A Randomized Controlled Trial of Trauma-focused Cognitive Behavioral Therapy

O’Callaghan, P., McMullen, J., Shannon, C. et al (2013). A Randomized Controlled Trial of Trauma-focused Cognitive Behavioral Therapy for Sexually Exploited, War-Affected Congolese Girls. Journal of the American Academy of Child & Adolescent Psychiatry 52 (4) 359-369

Bass, J.K., Annan, J., McIvor Murray, S. et al (2013). Controlled Trial of Psychotherapy for Congolese Survivors of Sexual Violence. New England Journal of Medicine 368 (23) 2182-2191

Reported rates of sexual violence in the conflict affected Eastern region of the Democratic Republic of Congo (DRC) are extremely high, with population based studies reporting rates ranging from 20% to 40% (see Johnson et al, 2010 ). While the rates of such violence may vary - influenced by a number of factors such as under-reporting due to associated stigma (see Guimond and Robinette, 2014 ) - there is marked consistency in findings showing that sexual violence against girls and women can result in serious physical injury, sexually transmitted diseases and psychological distress. Yet, there appears to be a lack of rigorously evaluated interventions for sexually abused or exploited women and girls in low-income, conflict affected countries.

Against this background, we draw our readers’ attention to the above two recent studies by Bass, Annan and colleagues, and O’Callaghan and colleagues. Each seeks to evaluate interventions in just such conditions. Both involve women or girl survivors of sexual exploitation and violence in the Kivu provinces of Eastern DRC.

In the paper by Bass, Annan and colleagues, some 270 female survivors of sexual violence showing impairing symptoms of anxiety and depression, and post-traumatic stress received one of two interventions. The women were drawn from 15 villages in the South and North Kivu provinces. The villages had been randomly assigned to provide participants with either group-based cognitive processing therapy or individual psycho-social support. Women in both types of intervention showed improvements in their functioning, anxiety and depression, and post-traumatic symptoms over the four month intervention period – improvements that were maintained at six month follow-up. However, those in the cognitive therapy group showed significantly greater improvements than those in the individual support group – and significantly more of the former were showing fewer difficulties six months later.

Similarly, O’Callaghan and colleagues conducted a rigorous randomised controlled trial of group-based trauma focused cognitive behavior therapy with 52 war affected girls aged 12-17 years who had been exposed to rape or sexual violence. The girls were drawn from a larger group of war-affected children. 24 were assigned to the intervention group with the remainder acting as waiting list controls. Those receiving the trauma focused cognitive behavioural intervention did significantly better on measures of various forms of emotional distress and trauma, showing a very marked reduction in symptomatology post-treatment with continued improvement evident at three month follow-up.

Despite the differences between these two studies in terms of participants’ ages and the specifics of the type of cognitive interventions offered, the strength of their findings rests upon rigorous research design, implementation and evaluation procedures. Both studies evidence the effectiveness of therapeutic interventions in a group setting – leading to reflections on how group processes may contribute positively to change. Both strive to incorporate local accounts of emotional distress, with O’Callaghan and colleagues using an African developed and validated questionnaire to assess locally defined bio-psychosocial deficits. Both employed local psychosocial assistants without medical or formal mental health training, to deliver successful therapeutic interventions, and both show that therapy can be adapted and made appropriate for participants with reduced literacy skills and those who potentially remain exposed to further violence in conflict affected areas. In short, both papers have much to offer practitioners in the field.

Dr Linda Dowdney
Editor, Psychosocial content for Child Soldiers International

October 2014

Bass, J.K., Annan, J., McIvor Murray, S. et al (2013). Controlled Trial of Psychotherapy for Congolese Survivors of Sexual Violence. New England Journal of Medicine 368 (23) 2182-2191.http://www.globalmentalhealth.org/sites/default/files/Bass%202013%20NEJM%20RCT%20cognitive%20processing%20therapy%20sexual%20violence%20survivors%20DRC.pdf Last downloaded 16.10.2014.

O’Callaghan, P., McMullen, J., Shannon, C. et al (2013). A Randomized Controlled Trial of Trauma-focused Cognitive Behavioral Therapy for Sexually Exploited, War-Affected Congolese Girls. Journal of the American Academy of Child & Adolescent Psychiatry 52 (4) 359-369.http://www.ncbi.nlm.nih.gov/pubmed/23582867 Unfortunately, due to publisher restrictions, we can only provide a link to the abstract of this article.

Johnson, J., Scott, J., Rughita, B. (2010). Association of Sexual Violence and Human Rights Violations with Physical and Mental Health in Territories of the Eastern Democratic Republic of the Congo. JAMA 304(5) 553-562. http://www.lawryresearch.com/553.full.pdf Last downloaded 16.10.2014.

Guimond, M-F. & and Robinette, K. (2014). A survivor behind every number: using programme data on violence against women and girls in the Democratic Republic of Congo to influence policy and practice. Gender and Development, 22 (2) 311-326. Downloadable only via Oxfam site:http://policy-practice.oxfam.org.uk/publications/a-survivor-behind-every-number-using-programme-data-on-violence-against-women-a-322277 Last downloaded 16.10.2014.

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