Narrative Exposure Therapy Intervention and Management of Memory Intrusion Symptoms of Traumatic Stress among Young People in Kakuma Division, Turkana County of Kenya

Kakuma refugee camp is currently the home of 196,666 people who fled from their various countries due to civil war and organized violence. Young people form 20% of this population. These young people live with constant reminders of negative memories of their traumatic experience. Against this background, this study sought to assess the young people’s traumatic stress with the use of post-traumatic stress disorder checklist for DSM-5 (PCL-5) tool. The study adopted narrative exposure therapy framework and intervention for traumatic stress management. The study used quasi-experimental research design whereby the researcher adopted a non-equivalent groups design. This design involved one treatment group and one control group. The study sampled 110 participants through multistage cluster and proportionate sampling. Descriptive and inferential statistics were used to analyse the data with the aid of statistical programme for social sciences (SPSS) version 23. Independent sample t-test was used to list the statistical significant differences between the means in the pre-test and post-test scores for the groups. The researcher established that Narrative exposure therapy intervention was effective in management of memory intrusion symptoms of traumatic stress among young people in Kakuma division, Turkana County of Kenya.


Introduction
Trauma as described by Van Rooyen and Nqweni (2012), is any life threatening experience that amounts to excessive fear and other psychosomatic reactions that impedes an individual functioning systems.
Traumatic stress is a resultant effect of traumatic experience which is diagnosed through assessment of symptoms often manifested after experiencing or witnessing a traumatic event (Hull & Corrigan, 2019).
Symptoms of traumatic stress are manifested in form of long-lasting psychological distress, from mild anxiety to symptoms that interfere with almost all aspects of individual functioning (Briere & Scott, 2015). This psychological distress affects an individual in four domain symptom clusters according to DSM-5 (APA, 2013), namely; memory intrusion, avoidance of stimuli, changes in thoughts and mood and hyper-arousal/ hyper-vigilance (Dimauro, Carter, Folk, & Kashdan, 2014).
Young people in Kakuma refugee camp are basically those who fled their own countries due to traumatic events of civil war and organized violence (Sanghi, Onder, & Vemuru, 2016). Consequently, they are at risk of developing psychological disturbances (Kelley, Weathers, Mason, & Pruneau, 2012). They are equally vulnerable to mental health challenges particularly Post-Traumatic Stress Disorder (PTSD) if proper trauma-based, psychological and social supports services are not made available (Spitzer, Vogel, Barnow, Freyberger, & Grabe, 2007;Koenen, Stellman, Sommer, & Stellman, 2008). The United Nations posit that refugees are at increased risk of developing mental health problems due to a range of risk factors including experiences of violence and upheaval in their home and in refugees' settlements (UNHCR, 2015;Silove, Ventevogel, & Rees, 2017). It was against this backdrop that this study sought to examine the effectiveness of narrative exposure therapy intervention in the management of memory intrusion symptoms of traumatic stress among young people in Kakuma division, Turkana County.

