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Trial registered on ANZCTR

Registration number
Ethics application status
Date submitted
Date registered
Date last updated
Date data sharing statement initially provided
Type of registration
Prospectively registered

Titles & IDs
Public title
Trauma Treatment Trial; 'Triple T'
Scientific title
A randomized-controlled trial evaluating EEG neurofeedback training adjunct to trauma counselling for reducing posttraumatic symptoms in adults with a refugee background
Secondary ID [1] 296263 0
Universal Trial Number (UTN)
Trial acronym
Triple T
Linked study record

Health condition
Health condition(s) or problem(s) studied:
Posttraumatic Stress Disorder (PTSD) 298310 0
Condition category
Condition code
Mental Health 298432 298432 0 0

Study type
Description of intervention(s) / exposure
There are two active arms to this trial;
Arm 1: Neurofeedback integrated with trauma counselling (NFT)
Arm 2: A ‘lifestyle enhancement intervention’ (LEI) involving trauma counselling, nutrition and exercise therapy

Both treatment arms will participate in 30 x 1 hour sessions, scheduled at two per week for 15 weeks. For NFT, each of the 30 sessions will include approximately 20mins of neurofeedback training integrated with 40 mins of counselling. LEI will involve a one hour session week in counselling (15 sessions) and one in a lifestyle enhancement session.

Both interventions will be delivered individually and face-to-face, onsite at STARTTS’s neurofeedback/counselling rooms. Adherence will be measured as number of sessions attended. Attendance, intervention and session length are recorded by the clinician as part of routine care.

NEUROFEEDBACK TRAINING is a non-invasive method of modifying brainwave patterns using principles of behavioural learning. Brain activity is measured using an electroencephalograph (EEG) and is shown to the trainee via a simple signal (visual or auditory) to indicate to them when their brain is producing the desired activity. Over sessions new patterns are strengthened, increasing mental flexibility for processing situations in a more self-serving way.

Training protocols are chosen based on a decision tree for symptoms, and informed by quantitative EEG. The default protocol will target the most prevalent presentation seen in PTSD of hyperarousal and involve reinforcement of alpha (8-10Hz) and right parietal and temporal regions. Neurofeedback therapy will be delivered by psychologists who have experience and training with neurofeedback and trauma counselling with this population.

LIFESTYLE ENHANCEMENT INTERVENTION was developed at STARTTS as a complement to standard counselling. They focus on improvement of lifestyle habits in diet, sleep and physical activity, through education, monitoring support and coaching, in order to improve physical health and psychological wellbeing.

Counselling delivered at STARTTS tailored for the special needs of refugees and draws on current research and clinical experience. A variety of therapy modalities will be used according to the presentation of the client and the background of the clinician. Methods include case management, psychoeducation, mindfulness, acceptance and commitment therapy, grief counselling and cognitive therapy.
Intervention code [1] 294431 0
Intervention code [2] 312598 0
Intervention code [3] 312600 0
Treatment: Other
Comparator / control treatment
Lifestyle Enhancement Intervention (LEI)
The Lifestyle Enhancement Intervention (LEI), will involve one counselling session per week (total 15). Weekly counselling will be augmented by a second weekly session (total 15) spent with either a) an exercise therapist (~7 sessions) or b) a nutritionist (~7 sessions).

Body Activation: The body activation part of this program is designed to alleviate symptoms of trauma and improve well-being using physical activity. The sessions work with motivation, mindset and goal setting, heart-rate variability training, exercise, visualizations and muscular relaxation. The guiding therapeutic principle across sessions is for the client to gain knowledge and awareness of how their body has responded to trauma, and to learn techniques for self-regulating to reduce symptoms and improve general well-being. Client’s abilities and previous experience with physical activity is diverse. Appropriate lifestyle changes may range from walking and low impact activities to more energetic forms of exercise. An important aspect of this program is to empower and educate clients to be able to find and evaluate resources of their own in making sustainable lifestyle changes. Sessions focussing on physical activity will be one-on-one with a qualified exercise therapist with expertise in working with individuals with PTSD related to refugee experience.

