezra, M., McElroy, E., Vang, M. L., … & Martsenkovskyi, D. (2023). Psychological consequences of war in Ukraine: assessing changes in mental health among Ukrainian parents. Psychological Medicine, 53(15), 7466-7468.
Kurapov, A., Kalaitzaki, A., Keller, V., Danyliuk, I., & Kowatsch, T. (2023). The mental health impact of the ongoing Russian-Ukrainian war 6 months after the Russian invasion of Ukraine. Frontiers in Psychiatry, 14.
Osokina, O., Silwal, S., Bohdanova, T., Hodes, M., Sourander, A., & Skokauskas, N. (2023). Impact of the Russian invasion on mental health of adolescents in Ukraine. Journal of the American Academy of Child & Adolescent Psychiatry, 62(3), 335-343.
Seleznova, V., Pinchuk, I., Feldman, I., Virchenko, V., Wang, B., & Skokauskas, N. (2023). The battle for mental well-being in Ukraine: mental health crisis and economic aspects of mental health services in wartime. International Journal of Mental Health Systems, 17(1).
