Research Article

Randomized Controlled Trial on the Healing Drawing Procedure (HDP) Group Trauma-Sensitive Treatment Intervention Provided by Non-Specialized Mental Health Providers to Internally Displaced People Living in the Cabo Delgado Province of Northern Mozambique

Leonardo Lino¹, Clara Bigel², Smith Sadie³*, Nicolle Mainthow⁴ and Givaudan Martha⁵

¹International Organization for Migration (IOM), Pemba, Cabo Delgado Province, Mozambique

²International Organization for Migration (IOM), Pemba, Cabo Delgado Province, Mozambique

³Department of Research, Breakout, Denver, United States of America

⁴Department of Research, EMDR Mexico, Mexico

⁵Department of Research, EMDR Mexico, Mexico

Submission:December 20, 2024;Published:February 20, 2025

*Corresponding author: Sadie Smith, Department of Research, Breakout, Denver, United States of America

How to cite this article: Lino L, Bigel C, Smith S, Mainthow N, Givaudan M. Randomized Controlled Trial on the Healing Drawing Procedure (HDP) Group Trauma- Sensitive Treatment Intervention Provided by Non-Specialized Mental Health Providers to Internally Displaced People Living in the Cabo Delgado Province of Northern Mozambique (2025). Psychol Behav Sci Int J. 2025; 23(1): 556101. DOI: 10.19080/PBSIJ.2025.22.556101.

Abstract

This randomized controlled trial had two objectives: 1) to evaluate the efficacy, safety, and efficiency of the Healing Drawing Procedure (HDP) group trauma-sensitive treatment intervention in reducing posttraumatic stress disorder (PTSD) symptoms among internally displaced people (IDPs) living in the Cabo Delgado Province of northern Mozambique, specifically the town of Pemba, and 2) to explore the efficacy, safety, and efficiency of non-specialized mental health providers (MHPs), also referred to as frontline workers, providing the HDP treatment after receiving training. 125 adults (78 females, 47 males) with a mean age of 40.4 years old participated in the study. A two-arm longitudinal randomized control trial (RCT) design was applied, comparing an immediate treatment group (ITG) and a waitlist/delayed treatment group (DTG) at four time points. ANOVA analysis showed significant differences by time with a large effect size (F (3, 123) = 307.17, p = <.001, η2 =.714) and by group with a medium effect size (F (1, 123), 145.54, p = <.001, η2 =.542). No significant differences by group were found at baseline. The comparison of means through time points highlights a large effect size between pre-treatment and post-treatment measurements in both the ITG and the DTG, with a significant decrease in PTSD symptoms, which was maintained at follow-up.

Keywords: Healing Drawing Procedure, HDP; Trauma Healing Training Program, (THTP); posttraumatic stress disorder (PTSD); non-specialized mental health providers (MHPs); frontline workers; mental health psychosocial support (MHPSS); low-and-middle-income countries (LMIC); Adaptive Information Processing (AIP)-Informed; internally displaced person (IDP).

Introduction

The Cabo Delgado Province of northern Mozambique has been severely affected by ongoing violence and conflict since 2017, leading to widespread displacement and conflict-related trauma exposure among its residents. Non-state armed groups (NSAGs) have engaged in brutal attacks, resulting in thousands of deaths and the displacement of over 900,000 people [1]. According to the Displacement Tracking Matrix of the International Office of Migration (IOM), 709,529 Internally Displaced People (IDPs), including 177,987 households, were identified in the region between November and December 2023, with 48% of those IDPs reporting being displaced more than three times [2]. This kind of conflict, displacement, and exposure to psychological distress contributes to a heightened risk of developing mental health difficulties, including symptoms of anxiety, depression, and posttraumatic stress disorder (PTSD). It is well established that the prevalence of PTSD is high among IDPs, with the percentage varying depending on the region [3-9] and that IDPs are more likely to develop anxiety, depression, and stress than non-IDPs in conflict-affected regions [10]. A meta-analysis and systematic review found that the pooled prevalence of PTSD among IDPs in Africa was 51% [11]. The impacts of PTSD lead to a greater likelihood of developing comorbid mood disorders, anxiety disorders, and substance use disorders [12]. Specifically in the Cabo Delgado province, mental health and psychosocial support (MHPSS) workers report signs of posttraumatic stress among the affected population, including “fear of attacks and trauma from previous attacks to the extent that some people reported recurrent nightmares” [13].

