Innovation summary

The eastern Democratic Republic of Congo is a low-resource, conflict-affected region in which political and economic instability are ongoing problems; nearly 40% of women in the region report having experienced sexual violence1. Women who experience sexual violence are at increased risk for a range of mental health problems2, including posttraumatic stress disorder (PTSD), depression, anxiety, and social maladjustment3. In high-income countries, there are effective treatments for mental health problems related to trauma and sexual violence4, but these have not been adequately tested in low-resource contexts in which conflict and violence is ongoing. In addition, increasing women’s functioning and access to social support within communities suffering from widespread trauma could provide critical resources to support recovery5; interventions therefore also need to evaluate structural social capital and social resource engagement in low-resource settings.

This innovation is an adaptation of group Cognitive Processing Therapy (CPT), a manualized therapy for survivors of sexual violence. Treatment included 1 individual session followed by 11 group sessions with six to eight women, led by community-based paraprofessionals (Psychosocial Assistants). Psychosocial Assistants received 2 weeks of in-person training using a manual that was adapted and translated locally. Ongoing supervision was provided through a multi-tiered supervision system. Adaptation of the therapy included an initial individual session, oral rather than written completion of assignments, and simplification of materials to facilitate provider understanding and memorization.

Impact summary

  • The study included 405 women from 15 villages; 154 women participated in the CPT treatment arm during the study; control participants were offered treatment after study was complete.
  • Scores on locally adapted measures of depression/anxiety, PTSD, and functional impairment showed significantly greater improvement for women in the CPT program compared with the individual support control condition.
  • Women in the CPT program reported an increase in social group membership and participation, as well as emotional support-seeking

"The CPT Program allowed me to delve more deeply into clients' feelings, thoughts and symptoms"

- A Psychosocial Assistant CPT provider

Innovation details

Background

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).

Psychosocial Assistants

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:

 
  1. Additional information on group psychotherapy, managing group process and replacing technical terms/American idioms with standard, simple terms.
  2. Translating the resulting materials into DRC French. Materials were reviewed by a bilingual clinical social worker for clarity and cultural appropriateness.
  3. 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.
  4. Prior to implementation, the adapted treatment was piloted by the PSAs and clinical supervisor, allowing for additional feedback.
  5. 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

Structural considerations

  • 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

Key drivers

Cross-cultural collaboration

  • The collaborative process for ensuring the cross-cultural appropriatness of the intervention and the mental health assessments involved US-based CPT trainers, the study investigators, local and international staff at International Rescue Committee, and the Congolese supervisors, psychosocial assistants, and interpreter.
  • Adaptation of the mental health and function assessments began with a series of qualitative studies in the study villages to understand how women talked about distress, what terms they used, and what tasks of daily living were relevant for them to take care of themselves and their families and participate in the community.
  • Adaptation of the CPT intervention was done through close collaboration with the local supervisors and PSA providers who provided valuable feedback and content and implementation adaptations.

Challenges

Participant Literacy

The women participating in CPT were mostly illiterate or with very low literacy, resulting in our need to adapt the homework portions of the CPT program to be more about easy to remember skills to practice.

Novelty of talk therapy

 

There was not a strong tradition of talk therapy or mental health treatment in the Democratic Republic of Congo. Based on suggestions from the local supervisors we therefore added an additional individual therapy session to describe mental health symptoms, describe the rationale for talk therapy, discuss what group treatment will be like, and answer client questions and concerns.

Cultural differences

 

Consideration of cultural factors was vital to adapting CPT for use in DRC. Some factors were identified before the training began through a preliminary qualitative study, whereas others emerged during the training and/or implementation. Certain difficulties around gender roles for example made cognitive restructuring challenging e.g specific beliefs about social status and rape i.e. that rape would permanently change a women’s social status.

Language differences

 

Some key concepts such as the distinction between thoughts and feelings did not readily translate into Swahili. We worked closely with the psychosocial assistants to identify ways to explain these concepts within the local languages.

