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\title{Applying Cognitive Processing Therapy to Posttraumatic Stress Disorders Syndrome among Internally Displaced Youth Victims of Terrorism in Nigeria}
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             \author[1]{Fidel O  Okopi}

             \author[2]{Joshua  Pindar}

             \author[3]{Naomi  Adamu}

             \author[4]{Amos  Williams}

             \affil[1]{  National Open University of Nigeria Jabi Abuja}

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\date{\small \em Received: 8 December 2017 Accepted: 2 January 2018 Published: 15 January 2018}

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\begin{abstract}
        


The main concern of this research was to identify those who were experiencing Posttraumatic Stress Disorder Syndrome after Boko Haran terror attacks and to employ Cognitive Processing Therapy strategy in minimising or preventing probable long-term psychological distress. Four (4) practicing counselling psychologists were involved. Traumatic Screening Questionnaire (TSQ) and Checklist- Civilian Version (PCT-C) were pilot-tested and used for the research. Descriptive survey design was used. Purposive and Stratified random samplings were used to select the youths. Cognitive Process Therapy treatment model - Civilian Version (PCL-C) was applied. Total sample population was 76. Findings showed that, after undergone Cognitive Processing Therapy, a total population of 57 (75%) of the respondents experienced little to no severity PTSD while 19 (25%) of respondents experienced moderate to moderately of PTSD.

\end{abstract}


\keywords{posttraumatic stress disorders syndrome; internally displaced youth victims of boko haran terrorism; cognitive processing therapy}