Regarding posttraumatic stress symptoms, individuals noted flashbacks and avoidant behavior. Some also expressed anxiety symptoms and hopelessness fearing the conflict will never end [14]. In conflict- and war- affected areas, PTSD is not only highly prevalent, but considered a central public health issue, and is disproportionately correlated with economic burden, insecure housing, and overall decreased quality of life, continuing beyond the conflict period, and even after war subsists [15]. Due to the persistent exposure to conflict- and war-related trauma, economic, housing, and food insecurity, coupled with insufficient mental health infrastructures, IDPs in LMICs are not only at risk of developing PTSD and PTSD symptoms, but are also vulnerable to suicide, homicide, substance abuse, and human rights abuses. This serves to exacerbate struggles with mental health, social exclusion, unemployment, and poverty. All of this can have generational effects and consequently a very long-lasting impact [16]. The World Health Organization (WHO) firmly asserts that mental health is a fundamental human right, essential for the well-being and dignity of all individuals [17]. This perspective highlights the responsibility of governments and organizations to ensure that mental health services are accessible to everyone, especially in regions afflicted by conflict and ongoing traumatic stress, such as the Cabo Delgado province of northern Mozambique. As the ongoing violence has precipitated a mental health crisis, the lack of adequate psychological support for affected populations, particularly IDPs, underscores a pressing human rights issue. Additionally, studies have demonstrated that the economic burden of PTSD is high, due to direct costs (i.e. hospitalizations) and indirect costs (impact on individual’s ability to work and contribute to the economy) [18]. The Internal Displacement Monitoring Centre’s report (2018) on the economic impact of IDPs specifically emphasizes the role of mental health and its long- and short-term socio-economic impacts, ranging from social isolation and lack of integration within host-communities to the lost economic potential of IDPs [19]. Pervasive mental health struggles, particularly PTSD and PTSD symptoms in IDPs in LMICs is a global health issue, affecting broader society in the long- and short-term.

Despite the intensifying need for mental health support, access to psychological services in Cabo Delgado province remains critically insufficient. Many IDPs face barriers such as stigma, lack of trained mental health professionals, and insufficient infrastructure for the provision of mental health services [20]. According to the 2021 International Committee of the Red Cross (ICRC) Mental Health Psychosocial Support (MHPSS) assessment of the Cabo Delgado province, there are 0.05 psychiatrists, 0.39 psychologists, 0.02 social workers, and 0.05 occupational therapists per 100,000 inhabitants [21]. According to the MHPSS Secondary Data Review–2023, Cabo Delgado Mozambique, conducted by the MHPSS Technical Working Group, November 2023, trained mental health professionals struggle to find jobs because there is very little investment in the health sector. They note that most professionals work for the Ministry of Health and are not providing counseling. Consequently, those trained mental health professionals who are available, are overwhelmed by the needs of the population, cannot ensure optimal support because of the workload, and are at heightened risk for burnout [22]. A recognized solution to the disparity between the availability of specialized mental health providers and resources, and those in need of trauma-sensitive treatment interventions, is the implementation of task-sharing and the optimization of existing resources, especially in LMICs [23]. Task-sharing is defined as “the formalized redistribution of care typically provided by those with more specialized training (e.g., psychiatrists, psychologists) to individuals, often in the community, with little or no formal training (e.g., community/lay health workers, peer support workers)” (p. 2). Success of task-sharing interventions is determined by high-quality trainings and consistent supervision, delivered in a local-specific context [24]. In 2023, the International Society for Traumatic Stress Studies (ISTSS) published a briefing paper advocating for increased access to psychological treatments (PTs) in the global context and called for task-sharing and the training of non-specialized MHPs to be seen as a primary resource to begin narrowing the gap between the need for mental health services and the availability of such services to those in need [25]. The Trauma Healing Training Program (THTP) is aimed at providing local non-specialized MHPs with high-quality training and supervision in trauma-sensitive treatment interventions to facilitate access to mental health interventions and adversely affected populations, particularly in LMICs.

