Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy JUNE 2013 LOGiCA Study Series The International Bank for Reconstruction and Development / The World Bank 1818 H Street, NW Washington, DC 20433 All rights reserved First published November 2014 www.logica-wb.net This Study Series disseminates the findings of work in progress to encourage discussion and exchange of ideas on gender and conflict related issues in Sub-Saharan Africa. Papers in this series are not formal publications of the World Bank. The papers carry the names of the authors and should be cited accordingly. The series is edited by the Learning on Gender and Conflict in Africa (LOGiCA) Program of the World Bank within the Social, Urban Rural and Resilience Global Practice. This paper has not undergone the review accorded to official World Bank publications. The findings, interpreta- tions and conclusions herein are those of the author and do not necessarily reflect the views of the International Bank for Reconstruction and Development/World Bank and its affiliated organizations, its Executive Directors, or the governments they represent. To request further information on the series, please contact ereessmith@worldbank.org LOGiCA. Papers are also available on the LOGiCA website: www.logica-wb.net. Cover and layout design: Duina Reyes Photos provided by United Nations photo library Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy Conducted by: International Rescue Committee (IRC) and the Applied Mental Health Research Group (AMHR) at Johns Hopkins Bloomberg School of Public Health (JHBSPH) Authors: Judith Bass Paul Bolton Debra Kaysen Shelly Griffith Sarah Murray Talita Cetinoglu Katie Robinette Marie-France Guimond Karin Wachter Jeannie Annan JUNE 2013 Table of Contents EXECUTIVE SUMMARY.......................................................................................... 1 ACKNOWLEDGEMENTS........................................................................................ 4 INTRODUCTION..................................................................................................... 5 Background and Purpose of this study............................................................................................................... 5 Context of Services for Women in eastern DRC.............................................................................................. 5 History of collaboration between JHU and the IRC....................................................................................... 8 Review of preliminary qualitative needs assessments .................................................................................... 9 Review of instrument development process...................................................................................................11 Review of the mental health section validation process...............................................................................12 INTERVENTIONS..................................................................................................14 Review of process for intervention selection..................................................................................................14 Description of CPT and evidence behind it in other populations.............................................................14 Training of PSAs and Intervention Implementation.....................................................................................15 Supervision description......................................................................................................................................15 CPT piloting..........................................................................................................................................................16 STUDY METHODS.................................................................................................17 Village selection and randomization.................................................................................................................17 Recruitment, baseline assessment and eligibility...........................................................................................17 Intervention monitoring system........................................................................................................................18 Follow-up Assessments ......................................................................................................................................18 Analysis process....................................................................................................................................................19 RESULTS..................................................................................................................23 Description of participation...............................................................................................................................23 Baseline demographic, mental health, and functioning characteristics of the CPT and IS samples.......................................................................................................................................................25 Mental Health Outcomes ...................................................................................................................................28 Function and Social Resource Outcomes.......................................................................................................30 Economic Outcomes ..........................................................................................................................................31 Qualitative follow-up results..............................................................................................................................35 DISCUSSION...........................................................................................................39 Mental health Outcomes.....................................................................................................................................39 Function and Social Outcomes.........................................................................................................................40 Economic Outcomes...........................................................................................................................................41 Limitations.............................................................................................................................................................41 CONCLUSIONS AND RECOMMENDATIONS....................................................43 Recommendations ..............................................................................................................................................44 REFERENCES.........................................................................................................45 APPENDICES..........................................................................................................49 EXECUTIVE SUMMARY S exual violence (SV) is recognized as a