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\let\tabcellsep& 	 	 		 
\section[{Introduction}]{Introduction}\par
errorism, according to the United Nations report in November 20014, is any act intended to cause death or serious bodily harm to civilians or noncombatants with the purpose of intimidating a population or compelling a government or an international organization to do or abstain from doing any act. Terrorism is, in the broadest sense, the use of intentionally indiscriminate violence as a means to create terror among masses of people; or fear to achieve a financial, political, religious or ideological aim. In this research. the above definitions of terrorism serves as the conceptual definition of Boko Haram terrorism in Nigeria. 
\section[{a) Boko Haran Terrorism in Nigeria}]{a) Boko Haran Terrorism in Nigeria}\par
Boko Haram, an Islamic extremist group ("Group of the People of Sunnah for Preaching and Jihad") based in North Eastern Nigeria. Boko Haram is also active in other countries of Chad, Niger and northern Cameroon (U.S. Department of State 2014). Boko Haram Sect was founded in 2002 by Mohammed Yusuf in Maiduguri, the capital of the North-Eastern state of Borno,  {\ref (IRIN, 2015)}. The Sect has the political goal of creating an Islamic State and it has become a recruiting ground for jihadis, \hyperref[b15]{(Cook 2011}). The name "Boko Haram" is usually translated as "Western education is forbidden" which is used to refer to secular Western education . Boko Haram has also been translated as "Western influence is a sin" and "Westernization is sacrilege ; Nigerian Independent Newspaper 17 August 2014). After its founding in 2002, Boko Haram's increasing radicalization led to a violent uprising in July 2009 in which its leader was summarily executed in a controversial circumstance. He was succeeded by Abubakar Shekau, formerly his second-in-command. Boko Haram has maintained a steady rate of attacks since 2011, striking a wide range of politicians, religious leaders, security forces and civilian as targets. The group continued to capture territory in north-eastern and eastern areas of Borno, as well as in Adamawa and Yobe states. These attacks extended across the Nigeria's borders leading to many people being killed and millions displaced from their homes. Global Terrorism Index in 2015 indicated that, terrorism in Nigeria ranked as one of the world's deadliest terror group and estimated above 13,000 Nigerians have been killed in Boko Haram violence between 2009 and 2014; countless more have been wounded (Nigerian Emergency Management Agency Report, NEMA 2015). Amnesty International (AI-2017) has revealed that at least 967 people were reportedly killed by Boko Haram attacks in the four countries as from January to November 2017.\par
In Nigeria alone, the insurgents increased their suicide attacks from \hyperref[b19]{19}   
\section[{c) Conditions of Living in IDP Camps in North-east Nigeria}]{c) Conditions of Living in IDP Camps in North-east Nigeria}\par
Many internally displaced persons in camps across Borno, Yola, and Yobe states are currently facing traumatic experiences due to the pitiable conditions of living in these camps, while some young girls have become victims of lascivious men and have contracted HIV \hyperref[b9]{( Bwala 2015}, Sunday Tribune 15 th February 2015). According to \hyperref[b9]{Bwala (2015)}, many of the internally displaced persons find it very difficult to adapt to the reality of life; to many of them, life has lost its meaning and the world has come to an end, judging by their attitude and resignation to fate. While physically injuries would have healed, the invisible scars left by those experiences would take far long (Saturday, Tribune 28 th Feb; 2015). He further explained that, many of them in IDP camps complained of high rate of criminality; cases of rape have been on the increase while prostitution has been the only way out for most of the young girls there, most of whom are poor. He explained that, to make the matter worse, many of them were orphans whom have nobody to take care of them. 2.5 million IDP population, comprises children under the age of five, pregnant women and nursing mothers.\par
The camps were overcrowded and lacking space due to continuous insecurity, precipitating food insecurity which remains a major concern with 5.2 million people in need of lifesaving food assistance. In August 2017, attacks against civilians, including suicide bombings in IDP camps, remains a major concern with over 10 person-borne explosive device attacks took place during the reporting period in Borno alone.  {\ref (}  During this type of event, the victim may think that, his or her life or others' lives are in danger. The victim may feel afraid or feel that he or she has no control over what is happening. Among co-occurring psychiatric disorders, some mental health professionals have suggested, depression may be most prevalent--and most lethal (Palgi, Ben-Ezra, Langer, \&Essar, 2009;  {\ref Pinna et al, 2013)}. Such life-threatening events include: combat, military sexual trauma, terrorist attacks, physical violence, sexual violence, such as rape, serious accidents, such as a car wreck and natural disasters, such as a fire, tornado, flood, or earthquake. After any of these events, the victims might be thinking a lot about what happened, avoiding reminders about the events, and thinking negative thoughts about themselves and the world.\par
According to American Psychiatric Association [APA], (2013)identifies four types of PTSD symptoms Reliving the event (also called re-experiencing symptoms): Memories of the traumatic event can come back at any time. The victim may feel the same fear and horror she or he did when the event took place. For example the victim may have nightmares such as a flashback feeling as if he or she is going through the event again or seeing or hearing, or smelling something that triggers the relive of the event. Examples of these could, news reports, seeing an accident, or hearing a car backfire A victim avoiding situations that is a reminder of the event: The victim may try to avoid situations or people that trigger memories of the traumatic event. She or he may even avoid talking or thinking about the event. For example the she or he may avoid crowds, because he or she may feel they are dangerous or keep very busy or avoid seeking help because she or he believes such action keeps he or her from having to think or talk about the event Negative changes in beliefs and feelings: The way the victim thinks about himself or herself and others changes because of the trauma. This symptom has many aspects, including the following: the victim may not have positive or loving feelings toward other people by staying away from relationships or may think the world is completely dangerous, and no one can be trusted. 
\section[{Feeling keyed up (also called hyper-arousal):}]{Feeling keyed up (also called hyper-arousal):}\par
The victim may be jittery, or always alert and on the lookout for danger. She or he might suddenly become angry or irritable. For example: she or he may have a hard time sleeping or .may has trouble concentrating or may be startled by a loud noise or surprise.\par
In summary, PTSD symptoms can change the victim's behaviour and how he or she lives his or her life. The victim may pull away from other people, work all the time, or use drugs or alcohol. The victim may find it hard to be in relationships, and you may have problems with your spouse and family. The victim may become depressed. Some people with PTSD also have panic attacks which are sudden feelings of fear or worry that something bad is about to happens\par
The main concern of this research was to identify those who were experiencing with a behavioural approach (the things the individual does). The goal is to help the individual learn new positive behaviours which will minimise or eliminate the issue. They further explained that, it seeks to help the client to manage problems by enabling him or her to recognise how his or her thoughts can affect his or her feelings and behaviour. It aims to break overwhelming problems down into smaller parts, making them easier to manage (Field, Beeson \&Jones 2015). While working with individuals diagnosed with PTSD, counsellors often expected to target decreasing the severity of (a) recurrent and intrusive distressing memories of the traumatic event, (b) emotional avoidance, and (c) heightened physiological arousal \hyperref[b24]{(Makinson \& Young, 2012)}. Outcomes may include decreasing aggressive outbursts, hyper-vigilance, and sleep disturbance that appeared or increased in intensity after exposure to the traumatic event (APA, 2013; Seligman \&Reichenberg, 2012).\par