The objectives of this paper were 1) to evaluate the efficacy, safety, and efficiency of the Healing Drawing Procedure (HDP) group trauma-sensitive treatment intervention in reducing posttraumatic stress disorder (PTSD) symptoms among internally displaced people (IDPs) living in the Cabo Delgado Province of northern Mozambique, specifically the town of Pemba, and 2) to explore the efficacy, safety, and efficiency of non-specialized MHPs, also referred to as frontline workers, providing the HDP group trauma-sensitive treatment intervention after receiving training in providing the HDP. The body of evidence demonstrating that task-sharing PTs can be safely and effectively administered by non-specialized MHPs continues to grow [26-31], and this study hopes to contribute to that ever-growing body of evidence.

The AIP Theoretical Model

The Adaptive Information Processing (AIP) model posits that memory networks of stored experiences are the basis of both mental health and pathology across the clinical spectrum [32]. When memories are adequately processed and adaptively stored, they form adaptive memory networks, which are the foundation for learning and future perceptions, behaviors, and responses [32]. When memories are inadequately processed and maladaptively stored due to heightened autonomic nervous system arousal states produced by adverse life experiences, pathogenic memory networks are formed, resulting in present-day suffering, difficulty, and symptoms (e.g., PTSD, anxiety, depression) [32]. These pathogenic memory networks are targeted and reprocessed through the facilitation of the information processing systems’ adaptive and natural processing of the information of the experience and the subsequent integration and storage of the information of the experience in adaptive memory networks linked by similar memory components, resulting in learning and mental health [32]. Shapiro’s (2018) AIP theoretical model is the foundational model of all treatment interventions incorporated in the THTP.

Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) is a pervasive mental health disorder causing extreme psychological and physiological distress. PTSD symptoms include intrusion symptoms (nightmares and flashbacks), avoidance symptoms, negative alterations in cognitions and mood, arousal symptoms, resulting in deterioration in daily functioning, with symptoms developing or being exacerbated after the experience of a Criterion A traumatic event [33]. This can lead to a deterioration of personal and professional relationships, impacts on physical health, and have devastating, long lasting, impacts on individuals, their families and consequently, on society as a whole [34]. Increased arousal and intrusion symptoms related to PTSD also correlate with sleep disturbances and overall lower quality of life [35,36].

The Trauma Healing Training Program

This study was conducted as part of the development of the Trauma Healing Training Program (THTP). This specialized training, with task-sharing as its foundation, is being developed to contribute solutions to the global mental health care crisis, particularly in LMICs. This training is being developed specifically to equip non-specialized MHPs with safe and effective AIP-informed trauma processing interventions, so that they may begin narrowing the great divide between mental health services required and the availability of mental health services within their communities. The THTP is a two-week training program that includes training in two AIP-informed group interventions: the Acute Stress Syndrome Stabilization for Groups (ASSYST-G) and the Healing Drawings Procedure (HDP) group treatment intervention, and two AIP-informed individual interventions: the Acute Stress Syndrome Stabilization for Individuals (ASSYST-I) and the Protocol for Paraprofessionals (PROPARA).

Fieldwork is conducted on all four interventions with in-person supervision and the support of the THTP trainer. Specifically, regarding the Healing Drawings Procedure (HDP) intervention of the THTP, trainees receive a two-day in-person training which includes a demonstration of the HDP, a didactic portion defining trauma and recognizing its impact, learning self-soothing skills, an understanding of the window of tolerance, and working memory theory. The training also includes practicum time where the trainees practice the HDP with each other before going into the field to provide the intervention with community members with the supervision and support of the THTP trainer. In-person supervision and feedback from the trainer is provided throughout the training as well as during all fieldwork. All trainees participated in discussions of how to make the administration of the HDP, along with other tools taught within the THTP, culturally successful within the Mozambican and IDP context in the Cabo Delgado province.

Healing Drawing Procedure Group Treatment Intervention

The HDP is modeled exclusively after the evidence-based Eye Movement Desensitization and Reprocessing Integrative Group Treatment Protocol for Ongoing Traumatic Stress (EMDR-IGTP-OTS) developed and extensively field-tested by Jarero et al. [37-40]. Similar to the EMDR-IGTP-OTS, the HDP is a scripted intervention incorporating elements of art therapy and utilizes the EMDR-Butterfly Hug method as a form of self-administered bilateral stimulation (BLS) to process traumatic material [41].