Literature Review
Narrative Exposure Therapy (NET) is a trauma-focused psychological treatment designed to address symptoms of traumatic stress among populations who have been exposed to multiple traumas and survivors of traumatic events . Individuals who have experienced trauma often manifest symptoms of fragmentation of memory, disorientation, dissociation and other symptoms (Herman, 2015). In trying to avoid reactivation of traumatic memories and fear of being back to the traumatic scene, survivors find it difficult to narrate their experience in a coherent and meaningful manner (Neuner, 2012). In some cases, the disconnection in memory presentation difficulty is not intentional but owing to dissociative amnesia (Gold & Cook, 2017). Narrative exposure therapy aims at enabling trauma survivors to recall and narrate their traumatization for the purpose of healing and integration. The emphasis on time and place of the event is maintained while at the same time re-experiencing the emotions until habituation is achieved.
Dual Representation Theory (DRT) of Brewin, Dalgleish and Joseph (1996) maintains that traumatic memories are retrieved by means of activation. Distressing intrusive memory is one of the symptoms that indicate traumatization. The memories often intrude upon a person's mind in different forms and affect 195 functioning. These memories come in variations such as nightmares, dissociative flashbacks whereby the person's state of consciousness is altered. Consequent upon intrusion, the individual acts and feels the same way during the first experience of the traumatic event. Intrusive traumatic memories equally include recurrent distressing dreams in which the content of the dream are related to traumatic events (Herbst et al., 2016). The intrusions typically take the form of visual images but can also include sounds, smells, tastes and bodily sensations. An individual experiences the recurrent flashbacks with a lot of unpleasant feelings connected with the "hot" memory of the traumatic event (Kessler et al., 2018).
Intrusive memories for most people decrease over time while for others they persist, causing significant level of psychological distress. Iyadurai et al. (2019), posit that intrusive memory are capable of causing clinical malfunctioning in an individual either at the early stage of traumatic experience or later on in life. In a research on the psychiatric effect of automobile accidents by Mayou, Bryant, and Duthie (1993) as cited by Iyadurai et al., intrusive memories in the first few weeks were recorded to be 76%, after three months it dropped to 25% and 24 % in one year. As Van Rooyen and Nqweni (2012) observed, trauma in its clinical sense is extremely difficult and overwhelming for individuals. In some cases traumatic memories may not be associated with psychological distress for some people (Berntsen, 2009).
Cognitive approaches to understanding traumatic stress has it that intrusive memories of trauma is at the center of symptomatology, influencing other traumatic symptoms within the symptom clusters of traumatic stress (Brewin, 2014). When intrusive memories occur, they ignite higher levels of physiological and psychological reactions. This inevitably disrupts an individual functioning and attentiveness to daily operation (Clark & MacKay, 2015). Network theories of traumatic stress assert that intrusive memories are intrinsically associated with other symptom clusters in the trauma network and are probably able to cue other symptoms of psychological disorders (Bryant et al., 2017). This is in line with the fear/trauma network developed by Foa and Kozak (1986).
In a study by Kessler et al. (2018) on recurrent intrusive traumatic memory reduction using a visuospatial interference intervention, 20 participants took part in the study. Those who met the criteria for intervention response were 16. loss and other events using traditional coping and spiritual coping but did not recover from trauma using the same mechanism (Paula & Bonnie, 2004;Varkey, 2010). Intervention for traumatized individuals must therefore be trauma-specific interventions and must target the source of distress.
Individuals with severe symptoms like refugees population due to multiple traumas when left untreated develop greater vulnerability to PTSD and comorbid disorders (Chloe, Chessen, Comtois, & Landes, 2011). In narrative exposure therapy, clients who manage to construct a coherent narrative of the traumatic event during exposure therapy profit most from treatment (Neuner, 2012). The focus of Narrative Exposure Therapy (NET) approach therefore is to encourage the activation of painful memories through narration and to prevent the client's strategies of avoiding or ending activation (Schaurer et al., 2011).

Research Design
This study used quasi-experimental design in which the researcher adopted a Non-equivalent groups design. This design involved one experimental group and one control group. The treatment group received a pre-test for traumatic stress, narrative exposure intervention and a post-test. The control group received a pre-test and post-test and a normal counselling intervention. This design is suitable for testing the effect of a single independent variable that can be used as a treatment (Leavy, 2017). Table 1 shows Nonequivalent group control group design. Data, 2020). A sample size of 110 respondents was obtained through proportionate sampling. According to Kathuri and Pals (1993), a minimum of 100 is recommended for a survey research.

Sampling Procedures and Sample Size
Sampling size refers to selected items from the entire group to make up a sample (Kothari, 2004). Those who met the criteria for traumatic stress were selected into the control group and experimental group.
While the experimental group received treatment representing the independent variable by being subjected to narrative exposure therapy intervention, the control group was subjected to normal counselling intervention. Both the treatment and control groups underwent post-test assessment to determine statistical significant differences after the experiment. The sample size of the study is shown in Table 2.

Data Analysis
Descriptive and inferential statistics were used to analyse the data with the aid of Statistical Programme for Social Sciences (SPSS) version 23. Independent sample t-test was used to list the statistical significant differences between the means in the pre-test and post-test scores for the groups.

Pre-test Results of Memory Intrusion Symptoms
The study sought to determine the effectiveness of the narrative exposure therapy intervention in management of memory intrusion symptoms of traumatic stress among young people in Kakuma whether there were significant differences in the levels of memory intrusion symptoms between young people in the treatment group exposed to narrative exposure therapy intervention and those in the control group exposed to normal counselling. Table 3 presents the pre-test group statistics of memory intrusion symptoms. The results indicated that the mean memory intrusion symptoms among young people in the narrative exposure therapy intervention group was 2.64 with a standard deviation of 0.834, while the mean among those in the normal counselling group was 2.43 with a standard deviation of 0.806. This therefore means that there was a minimal mean difference of 0.21. Table 4 presents results on whether the reported mean difference was statistically significant. The mean difference was 0.210 (95% CI = -0.109 to 0.529), t(102) = 1.305, p = .195 > 0.05. From the statistics, the independent t-test results showed that there was no statistically significant difference in memory intrusion symptoms between young people in the narrative exposure therapy group and those in the normal counselling group before intervention.