The objectives of Cognitive Processing Therapy are; to educate the client about the specific posttraumatic stress disorder (PTSD) symptoms and the way the treatment will help him/her overcome it; inform the client about his/her thoughts and feelings; helps the client develops skills of questioning his/her own thoughts; helps the client to recognise changes in his/her beliefs about what happened after going through the traumatic event. Theory behind CPT conceptualizes PTSD as a disorder of non-recovery, in which a sufferer's beliefs about the causes and consequences of traumatic events produce strong negative emotions, which prevent accurate processing of the traumatic memory and the emotions resulting from the events (Resick., \& Schnicke, 1993, Monson. Schnurr., Resick, Friedman., Young-Xu., \& Stevens., 2006). Because the emotions are often overwhelmingly negative and difficult to cope with, PTSD sufferers can block the natural recovery process by using avoidance of traumatic triggers as a strategy to function in day-to-day living. Unfortunately, this limits their opportunities to process the traumatic experience and gain a more adaptive understanding of it. CPT incorporates trauma-specific cognitive techniques to help individuals with PTSD more accurately appraise these "stuck points" and progress toward recovery (National Centre for PTSD, (2016). A type of counselling called cognitive-behavioural therapy has been shown to be the most effective form of counselling for PTSD  {\ref (Resick, \&Schnick, 1993} Descriptive statistic and t-test analyses were used to determine those who experienced PTSD before and after the treatment of cognitive processing therapy and to establish if there is gende difference between male and female samples. is significant or not  In in Shuwari IDP camp in Borno State, PTSD Checklist -Civilian Version (PCL-C) was administered to 28 respondents out of which thirteen \hyperref[b13]{(13)} were male and fifteen (15) were female. All the respondents showed PTSD before undergone Cognitive Processing Therapy. After undergone Cognitive Processing therapy, 10 male respondents showed little to no severity while 3 male respondents showed moderate to moderately severity of PTSD while twelve (12 ) out of fifteen (15) female respondents showed little to no severity and three (3) of them showed moderate to moderately severity of PTSD.\par
In Popomari IDP camp in Yobe State, PTSD Checklist -Civilian Version (PCL-C) was administered to 22 respondents out of which ten \hyperref[b9]{(10)} were male and twelve (12) were female. All the respondents showed PTSD before undergone Cognitive Processing Therapy. But after undergone Cognitive Processing therapy, seven \hyperref[b6]{(7)} of the male respondents showed little to no severity while three (3) of them showed moderate to moderately severity. For female respondents, nine (9) out of twelve \hyperref[b12]{(12)} of female respondents showed little to no severity while three (3) of them showed moderate to moderately severity after undergone Cognitive Processing Therapy.\par
In Malkohi IDP camp in Adamawa state, PTSD Checklist -Civilian Version (PCL-C) was administered to 26 respondents out of which fourteen \hyperref[b14]{(14)} were male and twelve \hyperref[b12]{(12)} were female. All the respondents showed PTSD before undergone Cognitive Processing Therapy but after undergone Cognitive Processing therapy, nine (9) of the male respondents showed little to no severity while five (5) of them showed moderate to moderately severity. For female respondents, ten \hyperref[b9]{(10)} out of twelve \hyperref[b12]{(12)} showed little to no severity while two    
\section[{Conclusion: Not Significant}]{Conclusion: Not Significant}\par
The total male sample of 37 in all the sampled IDP camps put together has the mean score of 24.5135 with 2.911 standards Deviation in PTSD Checklist -Civilian Version (PCL-C) after undergoing six Cognitive Processing Therapy while the female counteract sampled population of 39 with mean score of 25.025 and 2.680 in Checklist -Civilian Version (PCL-C)\par
Using SPSS (Version 20), the T-test result of -1.0215 was obtained when comparing male and female respondents' pre-test mean scores results in PTSD Checklist -Civilian Version (PCL-C) while the t-test at the post in PTSD Checklist -Civilian Version (PCL-C) for both sexes was -.7975 and at .005 level of significance. The T-test results of both male and female respondents at pre-and post-tests of PTSD Checklist -Civilian Version (PCL-C) showed no significant differences VII. 
\section[{Discussion of Results}]{Discussion of Results}\par
Research Question: What percentage of respondents' scores fall between seventeen and twenty-nine (17 to 29) in PTSD Checklist -Civilian Version (PCL-C) an indication of the cut-off point for severity of PTSD?\par
On table 1 above, 75\% of the respondents indicated little to no severity of PTSD after undergone the Cognitive Processing Therapy while 25\% of the respondents indicated moderate to moderately severity of PSTD. None of the respondent indicated high severity after undergone Cognitive Processing Therapy.. Though 25\% of the respondents scored above the cut-off points, the efficacy of Cognitive Processing Therapy on the treatment of terrorism victims is not in doubt as evidenced above. The 25\% of the respondents which indicated moderate to moderately severity PTSD could be attributed to anxiety created by continuous bombings (suicide bombing), and other criminal activities such as rapes, trading sex for food reportedly perpetuated by security agencies and state of insecurity in IDP camps across North-east of Nigeria The researchers therefore are suggesting eight weeks with two sessions per week of Cognitive Processing therapy for terrorism victims, improvement of security in IDP camps and four (4) weeks follow up therapy for more effective treatment.\par
These findings are in line with Blankenship's (2014) observation that, comparison studies of modalities, limitations, and training requirements of PTSD, identified five treatment modalities which are consistently recommended in the literature as most efficacious current treatments endorsed for PTSD prolonged exposure therapy: These are cognitive processing therapy, trauma-focused cognitive behavioural therapy, stress inoculation training, and eye movement desensitization and reprocessing therapy. He further explained that, research overall shows no significant differences in rates of efficacy between these treatments and therefore recommended for mental health counsellors to select any of the approach that best fits the client population and professional goals based on identified strengths and limitations of each therapy. Alvrez, Mclean and Harris (2011) state that, however, CPT appears to produce significantly more symptom improvement than treatment conducted before the implementation of CPT. They further observed that, there is still room for improvement, as substantial numbers of veterans continue to experience significant symptoms even after treatment with CPT in a residential program. Sur´?s, Link-Malcolm, Chard, Chul and North (2013) explain that, established literature that has demonstrated the effectiveness of CPT in treating PTSD related to sexual assault in civilian populations. The T-test results of both male and female respondents at pre-and post-tests of PTSD Checklist -Civilian Version (PCL-C) showed no significant differences. Birkeland, Blix, Solberg and Heir (2015) report that, among individuals with considerable levels of posttraumatic stress symptoms, women reported higher levels of physiological cue activity and exaggerated startle response but no significant gender differences in the networks of posttraumatic stress were found. In order to determine if this finding can be applied to other  
\section[{Conclusion}]{Conclusion}\par
In conclusion, as indicated above by the findings of this study, Cognitive Processing Therapy has a significant impact in the reduction of PTSD among youth victims of Boko Haran in the North-east part of Nigeria. Also there was no significant difference in the efficacy of Cognitive Processing Therapy among the sexes (gender).\par
IX. 
\section[{Recommendations}]{Recommendations}\par
1. In every IDP camp in Nigeria should have a counselling centre man by qualified counselling psychologists or psychotherapist 2. Effective Security should be provided in all the IDP camps so as to forestall further attacks 3. Every camp should be provided with basic needs of life such as food, shelter, water etc. 4. There should be follow-up treatment even when the victims of terrorism have left their camps and settled in their communities 5. Federal Government of Nigeria must be proactive enough to nip on bud situations that will potentially degenerate into terrorism or insurgency 6. The state government of Northern Nigeria should critically look at Almajiri System of education which has served as a breeding ground for the dire terrorism of the Boko Haram with the view of regulating, supervising and modernising its curricula, in order to mitigating against Almajiri scourge.    \begin{figure}[htbp]
\noindent\textbf{} \par 
\begin{longtable}{P{0.7720733427362483\textwidth}P{0.05155148095909732\textwidth}P{0.009590973201692525\textwidth}P{0.007193229901269394\textwidth}P{0.003596614950634697\textwidth}P{0.005994358251057828\textwidth}}
\multicolumn{6}{l}{these attacks took place. (World Report 2017: Nigeria |}\\
\multicolumn{3}{l}{Human Rights Watch)}\tabcellsep \tabcellsep \tabcellsep \\
\multicolumn{4}{l}{b) Internally Displaced Persons in Nigeria}\tabcellsep \tabcellsep \\
\tabcellsep \multicolumn{5}{l}{According to a survey conducted by the}\\
\multicolumn{6}{l}{National Emergency Management Agency, NEMA, in}\\
\multicolumn{6}{l}{collaboration with International Organisation for}\\
\multicolumn{6}{l}{Migration, IOM, identified 1,822,541 internally displaced}\\
\multicolumn{6}{l}{persons, IDPs, in Adamawa, Bauchi, Borno, Gombe,}\\
Taraba,\tabcellsep Yobe,\tabcellsep Nasarawa\tabcellsep states\tabcellsep and\tabcellsep Abuja\\
\multicolumn{6}{l}{through Displacement Tracking Matrix, DTM, as of}\\
\multicolumn{6}{l}{October 2016 . Nigeria's eight-year conflict with Boko}\\
\multicolumn{6}{l}{Haram has resulted in the deaths of over 20,000 civilians}\\
\multicolumn{6}{l}{and a large-scale humanitarian crisis (UN, 2017);}\\
\multicolumn{6}{l}{approximately 2.1 million people have been displaced}\\
\multicolumn{6}{l}{by the conflict while 7 million need humanitarian}\\
\multicolumn{2}{l}{assistance;.}\tabcellsep \tabcellsep \tabcellsep \tabcellsep \end{longtable} \par
 