Previous Treatment Intervention Studies

The EMDR-IGTP-OTS, after which the HDP is closely modeled, was initially developed by members of the Mexican Association for Mental Health Support in Crisis (AMAMECRISIS) when they were overwhelmed by the extensive need for mental health services after Hurricane Pauline ravaged the coasts of Oaxaca and Guerrero in 1997 [38]. While this study is only the second research project to study the effectiveness of the HDP being provided by non-specialized MHPs [26], there have been numerous studies showing the efficacy of the EMDR-IGTP-OTS [37-40], including the EMDR-IGTP-OTS being provided by frontline workers, or non-SMHPs [31].

Objective

This randomized controlled trial had two objectives: 1) to evaluate the efficacy, safety and efficiency of the Healing Drawing Procedure (HDP) group trauma-sensitive treatment intervention in reducing posttraumatic stress disorder (PTSD) symptoms among adult IDPs living in the Cabo Delgado Province of Mozambique, temporarily located in the town of Pemba, and 2) to explore the efficacy, safety, and efficiency of non-specialized MHPs being trained in and delivering the HDP group treatment intervention as part of the task-sharing focused Trauma Healing Training Program (THTP).

Method

Study design

To measure the effectiveness of the HDP on the dependent variable PTSD symptoms, this study used a two-arm longitudinal randomized control trial (RCT) design. For ethical reasons (providing therapy to all participants), a waitlist/delayed treatment control group design, comparing immediate treatment and waitlist/delayed treatment groups was selected. PTSD symptoms were measured at four points for all participants in the study: Time 1. Baseline assessment; Time 2. Immediate treatment group (ITG) post-treatment assessment 30 days after the last HDP session; Time 3. Waitlist/delayed treatment control group (DTG) post-treatment assessment 30 days after the last HDP session, and Time 4. Follow-up assessment was conducted three months after the last session for the ITG.

Ethics and Research Quality

For this study, the research proposal was reviewed and approved by the EMDR Mexico International Research Ethics Review Board (also known in the United States of America as an Institutional Review Board) in compliance with the International Committee of Medical Journal Editors recommendations, the Guidelines for Good Clinical Practice of the European Medicines Agency (version 1 December 2016), and the Helsinki Declaration as revised in 2013.

Participants

This study was conducted between July 1 and October 4, 2024 in the city of Pemba, Mozambique. A total of 126 adults (78 females, 48 males) ages 18-90 (M=40.40 years old) from the Cabo Delgado province, living in Pemba, Mozambique, met inclusion criteria and were able to complete participation in the study. Adults were recruited for this study through community outreach conducted by a team of four blind-to-the-study research assistants (RAs) working as community workers for International Organization of Migration (IOM) operating in Pemba, Mozambique. All of the adults who participated in the study live in an unofficial IDP camp on the outskirts of Pemba, and regularly receive services from IOM as well as other non-governmental organizations (NGOs). Consequently, the RAs were able to recruit participants for the study by visiting different shelters within the IDP camp and inviting individuals to participate in the study. Participation was voluntary, and a written consent that was translated from English to Portuguese was utilized. RAs read the consent to participants, translating from Portuguese into Emakua or Kimwani, (the participants’ native language) if needed. Participants were offered the chance to ask any questions they had about the consent or the project in general. All participants were advised that they would not receive any compensation for their participation other than to receive the HDP treatment being studied in the project. All participants signed the written consent in accordance with the Mental Capacity Act 2005.

Inclusion criteria for the study were: (a) being an adult 18 years old or older, (b) being a participant of the programs and services offered by IOM, (c) voluntarily participating in the study, (d) not receiving other specialized trauma therapy, and (e) not receiving drug therapy for PTSD symptoms. Exclusion criteria were: (a) ongoing self-harm/suicidal or homicidal ideation, (b) diagnosis of schizophrenia, psychotic, or bipolar disorder, (c) diagnosis of a dissociative disorder, (d) organic mental disorder, (e) a current, active chemical dependency problem, (f) significant cognitive impairment (e.g., severe intellectual disability, dementia), (g) presence of uncontrolled symptoms due to a medical illness.

Instrument for Psychometric Evaluation

To measure PTSD symptom severity and treatment response, the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) was utilized. This scale was used to measure and track the severity of symptoms of PTSD.