signifi- report provides results addressing the impact of cant problem in the Democratic Republic of a mental health intervention, Cognitive Process- the Congo (DRC). The DRC also has a recent ing Therapy (CPT), on specific domains of social, history of persistent conflict and insecurity, large- physical and economic functioning, and on the re- scale displacement of civilians and the death of mil- duction of mental health problems, including de- lions. Systems of protection and prevention are nec- pression, anxiety, and feelings of stigma and shame, essary for women in this region, as are healing and associated with being an SV survivor. empowerment programs for those who have expe- rienced SV. Yet access to services in eastern DRC— Trial Description both emergency and longer-term care—remains a Prior to initiation of the impact evaluation of CPT, major challenge. Having delivered services in the re- JHU and the IRC together implemented a series of gion for more than a decade, the IRC has identified a formative studies, including qualitative studies to wide range of challenges faced by women related to understand the needs of survivors of SV in their lo- accessing services in this region, including difficul- cal languages and the development, validation and ties in accessing services of quality in a timely man- piloting of tools to assess survivors mental health ner and lack of empowerment opportunities. The and functionality. Following these steps, JHU and IRC has been working with local NGOs and their the IRC implemented a randomized controlled trial case managers (psychosocial assistants – PSAs) to of CPT provided by psychosocial assistants (PSAs) provide psychosocial services to survivors of SV. compared with access to a individual support con- Reports from the local NGOs indicate a need for dition, with participants in both conditions having services to address women with high levels of per- received the usual care (i.e. case management and sistent symptoms who are not improving through supportive care) at some earlier time point. standard care. Sixteen rural villages in South and bordering North SV can contribute to high levels of mental health Kivu provinces were selected from among 23 vil- symptoms, impaired functioning, and experiences lages served by 3 Congolese NGOs. Selection was of social stigmatization in female survivors, many based on accessibility, security, and availability of a of whom also face extreme economic hardship and PSA for trial duration. PSAs in all villages had 1-9 poverty. Little is known about how improvements in years prior experience providing case management mental health impact social and economic improve- and individual supportive counseling to sexual vio- ment, and conversely, how social and economic im- lence survivors and at least 4 years post-primary provement programs impact mental health. Based school education. At time of hire, all PSAs received on this, JHU and the IRC set as their overall goal to 5-6 day trainings by the International Rescue Com- identify low-cost and scalable interventions which mittee (IRC) in case management and topic-specific demonstrate improvement in the mental, social, trainings. physical and economic functioning of sexual vio- Based on the results from the initial qualitative stud- lence (SV) survivors1 living in eastern DRC. This ies, the Hopkins Symptom Checklist (HSCL-25) was used to assess combined depression and anxi- ety and the PTSD Checklist (PCL) civilian version 1  In this study, “sexual violence survivors” includes women who to assess PTSD symptoms. Participants rated fre- report having experienced sexual violence (locally defined as “rape”) themselves, as well as women who report having directly witnessed quency of each symptom in the prior four weeks us- such acts. ing a 4-point Likert scale (0=not at all, 1=little bit, Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 1 2=moderate amount, 3= a lot). Average per-item municated with US-based trainers weekly. PSAs scores were generated for each measure; possible also provided access to individual support to CPT range 0-3 with higher scores indicating greater sever- participants as needed. ity. Cut-off criteria (average HSCL-25 > 1.75, aver- age PCL > 1.75, i.e. total score 30 averaged across 17 Study design items), were used as predictive of clinically-defined The trial included 15 study villages (7 CPT and 8 depression/anxiety and PTSD. Functional impair- IS). Recruitment and baseline assessments occurred ment was assessed measuring difficulty perform- in December 2010. PSAs reviewed their current and ing important tasks of daily living identified from prior client files to identify women currently suffer- qualitative data from study villages. For each of 20 ing from significant psychological problems and in- tasks, responses used a 5-point Likert scale for dif- vited them to their offices where research assistants ficulty doing the task (0=none, 1=little, 2=moderate administered consent and study questionnaires. The amount, 3= a lot, 4=often cannot do). An average intervention period lasted from April to July 2011. per-item score was generated for each participant; Follow-up data were collected within 1-month post- possible range 0-4 with higher scores indicating intervention and 6-months later. greater impairment. Results Study eligibility included: age 18 or older; experi- enced or witnessed sexual violence (translated as A total of 494 were screened for eligibility with rape locally); total symptom score of at least 55 (i.e. the final study sample including 405 women (157 average score of 1 for each of 55 symptoms includ- CPT; 248 IS). Two-hundred and thirty-one women ing the HSCL-25 items, PCL items plus additional (57%) completed all three assessments while 354 locally relevant symptoms); and a functional im- (87%) completed baseline and at least one follow- pairment score greater than 9 (i.e. some dysfunction up assessment. For CPT participants, the average on at least half the tasks). Exclusion was only for sui- number of sessions attended was 8.5 out of 12 ses- cidality judged by clinical staff to require immediate sions offered, with 141 (89%) completing at least 9 (defined as treatment completion). Among women treatment. Study measures were translated from in IS villages, 182 (73%) participated in at least one French into 5 languages: Kibembe, Kifuliro, Kihavu, session with the PSA. Among those who partici- Mashi and Swahili. pated in at least one session, their average number of Treatment conditions sessions was 5 during the study period. Compared with CPT, women in IS villages were younger, less PSAs in comparison villages provided access to in- likely to be married, and lived with fewer people. dividual support (IS). When women were informed On average women in IS villages reported higher of their eligibility, PSAs invited them to the office as symptom scores at baseline compared with women often as they wanted to receive IS services, which in CPT villages across all measures. consisted of psychosocial counseling and referral for legal, medical and