\caption{\label{tab_0}}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{} \par 
\begin{longtable}{P{0.85\textwidth}}
Humanitarian Affairs: 2017). In realisation of then egative\\
effects of Posttraumatic Stress Disorder on internally\\
displaced persons, the Federal Government of Nigeria\\
through the Office of the National Security Adviser\\
(NSA), in collaboration with Murtala Muhammed\\
Foundation established Crisis and Trauma a\\
Counselling Centre in Kano in 2014 (IRIN 2015). IRIN\\
report further explained that, also a new Crisis and\\
Trauma Counselling centre has been opened in\\
Maiduguri, the Borno state capital and the stronghold of\\
Boko Haram. According to (IRIN, 2014), In collaboration\\
with Programme Coordinator for the Murtala\\
Muhammed Foundation, the CTCC was part of a\\
strategy by the Federal Government to build capacity\\
within Nigerians national mental health framework to\\
treat PTSD among civilians and military personnel\\
II. What is Posttraumatic Stress\\
Disorder (ptsd)?\\
Posttraumatic stress disorder (PTSD) is a\\
clinical syndrome characterised by intrusive memories,\\
emotional avoidance, and heightened physiological\\
arousal following exposure to a traumatic event\\
(American Psychiatric Association [APA], (2013). Post-\\
traumatic stress disorder (PTSD) can occur after an\\
individual has gone through a life-threatening event.\end{longtable} \par
 