The PCL-5 was translated into Portuguese, and research assistants also verbally translated it into Emakua and Kimwani if needed. The time interval for symptoms focused on the past week. The screening tool contains twenty items and respondents indicated how much they have been bothered by each PTSD symptom over the past week, using a 5-point Likert scale ranging from 0=not at all, 1=a little bit, 2=moderately, 3=quite a bit, and 4=extremely. A total-symptom score of 80 can be obtained by summing the items. The sum of the scores yields a continuous measure of PTSD symptom severity and can serve as a screen for detecting PTSD. A PCL-5 score of 31-33 or higher suggests a probable determination of a PTSD status based on DSM-5 diagnostic rules [44].

Procedure

Enrollment, Assessments, Data Collection, and Confidentiality of Data

Four blind-to-the-study research assistants (RAs) were selected and invited to participate as RAs based on their work with IOM, their previous work with this particular community of IDPs, and their ability to speak Portuguese as well as Emakua and / or Kimwani, spoken by most IDPs living in this particular IDP camp. The RAs were trained by the corresponding author of this study in completing the consent form, the Portuguese language PCL-5, as well as how to help participants identify the worst memory of their IDP experience that they would focus on for the entirety of this research study, including all four assessment times, and for the HDP intervention. A manual simple randomization with a 1:1 allocation ratio was used to divide all participants into the Immediate Treatment Group (ITG) of 65 individuals and the Waitlist/Delayed treatment control group (DTG) of 61 individuals. The participants in the DTG received the same HDP intervention thirty days after the ITG received it.

For Time 1. Baseline assessment, RAs met with each participant individually to explain the project and ensure they understood all elements of the consent form before signing it. Participants were informed that all participation was voluntary and that they could withdraw from the study at any time without fear of repercussion. Participants were informed that they would not be compensated in any way for their participation in the study other than to receive the HDP treatment either as part of the ITG or one month later as part of the DTG. To identify the worst memory of their IDP experience that they would focus on for the study, the RAs asked participants to play a mental movie of, or to review, all of their difficult experiences of being displaced and to select the worst memory of their displacement. That memory was then written down on a note card to aid in ensuring participants were able to focus on the same memory for all four assessments as well as for the duration of the HDP intervention they would receive. Demographic information, age, gender, contact information, and when the memory occurred were also recorded.

For all assessment times, the RAs used the same notecards to ensure participants were answering the PCL-5 questions and measuring the severity of their symptoms within the previous week based on the same previously identified worst memory of their displacement experience. Due to logistical reasons and the availability of the RAs and the training team, assessment times were conducted one month after receiving the HDP intervention. This meant that the final follow-up assessment time, Time 4. Follow-up was conducted three months after treatment for the ITG and two months after treatment for the DTG. All data was collected, stored, and handled in full compliance with the EMDR Mexico International Research Ethics Review Board requirements to ensure confidentiality. Each study participant gave their consent to collect their data, which was strictly required for study quality control. All procedures for handling, storing, destroying, and processing data were in compliance with the Data Protection Act 2018. All people involved in this research project are subject to professional confidentiality.

Withdrawal from the study and Missing Data

All research participants had the right to withdraw from the study without justification at any time and with assurances of no prejudicial result. If participants decided to withdraw from the study, they would no longer be followed up in the research protocol. There were no withdrawals during this study.

Treatment

Over the course of three days, participants received six administrations of the HDP treatment intervention as a group to reprocess pathogenic memories that were an average of 51.4 months old (4.28 years old). Participants received six administrations of the HDP intervention over the course of three days totaling six hours of treatment. All administrations of the intervention were done in Portuguese with Emakua and Kimwani translation provided. A different team member from the THTP training team volunteered to administer each set of the HDP while seven other team members served as the Emotional Protection Team (EPT) per the 1:10 adult to EPT ratio required for the HDP intervention. The remaining team members who were not participating either as the leader or part of the EPT, observed or helped with childcare. Throughout the three days, all team members served either as the leader, or as an EPT member, and many served in both roles.

Non-Specialized MHPs and Treatment Fidelity

All 14 of the non-SMHPs who participated in the THTP either work as MHPSS workers for the International Office of Migration (IOM) or for organizations that partner with IOM within the province. Trainees were chosen to participate in this training and research project primarily because of their demonstration as leaders and effective MHPSS workers within their organizations. The training team successfully administered the HDP intervention to two separate participant groups as part of the fieldwork portion of the THTP. The THTP trainer, a licensed mental health professional in the United States, and an EMDRIA Approved Consultant and EMDR Basic Trainer, provided the two-day HDP training in person and supervised the fieldwork.