economic services. On average, women in both IS and CPT arms expe- rienced significant improvements during treatment PSAs in the intervention villages received a 2-week with effects maintained at 6-months. For depres- training in the group format of CPT. The CPT treat- sion/anxiety symptoms and PTSD symptoms, CPT ment included one 1-hour individual session and participants showed significantly greater improve- eleven 2-hour sessions with 6-8 women per group. ments compared with women in IS villages at both Each PSA concurrently led three therapy groups. follow-ups. Approximately 70% of CPT partici- Ongoing supervision was provided through multi- pants met our criteria for probable depression/anxi- tiered supervision: Congolese psychosocial super- ety at baseline, with 10% or fewer meeting criteria visors employed by the IRC provided direct super- at both follow-up assessments. Among women in vision to PSAs through weekly phone or in-person IS villages, 83% met cut-off criteria at baseline, 53% meetings; a bilingual US-trained clinical social met criteria post-intervention, and 42% at 6-month worker provided in-country supervision and com- follow-up. 2 CPT was effective in reducing symptoms of com- 1) while the average scores for women in the IS vil- bined depression/anxiety and PTSD and improving lages scores remained closer to a ‘moderate amount’. function, compared with individual support alone Differences in how CPT and IS were provided may among female survivors of sexual violence in east- affect our conclusions. CPT, but not IS, was pro- ern DRC. The benefits were large and maintained vided in groups. CPT PSAs received greater super- 6-months post-intervention. Therapy participants vision than IS PSAs. CPT participants also had on were significantly less likely to meet criteria for average a greater number of treatment sessions com- probable depression/anxiety and PTSD. pared with IS participants. Limitations Conclusions There are several limitations that need noting, in- This trial provides evidence of effectiveness of a cluding differences in symptom severity across mental health intervention, CPT, for SV survivors study arms. Randomization was done within blocks experiencing high levels of mental health symptoms of 2-4 villages grouped together based on language in a low-income conflict setting. Given the differ- and proximity. The small number of village clusters ences in how CPT and IS services were provided, (n=6) made randomization less likely to result in the CPT effects must be taken as program effects, comparability. An additional limitation is unknown which include CPT, number of sessions, group pro- validity of the cutoff score used to identify clinically cess and supervision systems. significant cases of combined depression/anxiety and PTSD. While the locally appropriate cut-off The results indicate that with appropriate training scores may be uncertain, the score itself can still be and supervision, psychotherapeutic treatments such meaningfully interpreted: 1.75 means women are as CPT can be successfully implemented and show reporting that symptoms occur, on average, nearly impact in settings with few specially trained mental a ‘moderate’ amount of the time (a score of 2.0). On health professionals. To meet the goal of identifying average, women in CPT scores dropped to lower low-cost and scalable interventions for this popula- than ‘a little bit’ for the average response (a score of tion and context, a cost-impact analysis is planned. Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 3 ACKNOWLEDGEMENTS IRC DRC staff: Catherine Poulton, Robyn Baron, Union pour l’émancipation de la femme autochtone Gabrielle Cole, Maria Scicchitano, Lionel Laforgue, (UEFA) – Bahati Bizibu, Verediane Kivanga, Nyota Georges Mugaruka, Daniela Greco, Claudine Rusa- Muhindo, Providence Musema. sura, Viviane Maroy Bora, Maimona Mabila, There- sita Zihalirwa, Cesarine Barhasima Nabintu, Bertille CPT intervention assistance: Matambura Kamole. Carie Rogers for her assistance with preparation of Psychosocial Assistants and partner NGO staff: the initial CPT treatment manual. Janny Jinor for providing in-country clinical supervision during the Programme de secours pour les vulnérables et sinistrés CPT intervention implementation. (PSVS) – Amini Magangala, Macozi Wabiwa, Fura- ha Seza, Nyota Amani, Furaha Amunazo, Mwajuma Other technical assistance: Kashindi, Nabindu Jumatatu, Kashindi Kisesa. Amani Matabaro for translation of written materials Action pour le développement intégral de la femme and live translation during CPT and research train- (ADIF) – Desiré Kalwira Hamuli, Judith Iragi Rwiz- ings. Alden Gross for providing rapid and compre- ibuka, Jacqueline Cibalonza Cinesha, Safina Lingo- hensive statistical advice and assistance. ma, Fungaroho Mastaki, Naminani Cimonge, Bora Kaharamba. 4 INTRODUCTION Background and Purpose of this mean that many survivors never receive adequate study care (Baelani & Dünser, 2011; Casey et al., 2011; Kohli et al., 2012; Scott et al., 2012). Monitoring Sexual violence (SV) is recognized as a significant data from ongoing International Rescue Commit- problem in the Democratic Republic of the Congo tee (IRC) programming for SV survivors has found (DRC). Much international interest on SV in the that many of those who do seek care demonstrate DRC focuses on SV in the country’s conflict-rid- substantially reduced ability to function, including den eastern provinces: North Kivu, South Kivu, reduced ability to perform basic tasks and activities Maniema, and Orientale. For 15 years, there has related to earning, self care, caring for family, and been persistent conflict and insecurity, leading to contributing to their communities. These survivors large-scale civilian death and displacement. Despite also describe mental health and psychosocial prob- a period of relative calm beginning in 2009, the lems including mood disorders, anxiety, withdrawal, country’s security deteriorated in 2012. According and stigmatization and rejection by family and com- to the United Nations Office for the Coordination munity (Murray et al., 2006). of Humanitarian Affairs (OCHA), the number of displaced people increased from 1.7 million at the Context of Services for Women in end of 2011 to more than 2.2 million by the end of eastern DRC June 2012 (OCHA press release, July 2012). One consequence of the conflict has been systematic vio- Having delivered services in the region for more lence against women and girls. While rape by armed than a decade, the IRC has identified a wide range groups continues, recent reports indicate that per- of challenges faced by women related to accessing petrators are both armed actors and civilians, in- services in this region, including: cluding intimate partners (Stony Brook University Difficulties in Accessing Services of Quality in a Timely Research Brief 2011; Bartels et al., 2012; Duroch et Manner: al., 2011; Peterman et al., 2011). A recent study in conflict-affected regions of eastern DRC indicated • Distance to services – With limited public that nearly 40% of