Overcoming Trauma

By the end of the Cognitive Processing Therapy (CPT) project with the Humanitarian Innovation Fund in January 2015, a total of 117 women survivors of sexual violence (SV) with high and persistent trauma symptoms completed 12 sessions of CPT within 13 groups, led by local trained nurses. The International Rescue Committee (IRC) held a closing workshop in January 2015 during which the IRC team and participating service providers from the health structures reviewed CPT results and discussed its overall implementation, successes, challenges, lessons learned, and its potential future in the Democratic Republic of the Congo (DRC).

Results for SV survivors

CPT was overall very beneficial for SV survivors and served as a valuable tool to help survivors where standard case management was not successful. Following the intervention, survivors showed significant improvements in mental health, with substantial decreases in trauma symptoms.

At the start of each session, therapists assessed trauma symptoms of each participant using a simple, standardized symptom checklist that had been adapted to the local context. The checklist contains 11 questions, each with a possible score of 0 to 3, with 3 indicating major difficulty with that symptom. Therapists recorded the sum of the scores of all 11 questions for each client, with 33 being the maximum score (indicating major difficulty with all 11 symptoms).

The graph below shows that the average total score for most groups was between five and nearly 30 at the beginning of CPT (implying between “a little bit of a problem” and “a big problem” for the 11 symptoms), and that the average for most groups dropped to nearly zero by the end of CPT, showing significant improvement in mental health and healing from lasting trauma.

Many CPT participants experienced a small increase in symptoms between sessions four and six, after an initial decline during sessions one to three. At this stage of CPT, the sessions focus on learning how to identify rather than repress harmful thoughts and feelings related to the trauma experienced, with the remaining sessions focusing on working through these thoughts and feelings. As a result, some may experience an increase in trauma symptoms during this phase of CPT. This trend is consistent with previous CPT groups in DRC in 2012-2013.

Feedback from CPT participants and therapists indicated that CPT helped survivors identify deeply hidden feelings related to trauma, improve decision-making and problem-solving power for survivors, and facilitate social reintegration.

Lessons for therapists

During the closing workshop, therapists highlighted key lessons learned, including the importance of taking time to prepare for each session and of holding a debriefing between the therapist and the supervisor for each therapy session.

Future of CPT in DRC

The results from this project, as well as stakeholder feedback, were dramatic in terms of improving trauma symptoms, and were consistent with studies among survivors of sexual violence in high-income countries of cognitive behavioural interventions generally (Olatunji, 2010) and of CPT specifically (Resick, 2002; Cloitre, 2010).

Such positive results show that CPT is an effective tool for improving mental health in insecure settings, which can be carried out successfully by therapists without an extensive background in mental health and psychotherapy. This pilot also shows that, with effective support and supervision, CPT can be successfully integrated into existing structures in DRC, which has great implications for making this therapy widely available in DRC.

As this was a pilot phase, the IRC has a few recommendations for CPT’s future operation, integration and sustainability in DRC. First, CPT should be expanded to other health structures within the Kabare health zone, as well as more widely in South Kivu province and DRC as a whole. Second, CPT should be expanded to survivors of all types of trauma that are found in the health structures.

The IRC also recommends sharing this project with stakeholders in order to facilitate CPT’s integration within the Operational Activity Plan for the Ministry of Health. Therapists’ capacity should be reinforced, community health workers trained in referrals and case management, and local personnel trained in CPT so that the project can expand in local areas. Through these actions, the IRC wholeheartedly believes that CPT can be an incredible tool to help trauma-affected populations address the challenges that they face.