Treatment Safety

Treatment safety was defined as the absence of worsening adverse effects, events, or symptoms. No adverse reactions were reported or identified during subsequent post-treatment assessment times.

Examples of the Pathogenic Memories Treated with the HDP

Examples of pathogenic memories treated during the HDP sessions were watching houses being burned down during the attacks and losing everything, watching loved ones being killed during the attack, watching people drowning during the escape when their boat wrecked, and being kidnapped by insurgents during the attacks.

Trainees’ Experience with HDP Treatment Intervention

In a pre-training/post-training survey that was completed by the trainees, data showed that the number of trainees indicating they felt “a little prepared, but I need more” to help their clients with trauma, reduced from 71.4% to 41.7%, and those indicating that they felt very equipped to help their clients with trauma rose from 21.4% to 58.3% chart 1 and 2.

Statistical Analyses

Analysis of variance (ANOVA) for repeated measurements (Time 1 Pre-treatment, Time 2 Post-treatment ITG, Time 3 Post-treatment DTG, and Time 4 Follow-up) was applied to analyze the effects of the treatment on PTSD. Within-subjects effects and between-subjects effects, including effect size (eta squared η2), are reported. One sample t-test was conducted for within and between mean comparisons. Cohen’s d was calculated in each case to report the effect size.

Results

PTSD symptoms

A repeated-measures ANOVA determined that mean scores on PTSD symptoms, measured through the PCL-5 total score, differed significantly across the four-time points with a large effect size (F (3, 123) = 307.17, p = <.001, η2 =.714). Significant differences by a group with a medium effect (F (1, 123), 145.54, p = <.001, η2 =.542) were found. A one-sample t-test was performed to evaluate whether there was a difference between time measurements in each group (ITG and DTG). For the ITG, the mean comparison between T1 and T2 showed significant differences with a high effect (t (63) = 17.10, p = .001, Cohen’s d = 2.13), TI (M = 45.57, SD =10.71) vs. T2 (M = 25.57, SD = 2.69); comparison between T2 and T3 was significantly different with a high effect, (t (63) = 6.46, p = .001, Cohen’s d = .80), T2 (M = 25.57, SD = 2.69) vs. T3 (M = 21.15, SD = 3.35), and comparison between T3 and T4 was significantly different with a lower effect size (t (63) = 3.24, p =. 001, Cohen’s d = .40), T3 (M=21.15, SD= 3.35) vs. T4 (M=18.94, SD= 5.31).

In the DTG, the mean comparison between T1 and T2 showed significant differences with a low effect, (t (60) = 3.64, Cohen’s d = .446), TI (M = 44.08, SD =10.43) vs. T2 (M = 38.95, SD = 6.63); mean comparison between T2 and T3 was significantly different with a high effect (t (60) = 8.13, p=.001, Cohen’s d =.1.04 ), T2 (M = 38.95, SD = 6.63) vs. T3 (M=31.26, SD= 3.35) and comparison between T3 and T4 showed significant differences with a high effect (t (60) = 10.89, p = .001, Cohen’s d = 1.39), T3 (M = 31.26, SD = 3.35) vs, T4 (M = 26.01, SD = 3.99). Comparison between groups using the t-test for independent samples confirmed the aleatory assignment of participants with no significant differences in Time 1 Pre-treatment. Time 2 Post-treatment ITG showed significant differences between groups with a large effect size (t (123) = -17.10, p = .001, Cohen’s d = -3.06), ITG (M = 25.57, SD = 2.69) vs. DTG (M = 38.95, SD = 6.63). Results in Time 3 Post-treatment DTG showed significant differences between groups with a large effect size (t (123) = - 19.20, p = .001, Cohen’s d = - 2.13), ITG (M = 21.15, SD = 3.35) vs. DTG (M=31.26, SD= -3.35). Time 4 Follow-up also showed significant differences between groups with a large effect size (t (123) = - 8.32, p = .001, Cohen’s d = - 3.41), ITG (M=18.94, SD= 5.31) vs. DTG (M = 26.01, SD = 3.99) (Table 1) (Figure 1).