adult females reported experi- transportation and the costs often prohibitive encing SV ( Johnson K et al. 2010). This violence for survivors, many walk for hours and some- is largely perpetuated within a culture of impunity times days to reach assistance. for perpetrators, negative societal attitudes toward • Rights of women and girls not respected – women, and the absence of a functioning judicial Women and girls in North and South Kivu system. provinces have difficulties accessing essential Systems of protection and prevention are neces- health services, particularly family planning, sary for women in this region, as are healing and due to legal and customary limitations. empowerment programs for those who have expe- • Impunity – A comprehensive law against SV rienced SV. Yet access to services in eastern DRC— was adopted in 20062, yet impunity contin- both emergency and longer-term care—remains a major challenge. Limited services as well as the potential stigma of seeking services, including the 2  Loi numero 06/018 du 20 juillet 2006 modifiant et completant le risk of rejection by husbands and/or communities, decret du 30 janvier 1940 portant Code penal congolais Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 5 ues due to judicial inaction and existing cul- their case managers (psychosocial assistants – tural norms that are at odds with protections PSAs) to provide psychosocial services to survivors laid out in the legal text3. Many cases are also of SV. The IRC also works with volunteers from settled out of the official judicial system and community-based organizations (CBOs) to pro- survivors’ best interests are hampered. vide social support and advocate for at-risk women at the village level. Reports from the local NGOs • Emergency situations – In a conflict-affected indicate a need for services to address women with setting where incidents of fighting occur regu- high levels of persistent symptoms who are not im- larly, health services are often the first servic- proving through standard care. The IRC has also es affected by the violence. This means that noted a great need for economic support among women and girls who already have difficulty women survivors because of their reduced function accessing services have even less options for and frequent alienation from family and community care. coupled with their often-extreme poverty. Lack of Empowerment Opportunities: Objective and Aims of this Study • Education – In the DRC, enrollment rates for SV can contribute to high levels of mental health girls are low, especially for secondary school. symptoms, impaired functioning, and experiences While 47.4% of boys aged 14 to 19 years old of social stigmatization in female survivors, many are attending secondary school, only 32.7% of whom also face extreme economic hardship and of girls are doing the same4. poverty. There is limited evidence for intervention • Economic opportunities and financial de- approaches that address these multiple, complex cision-making power – Women and girls in problems. One approach may be to treat women’s the DRC have limited opportunities to access mental health problems through an advanced psy- capital and financial resources, and even less chosocial intervention5 in order to reduce symp- power to manage such resources. Even if they toms and improve functioning. Another may be have access to employment or income-gen- to provide new ways to encourage participation in erating activities, the men in their lives often economic activities to reduce poverty and improve control how that money is used. functioning. A third option may be to combine the two approaches: first providing a mental health in- • Confidence and leadership – Women and tervention and then providing new economic op- girls in the DRC have limited opportunities portunities. Currently, it is not known which of for leadership, both inside and outside the these approaches are effective in ultimately help- home. ing these women function better in their daily lives, • Solidarity with other women and girls – since little is known about how improvements in Women and girls often lack safe social spaces mental health impact social and economic improve- and opportunities to share ideas and challenge ment, and conversely, how social and economic im- each other in a constructive and trusted set- provement programs impact mental health. Based ting. on this, the current study has the following overall objective and specific aims: The IRC has been working with local NGOs and Study Objective: To identify low-cost and scalable in- terventions which demonstrate improvement in the 3  “Analysis: New laws have little impact on sexual violence in mental, social, physical and economic functioning DRC,” IRIN News, June 7, 2011. Accessed June 14, 2011 at: http:// www.irinnews.org/Report.aspx?ReportID=92925 4  “The Adolescent Experience In-Depth: Using Data to Identify 5  “Advanced psychosocial intervention” is a term used by the and Reach the Most Vulnerable People”. 2007. Population Council WHO to include specialized care and evidence-based treatments and UNFPA, p. 19. Accessed June 20, 2012. such as cognitive behavioural therapies. 6 of sexual violence (SV) survivors6 living in Eastern fected communities (Tol et al, in press). Of the five DRC. studies identified in the review, all had serious meth- odological limitations including lack of controls and Specific Aim 1: To investigate the impact of a high attrition. While there are published guidelines mental health intervention, Cognitive Process- for the treatment of mental health problems in low- ing Therapy (CPT), on specific domains of so- and middle-income countries (mhGAP) as well as cial, physical and economic functioning, and guidelines for mental health in emergencies (IASC on the reduction of mental health problems, 2007), guidelines have not yet been published for including depression, anxiety, and feelings of the specific treatment of trauma-related mental stigma and shame, associated with being an SV health problems, though a trauma module from the survivor. World Health Organization (WHO) is in develop- Specific Aim 2: To investigate the impact of a ment. Despite this gap, there is an evidence-base socio-economic intervention, Village Savings for the treatment of mental health problems related and Loans Associations (VSLA), on specific to trauma, including but not limited to post-trau- domains of social, physical and economic func- matic stress disorder (PTSD), and specifically for tioning, and on the reduction of mental health mental health problems related to SV. Data from problems, including depression, anxiety, and high-income countries has shown that cognitive- feelings of stigma and shame, associated with behavioral-based therapies both with and without being an SV survivor. components of exposure therapy are evidenced for the treatment of mental health problems among SV Specific Aim 3: To investigate the combined survivors (Foa et al., 2010; Vickerman & Margolin, impact of a mental health intervention (CPT) 2009). Cognitive Processing Therapy (CPT), in