Cognitive Processing Therapy: Functionality Tool

With support from the Humanitarian Innovation Fund, the International Rescue Committee is piloting Cognitive Processing Therapy in eastern DRC, a targeted mental health therapy that gives survivors of sexual violence a new way to manage distressing thoughts and overcome trauma.

Case managers use a functionality tool to identify sexual violence survivors who would benefit from specialized mental health services

A functioning case management system is the foundation of the provision of specialized mental health services for survivors of violence in the Democratic Republic of Congo (DRC).  Volunteer case managers from local community-based women’s organisations provide support and care to survivors of sexual and physical violence through a collaborative process that helps survivors on their journey to recover from trauma.

Depending on the individual needs of each client, this support often includes linking survivors to services such as medical care or legal assistance. For survivors with high levels of trauma, depression and anxiety, this may also include linking clients to a specialized mental health service entitled Cognitive Processing Therapy (CPT), offered through the public health system at seven health centres.

But how can local volunteer case managers tell which clients need additional mental health care after case management?  What counts as a high level of trauma?

History of collaboration between Johns Hopkins University and the IRC

Starting in 2005, faculty from John’s Hopkins University (at that time working at Boston University) provided technical assistance to the International Rescue Committee (IRC) in the DRC, to develop a tool to monitor and measure mental health symptoms and functionality, defined as the ability to complete day-to-day tasks, of survivors of sexual violence.

This process included a study of how survivors view their own needs (Murray et al., 2006), the development and testing of a tool to assess those needs and a survivor’s ability to function, and analysis of data to monitor changes in these aspects among clients receiving case management services (Bolton P & Locket D, 2009; Bolton 2009).

Since the original development of the functionality tool, it has seen some modifications to adapt to changes in programming and changes in service providers.

Functionality Tool

Case managers use the functionality tool at the initial session when a survivor comes in for services, and again at the final session when survivors are discharged. This not only allows case managers to identify some of the main mental health and functionality problems that their client is facing and tailor their services accordingly, but also allows case managers to see how their clients have improved.

The functionality tool is composed of two sections – one to assess difficulty in carrying out daily tasks, and the other to assess problems with trauma, depression and anxiety.

One section of the functionality tool assesses severity of trauma, depression and anxiety symptoms

Overall, most of the survivors that come in for case management services see great improvements in functionality and mental health.  In 2013, survivors supported by the IRC and its partners reported a decrease of more than 80% in difficulties with trauma, depression and anxiety after completing the case management process.

High and persistent symptoms

However, some survivors continue to suffer from severe symptoms and functional difficulties even after going through case management; these are the clients for whom specialised mental health services like CPT were created.

Using cut-off criteria that were developed as part of a rigorous impact evaluation of CPT, case managers calculate scores for the two sections of the functionality tool.  If a client’s scores after case management indicate that they still experience at least a little bit of difficulty with all mental health symptoms, and at least a little bit of difficulty with half of daily tasks, this is an indication of enough persistent mental health and functionality problems to warrant receiving more specialized services.

Using these criteria, about 10% of survivors that came in for case management services and were discharged in 2013 had high and persistent symptoms. Given that CPT is indicated for only about 10% of survivors receiving support through the IRC, it has at times proven challenging to identify enough women with symptoms that merit referral to CPT after case management – although the IRC anticipates that this challenge would be reduced if survivors were being continuously identified over a longer period of time, rather than all at once, as is currently the case.

In communities where CPT is available, the functionality tool gives case managers a systematic method of identifying and referring survivors who would benefit the most from specialized mental health services like CPT, and allows for continuous monitoring and follow-up.

References

Bolton P (2009) Assessing the Impact of the IRC Program for Survivors of Gender Based Violence in Eastern Democratic Republic of Congo.  Final Report.  USAID:http://pdf.usaid.gov/pdf_docs/PDACP550.pdf

Bolton P & Locket D. (2009) Victims of Torture Fund Evaluation of the IRC Gender-Based Violence Program in the Democratic Republic of the Congo.  USAID Report:http://pdf.usaid.gov/pdf_docs/PDACN138.pdf

Murray L, Bass J, Bolton P (2006).  Qualitative study to identify indicators of psychosocial problems and functional impairment among residents of Sange District, South Kivu, Eastern DRC. USAID http://pdf.usaid.gov/pdf_docs/pnadi610.pdf