Due to difficulties in translating to Swahili, the therapy “cognitive processing therapy” was instead named “mind and heart” therapy. 13 villages in South Kivu province and 2 villages on the border in North Kivu province were selected for the study based on NGO coverage as well as accessibility, security, and availability of psychosocial assistants. Seven villages were randomized to provide Cognitive Processing Therapy (CPT) and 8 to continue to provide an existing individual support program (control).
CPT was delivered by PsychoSocial Assistants (PSAs; community-based paraprofessionals) who had 1-9 years of experience supporting survivors of sexual violence, at least 4 years of post–primary education and had undergone training by the International Rescue Committee (IRC) in case management and relevant topics.
To deliver CPT, PSAs underwent 2 weeks of in-person training with US-based trainers, using a locally translated and adapted manual. Ongoing supervision was provided through a multi-tiered system: Congolese psychosocial supervisors employed by the IRC provided direct supervision to PSAs through weekly telephone or in-person meetings, while a bilingual clinical social worker trained in the US provided in-country supervision and communicated with the US trainers for quality assurance.
Therapy and Adaptations Overview
CPT is a protocol-based therapy for treating depression, anxiety, and PTSD in sexual-violence survivors that has been tested through multiple trials in high-income settings. A group format was chosen for larger and the cognitive-only model was used. CPT materials were adapted to be both culturally appropriate and useable by local PSAs.
In villages that provided CPT, PSAs recruited up to 24 participants and concurrently led three groups (max 8 women per group). The treatment included 1 individual session (1 hour) and 11 group sessions (1-2 hours). Participants also had access to the PSAs as desired outside the therapy and were encouraged to practice the therapy skills as part of their daily routine and meet with each other between group sessions to help with homework.
Adaptation of the group manual and training materials
The adaptation of materials was iterative and guided by the local context to accommodate therapists with little to no training in cognitive behavioural treatments or group interventions; a client population with low levels of literacy; and specific beliefs and structures of cultural groups within DRC.
The iterative process for adaptation included:
- Additional information on group psychotherapy, managing group process and replacing technical terms/American idioms with standard, simple terms.
- Translating the resulting materials into DRC French. Materials were reviewed by a bilingual clinical social worker for clarity and cultural appropriateness.
- Adaptation continued in DRC during the two-week training of PSAs by soliciting daily feedback on clarity and cultural fit of materials, accessibility of client materials, and barriers to implementation inherent in a low resource environment.
- Prior to implementation, the adapted treatment was piloted by the PSAs and clinical supervisor, allowing for additional feedback.
- At the end of the study, a debriefing meeting was held with PSAs and clinical supervisors for any additional feedback, generating a final set of materials to use as reference material as they continue to provide the therapy as part of ongoing mental health services.
Adaptation of the therapy
The structure and essential elements of CPT were retained in the modified treatment however some aspects were simplified. The main changes to the manual involved:
- Reducing technical jargon
- Decreasing the emphasis on underlying theories of PTSD
- Including more information on specifics of group therapy and managing group interactions
- Including more scripts of therapy content in lay language
- Adding more group specific clinical case examples relevant to the experiences of sexual violence survivors in the Democratic Republic of Congo
- Modifying homework assignments for non-literate clients
- It was not possible in DRC to use written homework therefore materials were simplified to be easier to understand and memorize
- Skills taught to clients were simplified both in terms of language and number of items used for a skill and retained only questions that were the least abstract and easiest to memorize
- Clients Worksheets were also modified to use pictures as cues, so that the PA would teach the skill related to the worksheet during the group, and patients could refer back to the pictures on the worksheet as reminders of each step of the skill while doing the homework
- We also developed ways to help clients memorize skills, e.g. encouraging them to tap their heads as a reminder to notice a belief and touch their hearts as a reminder to notice the related emotion