followed by a socio-economic program particular, has a preponderance of empirical support (VSLA) on specific domains of social, physi- among SV survivors, with treatment effects lasting cal and economic functioning, and on the re- five or more years following intervention (Chard, duction of mental health problems, including 2005; Resick et al., 2002; Resick et al., 2012). depression, anxiety, and feelings of stigma and shame, associated with being an SV survivor. In these high-income country studies, these evi- dence-based therapies were provided by mental This report will address Specific Aim 1. The other health professionals working in contexts of relative Aims will be addressed in subsequent reports. stability. The context of eastern DRC is quite dif- Mental Health and Evidence for Services ferent, and includes a general lack of mental health professionals; long distances between villages and Distress and mental disorders are common conse- urban centers and poor travel conditions; stigma as- quences of SV in both general settings (Booth et al, sociated with being a SV survivor; and, ongoing po- 2011; Campbell et al., 2009; Chen et al., 2010; Chiv- litical and economic instability. Effectively adapting ers-Wilson et al, 2006; Resick et al., 1993; Tjaden evidence-based therapies to this context will have & Thoennes, 2006) as well as settings affected by important public health implications for SV survi- conflict (Betancourt et al., 2011; Johnson et al., vors in low-income and conflict-affected contexts 2010; Loncar et al., 2006; Roberts et al., 2008). Yet, globally. a recent systematic review demonstrated a paucity of evidence for mental health and psychosocial sup- The IRC’s Programming for Women and Girls port interventions for SV survivors from conflict-af- in this Region The evidence-based therapy referred to above was implemented within the context of IRC’s Women’s 6  In this study, “sexual violence survivors” includes women who Empowerment and Protection (WPE) program, report having experienced sexual violence (locally defined as “rape”) themselves, as well as women who report having directly witnessed which works to strengthen and improve local part- such acts. ners’ provision of quality case management, psycho- Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 7 social, medical, economic, empowerment and legal ering because participants build upon their services for women and girls. Included in the IRC’s own savings and—following a few months of WPE program are: intense training and follow-up—run the as- sociations themselves. In North Kivu, the IRC • Psychosocial and mental health service pro- runs its Economic and Social Empowerment vision: The IRC strengthens the technical (EA$E) activities. These include VSLAs but capacity of IRC staff and partner NGOs and also encompass business-skills training and a CBOs to provide quality psychosocial services discussion series between VSLA members and to survivors of gender-based violence (GBV), their spouses on economic decision-making in conduct case management and counseling for the household aimed at addressing the power survivors of GBV, and meet relevant interna- imbalances that are at the root of GBV. tional standards. • Community-based recovery: The IRC works • Clinical service provision: The IRC sup- with women-led CBOs to educate leaders on ports the Ministry of Public Health (MoPH) to provide quality clinical care for survivors of the meaning and consequences of GBV and sexual assault by providing material and tech- service availability, while also offering train- nical inputs such as training on Clinical Care ings on women’s rights, project management for Sexual Assault Survivors (CCSAS). and advocacy techniques. The IRC also pro- vides technical and financial help in the de- • Legal service provision: IRC is currently sign and implementation of micro-projects to partnering with local NGOs to provide legal increase the social integration and economic information as well as legal representation at independence of survivors and other vulner- the court level. able women. • Strengthening the referral networks: The • Confidentiality of data: The IRC seeks to im- IRC ensures a working referral network by prove understanding and knowledge among working to improve stakeholder understand- the practitioner community, UN agencies in ing of the need for other services, and to cre- the DRC, and the Congolese government ate stronger links between psychosocial service about responsible and ethical ways to collect, providers, health care personnel and legal as- store, and analyze GBV data in order to re- sistance providers. spect survivor rights and ensure their security as well as that of service provider staff and • Community outreach: The IRC constantly communities. disseminates information to the communities in which it works about services available and History of collaboration between how to access them. In addition, it works with JHU and the IRC key stakeholders to increase acceptability of services and community support for survivors. Since November 2005, JHU faculty (at that time working at Boston University) has provided techni- • Emergency service provision: In collabora- cal assistance to the IRC, beginning with the devel- tion with local partners, the IRC responds to opment of a tool to monitor and measure the func- emergency situations with rapid, high quality tionality of SV survivors for the IRC WPE program holistic service provision. in eastern DRC. During this initial period, IRC, • Village Savings and Loans Associations JHU faculty, and USAID also agreed on terms of (VSLA): The VSLA model provides partici- reference for a more complete program of techni- pants with access to a safe place to keep savings cal assistance to support program monitoring and as well as the opportunity to take out loans. It evaluation of the functionality of SV survivors. The also includes an emergency solidarity fund as IRC subsequently developed a program log frame a safety net. VSLAs are designed to be empow- for their SV activities, including an indicator on im- 8 provement of SV survivor functionality following acquisition of funding from USAID, the IRC and case management, measured with the functionality JHU held an initial meeting in Bukavu later in 2009 tool developed by JHU. The overall technical assis- to outline priority questions and initial methodolo- tance included the following activities: gy for an impact evaluation. In early 2010, to further develop the operational plan of the study (i.e., how 1. A qualitative study of how SV survivors the newly-introduced services and impact evalua- view their own needs (Murray et al., 2006). tion would be implemented) JHU had a 3-day meet- 2. Development and testing of a quantitative ing in Bukavu with IRC staff from the New York, instrument to assess those needs and to as- Kinshasa and Bukavu offices. During this meeting, sess ability to function (functionality tool). participants clarified program and evaluation aims and worked collaboratively to meet the needs of 3. Training of IRC SV program staff in