Psychological Interventions Amid Ongoing Threats

As I reflect on my home country, Ukraine, nearing the 1,000^th day of the Russo-Ukrainian war, it is clear that the emotional and psychological toll of living under constant threat is profound. Even on days devoid of direct attacks, the psychological burden of stress and witnessing traumatic events can severely impact one’s mental health (Hyland et al., 2023; Kurapov et al., 2023; Osokina et al., 2023). This ongoing conflict underscores the urgent need for comprehensive mental health treatments. Unfortunately, in Ukraine, the increasing demand for psychological support is met with a significant lack of resources and infrastructure to effectively address these needs (Seleznova, et al., 2023). Moreover, our understanding of effective psychological interventions for individuals facing persistent threats, such as war, remains limited (Ennis et al., 2021).

In the context of post-traumatic stress disorder (PTSD), the DSM-V emphasizes the emergence of distress primarily after a traumatic event has occurred. This conventional approach often frames trauma as a relic of the past, potentially leading to misconceptions that distort treatment efficacy (Ennis et al., 2021). However, recent findings by Yim et al. (2024) suggest that our traditional views on trauma may not adequately apply to individuals enduring ongoing threats like those faced during wartime. This raises critical questions: should therapeutic efforts focus on processing past trauma, or should they prioritize coping strategies for present circumstances? Furthermore, the ethical considerations surrounding the delivery of psychological support, such as the well-being of practitioners and the constraints imposed by governmental regulations, complicate these discussions.

To deepen our understanding of psychological interventions in contexts of ongoing threat, researchers at Oxford (Yim et al., 2024) meticulously reviewed existing studies on affected populations. Their synthesis of current intervention strategies highlights not only the challenges but also the promising avenues for future research, emphasizing the necessity for adaptable and context-sensitive approaches.

Comprehensive Overview of Methodological Approaches in Trauma Research

This systematic review builds upon the foundational work of Ennis et al. (2021), expanding the focus to encompass a broader range of trauma-related outcomes, including depression, anxiety, and overall quality of life, alongside the traditional focus on PTSD. A key aspect of this review is the explicit definition of what constitutes an ongoing threat, specifically targeting individuals living in dangerous situations characterized by persistent violence and/or intimate partner violence, while also recognizing other forms of ongoing threats.

The researchers conducted a rigorous search adhering to PRISMA guidelines, utilizing various relevant databases to ensure a comprehensive review. They meticulously extracted data regarding authorship, publication year, geographical context, types and definitions of ongoing threats, interventions employed, and the effectiveness and feasibility of these interventions, such as measurable outcomes and practical challenges encountered during implementation.

The criteria for inclusion in this review were carefully defined to ensure quality and relevance:

• Peer-reviewed articles employing diverse methodologies (e.g., RCTs, mixed-methods studies, case studies).
• Participants who experienced ongoing threats as defined a priori.
• The ongoing threat circumstances specifically related to two categories (dangerous situations and intimate partner violence).
• Publications available in English.

Studies that did not meet these criteria or adhered to poor academic standards (e.g., predatory journals) were excluded to maintain the integrity of the review.

Using the Mixed-Method Appraisal Tool, the authors evaluated the quality of the selected studies. The analysis of findings utilized a narrative synthesis approach, enabling the authors to explore relationships among the studies and assess their collective quality. Yim and colleagues also took into account the cultural adaptations of interventions when applicable, emphasizing the importance of context.

Key Findings on Psychological Interventions Under Ongoing Threat

A total of 18 studies were included in this comprehensive analysis, featuring 15 trials and encompassing 1,867 participants who were described as “experiencing elevated levels of trauma-related symptoms while receiving psychological interventions amidst ongoing threats” (p. 580, Yim et al., 2024). The majority of these studies were carried out in the Occupied Palestinian Territories and South Africa. The methodological landscape was diverse, with most studies being randomized controlled trials (n=11), alongside non-randomized, non-controlled studies (n=2) and case series (n=2).

Among the interventions examined, the duration varied significantly; the shortest being a single 30-minute session, while the longest spanned 14 weekly sessions of 90 minutes each. Notably, specialized interventions accounted for 46.7% of the total, while the remainder were provided by non-specialist practitioners, such as lay counselors.

Types of ongoing threats addressed included incidents such as terrorist attacks, shootings, ongoing fires, and various forms of physical and psychological abuse, alongside political and armed violence, as well as persistent intimate partner violence. The studies exhibited variability in their metrics for assessing experiences of threat and its associated consequences, reflecting the unique circumstances and specific needs of each research context.

Evaluating Intervention Outcomes for Populations in Crisis

For individuals enduring dangerous situations, Cognitive Behavioral Therapy (CBT) demonstrated efficacy in reducing symptoms of depression, grief, anxiety, and somatic distress (which refers to discomfort arising from excessive focus on physical symptoms, such as an accelerated heart rate). However, these positive effects were not consistently maintained during follow-up assessments. In contrast, narrative exposure therapy provided evidence of sustained benefits at follow-ups ranging from 7 to 20 months, particularly in diminishing PTSD symptoms. Interventions targeting children yielded mixed results; while significant improvements were observed in PTSD symptoms, there were no notable changes in depressive, grief, and anger symptoms. Additionally, non-CBT interventions were associated with substantial reductions in distress and modest improvements in quality of life scores.

For survivors of ongoing intimate partner violence, many interventions emphasized solution-seeking and empowerment strategies. However, the impact on daily functioning was largely insignificant, with only one study reporting noteworthy improvements in depression that persisted at a 6-month follow-up.