\caption{\label{tab_1}}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{1} \par 
\begin{longtable}{P{0.19753521126760562\textwidth}P{0.26038732394366193\textwidth}P{0.023943661971830985\textwidth}P{0.023943661971830985\textwidth}P{0.0329225352112676\textwidth}P{0.023943661971830985\textwidth}P{0.038908450704225356\textwidth}P{0.0329225352112676\textwidth}P{0.02095070422535211\textwidth}P{0.03591549295774648\textwidth}P{0.0329225352112676\textwidth}P{0.10475352112676056\textwidth}P{0.02095070422535211\textwidth}}
PTSD Checklist -Civilian Version (PCL-C scores\tabcellsep Level of Severity\tabcellsep \tabcellsep \multicolumn{2}{l}{Shuwari}\tabcellsep \tabcellsep Popomari\tabcellsep \tabcellsep \tabcellsep Malkoli\tabcellsep \tabcellsep Percentage\\
\tabcellsep \tabcellsep M\tabcellsep F\tabcellsep Total\tabcellsep `M\tabcellsep F\tabcellsep Total\tabcellsep M\tabcellsep F\tabcellsep Total\\
17-29\tabcellsep \multicolumn{3}{l}{Little to no severity 10 12}\tabcellsep 22\tabcellsep 07\tabcellsep 09\tabcellsep 16\tabcellsep 09\tabcellsep 10\tabcellsep 19\tabcellsep 57 (75\%)\tabcellsep Cut off\\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep Point\\
30-44\tabcellsep Moderate to\tabcellsep \multicolumn{2}{l}{03 03}\tabcellsep 06\tabcellsep 03\tabcellsep 03\tabcellsep 06\tabcellsep 05\tabcellsep 02\tabcellsep 07\tabcellsep 19 (25\%)\\
\tabcellsep Moderately severity\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
45-85\tabcellsep High Severity\tabcellsep 00\tabcellsep \tabcellsep \tabcellsep 00\tabcellsep \tabcellsep \tabcellsep 00\tabcellsep \tabcellsep \tabcellsep 00\\
Total\tabcellsep \tabcellsep \tabcellsep \tabcellsep 28\tabcellsep \tabcellsep \tabcellsep 22\tabcellsep \tabcellsep \tabcellsep 26\end{longtable} \par
 