the both. The IRC identified geographic areas and spe- supervision of data collection using the cific villages that could be included in the mental functionality tool and the management of health (CPT) program specifically for the evalua- the resulting data. tion study. The decision on which areas and villages would be targeted for each program was based on 4. Training of local partner staff in its use, the availability of a partner NGO (for CPT activi- specifically those staff acting as counselors ties) as well as logistics and security considerations. and directly providing services to SV sur- Also during this meeting, plans for program recruit- vivors. ment, implementation and evaluation design were 5. Implementation of the instrument into the further refined. One of the biggest challenges of do- program regimen (counselors interview ing this extensive work in this region is the logistics new program participants using the instru- of transporting staff and supervisors to sites that are ment, then interview them again after par- often a full-day’s journey from Bukavu, particularly ticipation in the program). as the security situation is ever-changing. The 3-day meeting was successful in getting buy-in from all of 6. Management and analysis of data by JHU the Bukavu and Kinshasa-based staff who had previ- and the IRC data management staff to ously only heard about the evaluation program via monitor changes among clients receiving emails. Thus, JHU and the IRC were able to draft a services. plan of action and move forward on the budgeting As part of a USAID evaluation report, faculty from of all research and program components. The result JHU reviewed functionality data in 2009 that had was the finalization of a design framework docu- been collected as part of the ongoing monitoring ment included as Appendix A. of psychosocial services provided by IRC partner Review of preliminary qualitative NGOs. Preliminary analysis suggested that the lev- needs assessments els of symptoms and dysfunction at first interview were high with improvements as measured after par- A series of qualitative needs assessments were con- ticipation in the program. These data provided some ducted following the 3-day planning meeting in or- information on the impact of the psychosocial ser- der to identify psychosocial needs of SV survivors, vices. However, without a systematic evaluation and inform the adaptation of instruments for use with a control population to compare the changes over current programming, and inform the selection of time, it was not possible to conclude that changes intervention strategies. The information from these in functioning were specifically a result of the psy- assessments were intended to provide a basis for: chosocial services or other unmeasured factors. This monitoring data established the basis for the current • Identifying current problems that can be ad- study (Bolton P & Locket D, 2009; Bolton 2009). dressed by programs for SV survivors; Following this report and subsequent to additional • Informing the selection of intervention(s) to Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 9 address these problems that are acceptable and During free listing, participants were asked to iden- feasible, by reviewing what local respondents tify problems that survivors of SV tend to have. The describe as existing ways in which these prob- most frequently mentioned problems were financial lems are dealt with; in nature (poverty/ lack of food/ lack of medicine). Following that, the problems and description of • Selecting indicators and instruments to be problems, particularly the psychosocial issues, var- used to assess the level of mental health prob- ied by village. The three psychosocial problems that lems, monitor the progress of interventions, were the most common across the three villages and and assess their impact. that formed the basis for the subsequent key infor- mant interviewing were feeling abandoned/ reject- An important consideration when doing work ed by family and friends, fear (e.g., of disease), and in South Kivu is the diversity of languages. In re- having too many thoughts. viewing all the primary and secondary languages of the areas in which the evaluation would be im- Key informants were then asked to describe indi- plemented, JHU and the IRC selected three lan- viduals suffering from these problems. These infor- guages (Swahili, Mashi, Kifulero) representing the mants identified the following signs and symptoms7: most probable languages spoken in all the different madness, tension and shame were most commonly mental health program evaluation villages. It was mentioned across communities, with wanting to decided that three independent qualitative needs die/ feeling dead, crying, trauma, feeling cold (cold assessments were needed to cover the three differ- body) and fainting following close behind. Symp- ent languages in order to identify whether problems toms that were mentioned by respondents from were described similarly or differently across the some, but not all, of the communities include symp- languages. A copy of the report from these qualita- toms that are common to many mental health prob- tive studies is available at from the authors (jbass@ lems (e.g., sleeping and appetite problems) as well jhsph.edu). as signs and symptoms commonly associated with depression-like problems (e.g., hurting heart, think- With logistical and technical support from the IRC, ing of death), and/or anxiety-like problems (e.g., JHU first trained 20 local interviewers and conduct- tension, thoughts not focused/too many thoughts). ed a qualitative needs assessment initially in two Over the course of the qualitative interviews, the lo- villages representing two of the study languages. cal informants did not indicate the existence of spe- A second group of 10 local interviewers were then cific disorders or grouping of symptoms. This could trained by an IRC staff to implement the study in a be an indication that there are many diffuse symp- third village representing the third language. These toms being experienced by these populations rather assessments were conducted to identify the mental than more specific syndromes, but confirming this health service needs of women affected by SV. The would require more extensive research. interviewers were all women, and were required to pass a written and verbal evaluation of their language During the free listing interviews, data were also capacity in at least one of the three study languages. gathered on specific tasks and activities that women regularly do to take care of themselves, their family Two interviewing methods were used: and participate in their communities. These items were used to further refine the functionality tool 1. Free Listing, to identify problems per- already in use in the IRC psychosocial monitoring ceived by local people to be the results of system. SV, and to explore the tasks and activities that constitute normal functioning for men and women; 7  These are English translations of the words and terms used by 2. Key Informant Interviewing, to obtain the survivors themselves and by other women and key informants in the communities. The words and terms were first recorded in detailed information on those psychoso- the local languages, then translated into French and then translated cial problems emerging from the free lists. into English. 