Discussion

This randomized controlled trial had two objectives: 1) to evaluate the efficacy, safety, and efficiency of the Healing Drawing Procedure (HDP) group trauma-sensitive treatment intervention in reducing posttraumatic stress disorder (PTSD) symptoms among internally displaced people (IDPs) living in Pemba, Mozambique, and 2) to explore the effectiveness and safety of non-specialized MHPs being trained in and delivering the HDP group trauma-sensitive treatment intervention. This project was done as part of the development of the task-sharing focused Trauma Healing Training Program (THTP), which is being developed to safely bring effective mental health treatment interventions to high-need, low-resource contexts, specifically in low-and-middle-income countries (LMICs). A total of 125 adult participants met the inclusion criteria and participated in the study. Participants’ ages ranged from 18 to 90 years old (M = 40.40 years old). The results of this study support that this project was successful in training non-specialized MHPs to effectively and safely provide the HDP group trauma-sensitive treatment intervention and that the trainees were successful in reducing participants’ posttraumatic stress disorder (PTSD) symptoms. Statistical analysis results showed that the HDP group treatment intervention had a high effect, specifically in the comparison between pre-treatment and post-treatment in both the Immediate Treatment Group (ITG) and the Delayed Treatment Group (DTG). Repeated measure linear model reported significant differences by time with a large effect and significant differences by group with a medium effect. Both groups presented the same tendency after the treatment with statistically significant results. However, the scores in the ITG decreased notably after treatment, differing from the DTG, where even with significant differences between pre-treatment and post-treatment measures, the effect size was lower. In both groups, the reduction of posttraumatic stress disorder (PTSD) symptoms was maintained at follow-up, highlighting the efficacy, safety, and efficiency of the treatment. Due to the high mobility among internally displaced people (IDPs), it is extremely difficult to explore more qualitative information from participants to provide a solid explanation of these subtle and interesting differences.

About this study’s secondary objective, exploring the efficacy and safety of non-specialized MHPs being trained in and delivering the HDP group trauma-sensitive treatment intervention as part of the task-sharing focused THTP, the study results specifically showed the success of non-specialized MHPs in reducing individuals’ PTSD symptoms through successfully providing an effective mental health treatment, the HDP, to a low-resource conflict affected area where the need for mental health treatment is very high.

Conclusion, Limitations, and Future Directions

PTSD is a pervasive mental health disorder that has devastating effects on individuals and society. Therefore, there is a great need for evidence-based, time-limited, cost-effective, and safe interventions to enhance the treatment of posttraumatic stress symptoms. This study's results showed that non-specialized MHPs effectively and safely provided the HDP group trauma-sensitive treatment intervention to an adult population with pathogenic memories associated with being forcibly displaced. The study also showed that the provision of the HDP group trauma-sensitive treatment intervention by non-specialized MHPs effectively reduces the impact of PTSD symptoms for these individuals. Participants reported no adverse effects or events during the treatment intervention administration or at any of the assessment times. None of the participants showed clinically significant worsening/exacerbation of symptoms according to their PCL-5 scores. Non-specialized MHP reports, based on their experiences during the training and in providing the intervention, also suggest that the HDP is a provider-friendly treatment intervention that can be successfully applied by novice and seasoned providers alike, yielding positive treatment results. This also facilitates provider confidence and motivation and emphasizes the feasibility of non-specialized MHPs providing trauma-sensitive treatment interventions to high-need populations in LMICs, where the prevalence of and access to specialized mental health providers is limited. Due to the unpredictable and transient nature of living displaced, a six or twelve-month follow-up was impossible to conduct. Therefore, to further enhance the robustness of this study, we recommend future randomized controlled trials to include a longer follow-up period whenever possible to evaluate the long-term impacts of this treatment intervention.

Conflict of Interest and Funding

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

We want to express our gratitude to all individuals that participated in this study. The THTP training team: Sofia Arizane, Àcio Bande, Carlos Bila, Leonardo Lino, Samissone Luís, Domingos Mucareia, Mércia Mulungo, Sófia Nampula, Agosto Nhantumbo, Maxwell Raiva, Juma Roroje, Foia Soca, Zarina Sualei, Melânia William; the Research Assistants: Luis Agira, Cassimo Iassine, Alexandre Miuwari, & Cassimo Silvestre; the fieldwork participants for giving us your time for the HDP intervention and the assessment times; and the International Office of Migration (IOM) staff who helped make this project happen.

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