\caption{\label{tab_2}Table 1 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{2} \par 
\begin{longtable}{P{0.19338624338624338\textwidth}P{0.09894179894179893\textwidth}P{0.04047619047619047\textwidth}P{0.1439153439153439\textwidth}P{0.18888888888888888\textwidth}P{0.18439153439153438\textwidth}}
Volume XVIII Issue VI Version I\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
( H )\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
\tabcellsep Gender\tabcellsep N\tabcellsep Mean\tabcellsep Std. Deviation\tabcellsep Std. Error Mean\\
pre\tabcellsep 1.00\tabcellsep 37\tabcellsep 58.1081\tabcellsep 6.30601\tabcellsep 1.03670\\
\tabcellsep 2.00\tabcellsep 39\tabcellsep 59.7436\tabcellsep 7.59057\tabcellsep 1.21546\\
post\tabcellsep 1.00\tabcellsep 37\tabcellsep 24.5135\tabcellsep 2.91187\tabcellsep .47871\\
\tabcellsep 2.00\tabcellsep 39\tabcellsep 25.0256\tabcellsep 2.68021\tabcellsep .42918\end{longtable} \par
 
\caption{\label{tab_3}Table 2 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{3} \par 
\begin{longtable}{P{0.85\textwidth}}
The T-test result obtained at pre-test was -1.0215\\
The T-test result obtained at post-test was -.7975\\
Level of significance was .005 alpha level\\
VI.\end{longtable} \par
 
\caption{\label{tab_4}Table 3 :}\end{figure}
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\end{document}