10 Review of instrument development Several depression, anxiety, and posttraumatic process stress screeners were reviewed to identify those covering the many symptoms that were also found The process of adding, removing and deciding on in the preliminary qualitative studies, indicating items to be included in the final study instrument appropriateness for local adaptation. For depres- was a collaborative process between several JHU sion, we reviewed the Hopkins Symptom Checklist faculty and IRC staff, with all involved providing – Depression scale (HSCL-D) and the Center for feedback and suggestions throughout the process. Epidemiologic Studies – Depression Scale (CES- In addition to the mental health and function as- D). For anxiety, we reviewed the HSCL – Anxiety sessments described below, demographic ques- scale (HSCL-A). And for post-traumatic stress we tions were included, as were questions regarding reviewed the PTSD Checklist – Civilian version exposures to a range of traumatic events and use of (PCL-C), the Post-trauma Symptom Scale (PTSS- services. The study instrument (Appendix B) was 10), the Impact of Events Scale – Revised (IES-R), translated from English into French and then into and the Harvard Trauma Questionnaire (HTQ) local languages. Following a review of all the study PTSD symptoms section. Based on the review, the villages, two additional local languages were identi- Hopkins Symptom Checklist-25 (HSCL-25 De- fied (Kihavu and Kibembe), resulting in five local pression and Anxiety subscales) (Hesbacher et al., language versions of the study instrument. Fol- 1980; Winoker et al., 1984) and the civilian ver- lowing the translation of the instrument, a review sion of the PTSD Checklist (PCL-C) (Weathers of each question was undertaken during the initial et al. 1994) were adapted to assess for depression, training by all the interviewers familiar with the lo- anxiety, and PTSD symptoms. JHU has extensive cal language. After adjustments were made to the experience with the HSCL-25 and have found it to instrument based on the interviewers’ feedback, the be easy to adapt and use as well as reliable in cross- instruments were all pilot tested with small samples cultural contexts. Both the HSCL-25 and PTSD in each of the linguistic communities to ensure local comprehension. Checklist have been used internationally with sexual violence survivors (Tsutsumi et al., 2008) and have Mental Health Assessment solid psychometric properties with conflict-affected samples (Conybeare et al., 2012; Ruggiero et al., Results from the qualitative study indicated that the 2003; Ventevogel et al., 2007). functionality tool currently used by the IRC cap- tured some but not all of the relevant mental health Items probing additional locally-relevant symptoms problems particularly relevant to the SV survivor of distress that were not found in either of these populations in the study villages. Based on this, and screeners were also included in the complete assess- the desire to expand the range of outcomes for the ment of mental health problems. The final version formal impact evaluation, a longer and more com- consisted of questions on 55 signs and symptoms. plete assessment of mental health and psychosocial For each symptom, participants were asked to rate problems and functional impairment was devel- how often they perceived that they experienced the oped. problem in the prior four weeks on a Likert scale (0=not at all, 1=little bit, 2=moderate amount, 3= For the assessment of mental health problems, the a lot). A graphical representation was provided to first step was to review existing questionnaires for help the women distinguish between these different identifying mental health problems. These ques- levels. The mental health symptom questions are lo- tionnaires are generally referred to as screening in- cated in section B of the study instrument. struments as they do not specifically generate men- tal health disorder diagnoses (as a clinical interview Functionality Assessment might). Rather, screening instruments are used in mental health to identify individuals with high lev- To assess functioning, we expanded the IRC func- els of symptoms in order to ‘screen’ in those who tionality tool using data collected during the quali- require services. tative needs assessments (described above) iden- Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 11 tifying important tasks and activities that women functioning should lead to higher household living regularly do to care for themselves, their families, standards. The economic questions are in sections and participate in their communities. JHU and the E and F of the study instrument. IRC included items from each domain (caring for self; caring for family; participating in community) Review of the mental health section mentioned by women in at least two of the three validation process qualitative study communities and combined these Prior to initiating the interventions and impact eval- with the tasks and activities already in the IRC func- uation study, JHU and the IRC needed to confirm tionality tool for a total of 20 tasks and activities. Par- the ability of the mental health section of the study ticipants were asked to rate how much difficulty they instrument to identify eligible women. Eligibility had performing each task or activity in the prior four was based on self-reported exposure to SV (defined weeks on a Likert scale (0=none, 1=little, 2=moder- locally as “rape”) and having severe enough mental ate amount, 3= a lot, 4=often cannot do). As with health problems and functional impairment to war- the mental health questions, a pictoral representa- rant participation in the new program. Because no tion of the different levels of difficulty was provided locally-validated measures of mental health prob- to the respondents. The function questions are lo- lems and functional impairment existed, JHU and cated in section A of the study instrument. the IRC implemented a validation study for the In addition to functioning related to tasks and activi- mental health and functional impairment sections ties of daily living, JHU and the IRC included a se- of the evaluation instrument in order to determine ries of measures on coping, social participation and what scores might define severe enough symptoms familial and community connectedness in order to to warrant services. understand the social experiences of the participat- ing women. In the qualitative studies, many of the To evaluate the validity and utility of the mental respondents talked about the isolation and rejection health section of the study instrument we conduct- survivors experienced. Therefore, JHU and the IRC ed an initial pilot test followed by a validation study wanted to look at whether