STUDY DESIGN

In addition to developing and assessing the effectiveness of a self-help guide, the study included developing and validating self-report scales, and collecting data about the prevalence rates of PTSD, and risk factors including trauma history, coping strategies, posttraumatic cognitions, and social support. The

prevalence rates of depression and anxiety were also assessed. Kazdin (2003) highlighted that self-report scales were used widely within counselling, clinical, educational psychology. He states that there are three reasons to use these kinds of scales. First, the definition of many states, feelings, and

psychological problems is based on what people say or feel. Second, people are in a unique position to report upon their feelings, thoughts, dreams etc. This may be not available with other assessment techniques. Third, the

administration is easy, and therefore this has made use of such scales

particularly useful for screening purposes. In addition to these reasons, other reasons made use of self-report scales in the current study acceptable. First, one of the aims of the study was to examine the prevalence of traumatic events and trauma-related symptoms; therefore, selecting a large representative sample is essential to achieve this aim. Second and related, the time for data collection is limited due to the availability of students during the academic year as well as the travel arrangements to Iraq. Third, the participants of the current study were university students, which means they were well educated and perhaps more likely to have the ability to report their feelings and emotions more effectively than the general population. Fourth, some studies (e.g. Alhasnawi, et al., 2009;

Sadik, et al., 2010) demonstrated that a significant percent of Iraqi people considers seeking therapy to be stigmatising; then it is expected that the participants may not prefer to talk about their feelings to the strangers.

Consequently, self-report scales rather than other techniques (e.g. interview) were essential instruments to collect data for the reasons mentioned above.

Although interviews may provide data in depth, Bordens and Abbott (2010) highlighted some limitations; the interview is taken place in a social context,

and this may impact on the participant’s responses where the participants may tend to present socially desirable responses. In addition, in the current study, it was more difficult to do comparisons using interviews. Furthermore, it may be difficult to ensure the reliability of data that are collected by interviews

(Abramson & Abramson, 2008). Moreover, as most of the participants in the current study were female, the likelihood of their participation in the study was low if the interview was used to collect data. For social and religious reasons, the women may not accept to be alone with a man to participate in a research.

In contrast, a self-report scale could be an objective instrument to collect data and provides a numerical measure (Anastasi & Urbina, 1997) and could cover larger area of the examined concept than the interview could. Particularly in this study when the time available for the administration was limited. In addition, Lazarus and Folkman (1984) demonstrated that studies found that self-reported coping had a significant relationship with adaptation outcomes.

Foa, Cashman, Jaycox, and Perry (1997) stated that the self-report measures are economic instruments, in terms of less administration time and minimum clinician time, to screen PTSD. Nevertheless, some limitations may relate to the use of self-report scales. Of these, first, the wording, format, and order of appearance of the items could affect the responses to them. A second limitation is the possibility of bias; where the participants might not truly respond or their responses being influenced by their motives or self-interest (Kazdin, 2003). In the current study, most of scales were widely used and validated in previous studies. In addition, the Arabic versions of them were presented to a group of psychologists and psychiatrists to assess the extent to which these scales were

appropriate to be used with Iraqi participants. Furthermore, the scales were validated as a part of these study procedures.

After validating the scales, a self-help guide was developed. To develop a suitable guide for traumatised people in Iraq, several issues were considered.

The guide had to help people to understand traumatic events and their aftermaths, and also provide coping skills that focus on dealing with the problem rather than avoiding. Therefore, the developing process was based on literature about PTSD and coping. The literature review showed that PTSD symptom could be reduced using active coping strategies, improving the cognitions about self and the world and perceiving social support. In addition, self-help materials for trauma were reviewed. To find self-help books for trauma-related symptoms, these books were identified by review an article about self-help books (Redding,Herbert,Forman, &Gaudiano, 2008) and also by conducting an online search of number of websites including

Books.google.com, Books4selfhelp.com, and the Internet book dealer Amazon.com. The search was conducted by using keywords, such as

“recovery, overcome, healing, self-help, traumatic stress, posttraumatic stress, trauma, or PTSD”. The inclusion criteria were the book did not target a specific trauma (e.g. rape) or a specific sex (e.g. for men or women) as the guide in this study aimed to deal with different traumas and for both sexes. In addition, the book should be written by people with professional or academic qualifications in health or clinical psychology or psychiatry.