Post-test Results of Memory Intrusion Symptoms
A post-test was conducted after the intervention. The aim of the post-test was to examine whether there were significant differences in the levels of memory intrusion symptoms between young people exposed to the narrative exposure therapy and those exposed to normal counselling.  The post-test results indicated that the mean of memory intrusion symptoms among young people in the narrative exposure therapy group was 1.19 with a standard deviation of 0.761, while the mean among those in the normal counselling group was 2.06 with a standard deviation of 0.705. There was a mean difference of -0.87. An independent t-test was carried out. Table 6 presents the t-test results on whether the reported mean difference was statistically significant. From the report, the independent t-test showed memory intrusion symptoms being higher among young people who received normal counselling than those in the narrative exposure therapy intervention group. The mean difference was -0.870 (95% CI = -1.156 to -0.585), t(102) = -6.045, p < 0.000. The hypothesis stating that there is no significant effectiveness of narrative exposure therapy intervention in management of memory intrusion symptoms of traumatic stress among young people in Kakuma division was rejected and the study concluded that there is statistical significant effectiveness of narrative exposure therapy intervention in management of memory intrusion symptoms of traumatic stress among young people in Kakuma Division.

Discussion
The study findings revealed that memory intrusion symptoms were higher among young people that were exposed to normal counselling as compared to those exposed to the narrative exposure therapy intervention. The therapy intervention was therefore effective in management of memory intrusion  Nickerson, Bryant, Silove, and Steel (2011) averred that the mainstay of treatment and management of mental disorders among refugees and asylum seekers remains counselling and psychotherapy.
In addition to past traumatic effects, refugees are confronted with severe human conditions in their new environment. These include ongoing insecurity, access to mental health, educational services and host society attitudes of hostility. The consequent effect is that refugees do not have the support of nuclear family or extended family or other support traditional to them. Against these backdrops Silove, Ventevogel, and Rees (2017) maintained that social programmes for refugees as adjunct services to psychotherapy have the capacity to improve in them a sense of connection and promotion of self-help activities.
In addressing mental health challenges resulting from trauma and other life events, Bickman (2020) is of the opinion that mental health service can be improved if evidence-based services are made available.
According to the findings, fewer clients are exposed to effective evidence-based interventions that are sufficiently qualitative. Those who administer evidence-based mental health services at time do not do so with utmost commitment. Consequently as observed by Costello et al. (2014), more than 60% of youth populations suffering mental health challenges like major depressive disorder do not receive interventions aimed at reducing their distress. The situation becomes alarming when it comes to low and middle income countries like Kenya and other African countries. Esponda et al. (2020) observe that in this low income countries, mental health interventions become severely limited. Kakuma refugee population belongs to this group of individual across the world with challenges accessing basic human needs. As Hodgkinson (2017), puts it, less than 15% of those in the margin of the society receive needed mental health support.
Trauma survivors avoid coming in contact with cues of their past traumas which may include people, places or events due to strong physical reactions associated with being reminded of the painful experience. Survivors may also try to avoid the therapeutic process due to labelling or stigmatization or when they are not sure of the outcome. This is why Schaurer et al. (2011) incorporate psycho-education in the beginning of the therapeutic process in NET intervention. Here trauma survivors are prepared with the help of the therapist to embark on a journey of remembering the painful experience for the purpose of healing and integration of fragmented trauma memories into a holistic narration. 201

Conclusion and Recommendation
The study findings have proven that narrative exposure therapy intervention is effective in the management of memory intrusion symptoms of traumatic stress by causing a significant reduction of symptoms level at post-test among respondents who were subjected to treatment as compared to those who were in the control group. Based on the findings and conclusion of the study, the researcher recommends to counselors, psychotherapist and other mental health workers working with traumatized population the use of narrative exposure therapy intervention as an effective intervention in management of memory intrusion symptoms of traumatic stress among young people. Narrative exposure therapy may also be tested on children using KIDNET version and other traumatized population since the focus here was on young refugees.