Nutrition: The aim of nutritional intervention at STARTTS is to introduce (or reinforce) healthy eating habits people from refugee backgrounds to promote their physical and mental wellbeing as well as their self -awareness and self-care. This is done by providing information about the health benefit of foods that can enhance their diet and which can be introduced into meals that are culturally congruent with the client. Support and discussion about barriers to change and ongoing evaluation about changes are discussed in session. The nutritional intervention is tailored to each individual’s needs, based on their cultural, financial, physical and mental status. The nutritional intervention is provided by a qualified nutritionist (Diploma of Nutrition) who is an accredited member of professional associations.
Control group

Primary outcome [1] 298442 0
Difference in PTSD symptoms (Harvard Trauma Questionnaire; Symptoms 1-16) between NFT and LEI groups
Timepoint [1] 298442 0
Week 16: Post-treatment. Week 28: Follow-up
Primary outcome [2] 307687 0
Difference in symptoms of anxiety and depression (Hopkins Symptom Checklist) between NFT and LEI groups
Timepoint [2] 307687 0
Week 16: Post-treatment. Week 28: Follow-up.
Secondary outcome [1] 324249 0
NFT versus LEI on cognitive control as indicated by the P300 NOGO ERP elicited by a Visual Continuous Performance Task, and associated behavioural responses
Timepoint [1] 324249 0
Week 16: Post-treatment
Secondary outcome [2] 324252 0
NFT versus LEI on emotion regulation as indicated by the VPP and P300 ERPs to fearful versus neutral facial expressions and self-reported difficulties in emotion regulation scale (DERS)
Timepoint [2] 324252 0
Week 16: Post-treatment

Key inclusion criteria
(1) Exposure to refugee related trauma (2) Meets DSM-V criteria for PTSD
Minimum age
21 Years
Maximum age
65 Years
Both males and females
Can healthy volunteers participate?
Key exclusion criteria
Suicidal intent, Psychotic, Substance use disorder

Study design
Purpose of the study
Allocation to intervention
Randomised controlled trial
Procedure for enrolling a subject and allocating the treatment (allocation concealment procedures)
Participants will be treatment seeking individuals attending trauma counselling services at STARTTS. Trial participants and all study personnel will be unaware of the next study group assignment in the allocation sequence. The allocation sequence will be generated by an offsite investigator who is not involved in consenting, screening or randomization. They will use an online system which will allow access by researchers at different sites when needed.
Methods used to generate the sequence in which subjects will be randomised (sequence generation)
Participants will be randomly assigned according to a block randomization schedule per four sites with a 2:2 allocation.
Masking / blinding
Blinded (masking used)
Who is / are masked / blinded?

The people assessing the outcomes
Intervention assignment
Other design features
Not Applicable
Type of endpoint(s)
Statistical methods / analysis
To assess the main outcome of PTSD (HTQ) symptom levels, the two treatment groups will be compared on post-intervention Week-15/16 scores using an independent groups t-test with significance level of p<.05, 2-tailed. A sample size of n=32 in each group will have 90% power to detect a difference in means of 0.5 (e.g. if M1=3.0 and M2=2.5) assuming that the common standard deviation is 0.6. This is congruent with a clinically meaningful difference, and with effect size estimates of symptom changes for neurofeedback for PTSD and psychotherapy for refugee PTSD. Our target is n=40 in each group to allow for a 20% drop-out rate.

Other variables will be analysed in this way using t-tests for continuous variables, and chi-squared tests for categorical variables.

It is expected that randomization will result in systematic group differences on base levels of variables and demographic variables. Where there are baseline differences in variables or difference in demographic variables, analyses will be re-run using ANCOVA/Regression to test the effect of the variable on the outcome measure.

Additional Analyses
1. There are five symptom domains of PTSD as measured by the HTQ; Intrusion, Numbing, Anxious arousal, Dysphoric arousal and Avoidance. Pending a significant change in overall symptoms, we will run a further analysis (ANOVA) to identify in which symptom sub-scale we see the largest changes associated with neurofeedback.
2. There are hypothesized subtypes of PTSD that have been validated by a factor analysis of scores on the HTQ subscales. We will use factor analysis to test how well this proposed factor structure fits the current sample. We will then investigate the strength of treatment response for each subtype e.g. dysphoric arousal, emotional numbing.

Recruitment status
Date of first participant enrolment
Date of last participant enrolment
Date of last data collection
Sample size
Accrual to date
Recruitment in Australia
Recruitment state(s)
Recruitment postcode(s) [1] 24274 0
2144 - Auburn
Recruitment postcode(s) [2] 13291 0
2163 - Carramar
Recruitment postcode(s) [3] 24273 0
2165 - Fairfield
Recruitment postcode(s) [4] 24275 0
2170 - Liverpool