Based on the literature review about PTSD and coping and a review of self-help books, a list of contents was suggested. In addition, real traumatic stories were collected via an internet-based questionnaire to be added to the guide as

examples. Iraqi psychiatrists and psychologists with experiences of treating and/or studying trauma were asked to evaluate the list of suggested contents of the guide and later the contents themselves. The psychiatrists were contacted via the Iraqi Mental health Forum in the UK. Psychologists were contacted via Educational studies and Psychological Research Centre in the University of Baghdad. The effectiveness of the guide was examined. The examination procedures involved presenting the guide to a group of Iraqi psychiatrists and psychologists to assess whether the guide’s contents are based on

psychological ground, useful and helpful to deal with traumatic experiences, and appropriate for traumatised people in Iraq.

Based on the literature review, it was hypothesised in this study that the guide will improve positive coping strategies and posttraumatic cognitions and therefore reduce the severity of trauma-related symptoms. Consequently, it required examining the causal relationship between the use of SHG and coping strategies, posttraumatic cognitions, and trauma-related symptoms to

demonstrate the guide’s effectiveness. Therefore, an experiment was conducted to examine the effectiveness of the guide. Originally, the design in this study was intended to be a mixed between-subjects and within subject design. The aim firstly was to examine whether there are significant differences between those who used the guide and those did not (between subjects). The second was to assess whether the differences are due to use of the guide and not to other variables (within subjects). The design had two groups; one experimental and one control. The suggested procedure comprised the following steps:

1- Conduct baseline tests for all participants with full PTSD.

2- Divide the participants randomly into two groups; treatment and control.

3- Use the guide for at least six weeks.

4- Conduct post tests for both groups.

5- Repeat the steps 3 and 4 but the group that already has used the guide does not use and vice versa.

Step 5 was excluded for practical reasons including travel delay to Baghdad due to suspending all flights from the UK for several days in April 2010 due to ash from a volcanic eruption in Iceland. Therefore, the time was not enough to follow all the steps. Therefore, the participants in the control group did not use the guide during the study. Hence, an ethical issue arose. These participants were told that hard copies of the guide will be available to collect with their lecturers after the post tests, or they can ask for an electronic copy via email.

The modified design was a between-subjects design. However, this design was still applicable for some reasons. Of these, first, traumatic events in Iraq have occurred on ongoing and multiple bases. Secondly, it is more economic in terms of time required to conduct the experiment compared with a within-subjects design; consequently, it reduces the likelihood of losing

participants. Finally, it can control the effects of variables that may threat the internal validity of the experiment (e.g. history, statistical regression, and testing). It is worth stating that this experimental design was not a full randomised control trial (RCT). RCT has three main components including comparison between two or more of treatment conditions, a method of assigning participants to each group, and the assessment means of the

effectiveness (Everitt & Wessely, 2008). In the current study, due to the shortage of psychiatrists and the security situation in Baghdad, it was not possible recruiting a psychiatrist or clinical psychologist to conduct further diagnosis or assessment. Hence, it was unavoidable to rely on only self-report scales to conduct the baseline tests and post tests. In addition, the multiple-occurrence of traumatic events in Iraq may make people had different accounts of traumatic experiences. In addition, the participants had to use the guide at their homes. Therefore, the research could not be under the full control of the researcher. Nevertheless, to ensure that the guide was used regularly, the participants were continuously contacted either in person once a week by the four lecturers or via email.

Blaxter, Hughes, and Tight (2010) present several advantages of focus groups.

Of these, focus groups may generate different and diverse views, some people feel safer and prefer to discuss issues within a group instead individually, and unexpected findings may be generated due to the way of discussion. Hence, two focus groups with groups of participants were conducted to discuss and assess the aspects of weakness and strength of the guide as this method could provide significant information to develop an effective guide. These focus groups provided qualitative data that could support the data of self-report scales. The participants in each focus group were of same sex (one for males and one for females), as they expressed that it will not be comfortable to them to participate in a mixed group. In addition, the participants did not agree to the use of any device to record the discussions; instead the discussions were

written in a note form. The discussions were guided to be within two categories which were the strengths and weaknesses of the guide.