Cultural and Contextual Adaptations of Interventions

Eight studies indicated that they modified their interventions, with seven detailing specific adaptations made. These adaptations included the incorporation of Thai meditation techniques and contextual metaphors drawn from the Qur’an. Certain studies also reframed the nature of the threat to align with the participants’ lived realities. Ethical considerations were also pivotal, particularly in contexts where confidentiality was crucial, such as keeping interventions discreet from partners of individuals experiencing intimate partner violence. Overall, the papers included in this review illustrate the necessity of applying cultural sensitivity, contextual awareness, and ethical diligence when addressing the needs of populations facing ongoing threats.

Insights and Future Directions in Trauma Research

The authors concluded that there are significant indications that psychologically informed interventions, particularly those based on CBT, have the potential to positively impact individuals’ mental health while they are under ongoing threat. Nonetheless, the practical limitations surrounding these interventions can hinder their effectiveness. Despite these challenges, the studies indicate that it is feasible to implement such interventions with careful planning and consideration of the unique challenges posed by ongoing threats and related ethical issues. The authors summarize their findings with the following statement:

…though the volume and quality of available studies do not yet allow for definitive conclusions, this does not diminish the significance of the research question or the findings of this review, which we anticipate will inspire further inquiries in the field (p. 589).

Evaluating Strengths and Limitations of the Review

This systematic review boasts several strengths, foremost among them being its extension of the existing review by Ennis et al. (2021), which was conducted with a clear and targeted purpose. The authors, Yim and colleagues, significantly refined the definition of ongoing trauma, ensuring that studies focusing on past events were meticulously excluded. I found their thorough section on definitions particularly valuable as it provided a solid rationale for the terminology used in the search process. However, I would be intrigued to see a more developed taxonomy of ongoing threat; currently, the authors explore only two categories, but this may not fully capture the complexity of ongoing threats. Recognizing a broader spectrum of nuances, such as context, duration, and intensity, could enrich our understanding of what kind of support might be most effective and practical. Additional strengths of the review include the authors’ transparency and integrity in reporting, adherence to PRISMA guidelines, and careful selection of papers to avoid predatory journals while addressing the methodological shortcomings inherent in the current research.

However, the studies reviewed also present significant limitations, largely stemming from the nascent stage of this research domain and the practical hurdles associated with conducting studies in such contexts. Methodological shortcomings include the validation of cross-cultural measures, which may not accurately reflect the lived experiences of specific populations. Moreover, some studies were prematurely terminated or experienced therapist dropout due to the tumultuous circumstances (e.g., political unrest/war). While it is understandable that not all practical challenges can be anticipated, the existing literature can serve as a valuable guide for future researchers to consider the necessity of ensuring that appropriate wellbeing support is available to therapists.

Additionally, the review itself has some limitations. Notably, it may not provide a complete picture since only articles published in English were included. This exclusion may overlook valuable local studies that provide deeper insights into the unique circumstances and challenges faced by those under ongoing threat. Furthermore, the review did not encompass all current conflicts (e.g., the Russo-Ukrainian war), highlighting the importance of remaining critical of the specific socio-political contexts of different populations and refraining from generalizations across cultures or countries. As emphasized by the authors, there is a pressing need for culturally-sensitive psychological interventions. This resonates deeply with my personal experiences in seeking support, whether from professionals or loved ones, as it highlights the importance of being recognized for one’s unique circumstances and cultural background in the healing process.

Future Directions for Research and Clinical Practice

Enhancing Clinical Practice for Ongoing Threat Populations

Current evidence suggests that there are several promising interventions for populations enduring ongoing threats, although the benefits may manifest as short-term or of limited practical significance. This systematic review should not be viewed as a definitive guide to “the best” intervention but rather as a framework identifying potentially beneficial interventions that necessitate a larger evidence base in this context (e.g., trauma-informed CBT).

Crucially, Yim and colleagues highlight that our understanding of trauma, particularly regarding past-focused interventions, may be inadequate and should not be rigidly applied when assisting individuals for whom the threat remains both real and ongoing. One of the primary takeaways for clinical practice is the importance of remaining attuned to the cultural context and the lived realities of service users. It is equally important for clinicians and wellbeing practitioners to remain aware of their own emotional distress while providing support.

Research Opportunities and Implications

While the current review has defined ongoing threat, there remains a pressing need for a more operationalizable term that can be consistently applied across studies. The inclusion of relevant constructs, such as feelings of hopelessness and emptiness (Yim et al., 2024), is critical, as is the development of tools designed to sensitively and ethically assess the nature and intensity of ongoing threats. These measures will also need to undergo psychometric validation, representing a fruitful avenue for future research.

Additionally, I concur with the authors that it would be fascinating to explore individual versus collective exposure to traumatic events; how does trauma manifest on both personal and collective levels? Addressing collective trauma may yield more positive outcomes in highly collectivist cultures. Ultimately, we must strive to develop a nuanced understanding of ongoing threat, which involves identifying shared psychological needs (or a hierarchy of needs) while also recognizing the distinct impacts of various types of threats.

Disclosure of Interests and Personal Background

As a Ukrainian citizen residing and studying in the UK, with family and friends still in Ukraine, I declare no conflicts of interest regarding the authors of the paper, any funding sources, or involvement in this research area.

Essential Resources and References

Primary Research 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.

Additional References

Ennis, N., Sijercic, I., & Monson, C. M. (2021). Trauma-focused cognitive-behavioral 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