Use of measures of unknown validity


It was difficult to identify clinical cases of PTSD and combined depression and anxiety. Because symptoms of these disorders could be nonpathologic reactions to extreme circumstances, it is unclear what proportions of participants actually met clinical criteria.

Continuation

USAID is currently funding IMA World Health to expand the availability of CPT in North and South Kivu through local health psychologists and the Panzi and Health Africa Centers for Excellence.

Partners

Funders

Evaluation methods

We selected, adapted, and tested measures based on qualitative studies in three linguistically different communities to identify salient mental health problems of sexual-violence survivors. On the basis of the findings, we selected:

  • the Hopkins Symptom Checklist (HSCL-25) to assess depression (15 items) and anxiety (10 items)
  • the Harvard Trauma Questionnaire (HTQ) to assess PTSD symptoms (16 items)
  • Assessment of functional impairment, based on the degree of difficulty in performing important tasks of daily living (20 tasks)

The checklists were adapted and pilot-tested in each language group.

 

Social capital was measured by:

 
  • Selected items from the Integrated Questionnaire for the Measurement of Social Capital based on the study formative phase
  • Group membership and participation in 9 locally relevant groups
  • Financial social network size
  • Instrumental support network size
  • Emotional support seeking

Measures were assessed at baseline and 2 follow-up time points at the end of treatment (within 1 month) and 6 months later.

PSAs' fidelity to the therapy protocol was assessed with checklists of treatment elements and ratings of knowledge and skills, as observed by supervisors during group sessions.

Cost of implementation

A cost-analysis was not conducted as part of this research study.

Impact details

Reach

  • The study included 405 women; 154 who were in the villages where CPT was provided during the study.

Treatment response

  • Both the individual-support (control) and therapy groups had significant improvements during treatment, with effects maintained at 6 months.
  • For PTSD symptoms (HTQ) and combined depression and anxiety symptoms (HSCL-25), participants in the CPT group had significantly greater improvements than those in the control group at both follow-up assessments, with all treatment-effect sizes greater than 1.0.
  • Approximately 70% of participants in the CPT group met the criteria for probable depression or anxiety at baseline, with 10% or less meeting the criteria at either follow-up assessment (compared to 53% at the end of treatment and 42% at 6 months in the control group).
  • At 6-month follow-up, CPT participation (compared to control) was also significantly associated with improvements in social group membership and participation.
  • We observed no significant differences between CPT and control for contact with non-kin social networks, instrumental support network size, or financial network size.
  • Although we did not observe between-group differences, financial and support network size increased for both groups between baseline and 1-month follow-up.
  • At 1-month follow-up, women in CPT also reported significantly higher emotional support-seeking compared with women in the control condition.

Our findings suggest that despite illiteracy and ongoing conflict, this evidence-based treatment can be appropriately implemented and effective within the Democratic Republic of Congo setting.

References

  1. Johnson K, Scott J, Rughita B, et al. Association of sexual violence and human rights violations with physical and mental health in territories of the Eastern Democratic Republic of the Congo. JAMA 2010;304:553-562
  2. Chen LP, Murad MH, Paras ML et al. Sexual abuse and lifetime diagnosis of psychiatric disorders: systematic review and meta-analysis. Mayo Clin Proc. 2010;85(7):618–629.
  3. Resick PA. The psychological impact of rape. J Interpers Violence. 1993;8(2):223–255.
  4. Resick PA, Williams LF, Suvak MK, Monson CM, Gradus JL. Long-term outcomes of cognitive-behavioral treatments for posttraumatic stress disorder among female rape survivors. J Consult Clin Psychol 2012;80:201-210
  5. De Silva MJ, McKenzie K, Harpham T, Huttly SRA. Social capital and mental illness: a systematic review. J Epidemiol Community Health. 2005;59(8):619–627.

Research

Tools

Associates

Judy Bass
Debra Kaysen
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Country

Congo (Democratic Republic of the)

Affiliated organizations

International Rescue Committee
Johns Hopkins University

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