Funding & Sponsors
Funding source category [1] 293684 0
Government body
Name [1] 293684 0
NSW Service for the Treatment and Rehabilitation of Torture and Trauma Survivors
Address [1] 293684 0
Street Address: 152 - 168 The Horsley Drive, Carramar NSW 2163
Postal Address: PO Box 203, Fairfield NSW 2165
Country [1] 293684 0
Primary sponsor type
Government body
NSW Service for the Treatment and Rehabilitation of Torture and Trauma Survivors
Street Address: 152 - 168 The Horsley Drive, Carramar NSW 2163
Postal Address: PO Box 203, Fairfield NSW 2165
Secondary sponsor category [1] 300414 0
Name [1] 300414 0
Address [1] 300414 0
Country [1] 300414 0
Other collaborator category [1] 280381 0
Name [1] 280381 0
University of Sydney Medical School - Westmead
Address [1] 280381 0
Westmead Hospital
Hawkesbury Road
Westmead NSW 2145
Country [1] 280381 0

Ethics approval
Ethics application status
Ethics committee name [1] 295123 0
South Western Sydney Local Health District (SWSLHD)
Ethics committee address [1] 295123 0
Liverpool Hospital, NSW 1871
Postal address: Locked Bag 7103 Liverpool BC NSW 1871
Ethics committee country [1] 295123 0
Date submitted for ethics approval [1] 295123 0
Approval date [1] 295123 0
Ethics approval number [1] 295123 0

Brief summary
Background summary: Refugees experience a higher incidence of posttraumatic stress disorder (PTSD) and increased levels of chronicity. Effective treatment is a challenge worldwide and is likely to require a multifaceted approach. Neurofeedback (EEG biofeedback) is utilized to enable individuals to modulate and retrain brain electrical activity through training new pathways of activation that can increase the brain’s capacity to self-regulate. STARTTS’ neurofeedback program was developed to complement counselling for refugee related PTSD and has had good clinical success. However, evidence from a randomized controlled trial is needed.

Objectives: The primary aim of this project is to examine the efficacy of neurofeedback training for alleviating chronic posttraumatic stress symptoms in adult refugees. We hypothesize a reduction in symptoms, accompanied by changes in functional brain activity reflecting improved cognitive control and emotion regulation.

Study Plan: Willing and eligible, existing STARTTS clients will be randomized to participate in neurofeedback integrated with counselling (NFT) or to an active control “lifestyle enhancement intervention” (LEI) involving sessions focusing on nutrition and physical activity in addition to counselling. Both interventions will involve 30 bi-weekly sessions over 15 weeks. A total of eighty participants will be enrolled over two years and will complete questionnaire and EEG assessments pre- and post-intervention and at 3-month follow-up.
Trial website
Trial related presentations / publications
Askovic, M., Watters, A. J., Coello, M., Aroche, J., Harris, A. W. F., & Kropotov, J. (2019). Evaluation of Neurofeedback for Posttraumatic Stress Disorder Related to Refugee Experiences Using Self-Report and Cognitive ERP Measures. Clinical EEG and Neuroscience, 1–8.

Askovic, M., Watters, A. J., Aroche, J., & Harris, A. W. F. (2017). Neurofeedback as an adjunct therapy for treatment of chronic posttraumatic stress disorder related to refugee trauma and torture experiences: Two case studies. Australasian Psychiatry, 25(4), 358–363.

Public notes

Principal investigator
Name 65002 0
Dr Anna Watters
Address 65002 0

Street Address: 152 - 168 The Horsley Drive, Carramar NSW 2163

Postal Address: PO Box 203, Fairfield NSW 2165
Country 65002 0
Phone 65002 0
+61 (0)2 9794 1900
Fax 65002 0
+61 (0)2 9794 1910
Email 65002 0
Contact person for public queries
Name 65003 0
Ms Mirjana Askovic
Address 65003 0

Street Address: 152 - 168 The Horsley Drive, Carramar NSW 2163

Postal Address: PO Box 203, Fairfield NSW 2165
Country 65003 0
Phone 65003 0
+61 (0)2 9794 1900
Fax 65003 0
+61 (0)2 9794 1910
Email 65003 0
Contact person for scientific queries
Name 65004 0
Prof Anthony Harris
Address 65004 0
Westmead Institute for Medical Research
176 Hawkesbury Rd, Westmead NSW 2145
Country 65004 0
Phone 65004 0
+61 (0)2 9845 668
Fax 65004 0
+61 (0)2 9635 7734
Email 65004 0

Data sharing statement
Will individual participant data (IPD) for this trial be available (including data dictionaries)?
No/undecided IPD sharing reason/comment
we'd have to check if this is permissible
What supporting documents are/will be available?
No other documents available
Summary results
No Results