participating in the group in villages representing two of the study languages intervention may have an impact on a range of social (Mashi and Kifuliro). Human and financial resourc- resources, including socialization and connected- es constrained our ability to conduct full validation ness. The coping and social resource questions are studies in all five local study languages. For the pi- in sections C and D of the study instrument. lot test and validation study, we interviewed 172 women in two different areas of South Kivu where Economic functioning and standard of living were two of the study languages were spoken. The study assessed using standard economic modules widely participants were identified by NGO staff who pro- used in comprehensive socioeconomic household vided psychosocial services in the study villages (the surveys (such as the World Bank’s Living Standards psychosocial assistants-PSAs). These PSAs were Measurement Surveys-LSMS- and the UNDP’s asked to review their case files and identify women Core Welfare Indicators Questionnaire-CWIQ). they thought had few/no symptoms and prob- To measure economic functioning, we focused on lems as well as women they thought had a moder- women’s participation in the labor market, mea- ate amount/a lot of symptoms and problems. The sured by the supply of labor for economic and do- symptoms and problems JHU and the IRC asked mestic activities, both inside and outside the home. the PSAs to think about were those on the function- The hypothesis is that as women’s mental status im- ality tool used in the program monitoring process. proves, so will their economic functioning through We relied on the functionality tool, which included increased participation in the labor market. To mea- both symptoms and functional impairment items, sure the standard of living of the women’s house- because the PSAs had already been using it in their holds, we included a series of questions on house- programs and would be able to identify women with hold-level asset holdings, quality of housing and different severity levels based on their experience food consumption. Over time, improved economic with it. Across the study villages, N=65 women were 12 identified by the PSAs as having few/no symptoms dent on a 4-point Likert scale for how often the and problems and N=107 women were identified as respondent had experienced each symptom in the having a moderate amount/a lot of symptoms and prior 4 weeks: 0=not at all, 1=little bit, 2=moderate problems. amount, 3= a lot. With the instrument including 55 symptom questions, we decided that a minimum For the validation process, we focus on discriminant score of 55 – or an average score of 1 on every symp- validity; that is, we focus on whether our mental tom – would be an indication of enough psychoso- health assessment can validly distinguish (or dis- cial and mental health problems to warrant receiving criminate between) women identified as having a services. Using this cut-off, 98% of the validity study lot of symptoms with those having few or no symp- sample met the symptom criteria. toms. When discriminant validity is established, the average scores of the group having a moderate to a We went through the same process for the identifica- lot of symptoms can be used as a cut-off score for tion of a functional impairment cut-off score. There inclusion in the study. are 20 functioning questions, each rated on a 5-point Likert scale in terms of degree of difficulty engaging During data analysis with 172 study women, it be- in the task (0=none, 1=little, 2=moderate amount, came clear that although the PSAs identified wom- 3= a lot, 4=often cannot do). Given that the goal of en they thought had few or no problems, in reality the intervention was to improve both mental health nearly all of the women had a significant number of symptoms and functioning, we needed to identify a mental health and psychosocial problems8. Thus, cut-off score that indicated at least some functional our standard methods for validating the measure impairment, but not so much that we would exclude and identifying cut-off symptom scores were not ap- women who had significant mental health problems propriate and we had to come up with an alternative yet were managing to take care of themselves and method of defining study eligibility. their families at a minimum level of success. We The symptom questions were rated by each respon- decided that experiencing at least some difficulty (a score of 1) on at least half of the functioning items (i.e., a total score of at least 10) would provide suffi- 8  This inability to correctly classify cases was confirmed by study cient rigor to ensure we were including women with PSAs during a review after the impact evaluation was complete. The significant problems while not excluding women PSAs at this review session commented that regular case manage- who had at least some functional capacity. Using ment did not always give them the tools to explore the survivor’s feel- ings beyond what the survivors reported directly to them and thus this cut-off, 90% of our validity study sample met they may have missed important problems. the function criteria. Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 13 INTERVENTIONS Review of process for intervention model (i.e., without written exposure) because it has selection comparable efficacy to the original model (Resick P et al. 2002), while providing greater retention and Relying on results from an earlier qualitative inves- ease of administration in groups (Chard KM 2005). tigation (Murray L et al., 2006) of mental health Additionally, evidence from JHU trial in Northern needs of men and women in one area of South Kivu Iraq (Kaysen D et al., 2011) indicated that it could (Uvira and Sange), we considered implementing be adapted for low-literacy and illiterate clients. We interpersonal psychotherapy (IPT) as the mental therefore decided that CPT was the best option for health intervention. This consideration was guided implementation in this study. by the depression-oriented symptoms identified in that earlier qualitative study. The qualitative studies Description of CPT and evidence implemented specifically for this study (described behind it in other populations above) identified both depression and trauma-relat- ed symptoms, such as avoidance of situations that Cognitive processing therapy (CPT) is a structured, remind women of the trauma and fears specific to protocol-based therapy. It provides participants the trauma. Thus, a review of interventions with evi- with skills to recognize maladaptive beliefs they dence for both depression and trauma-related men- have related to the trauma and learn to challenge tal health problems was warranted. those beliefs, thereby reducing negative emotions. The theory behind CPT is that through discussing In addition to a review of the evidence-based psy- the trauma and these maladaptive beliefs, the par- chotherapy treatments for trauma (e.g., Ougrin D, ticipant can decrease internalized feelings of stigma 2011), we consulted several trauma-treatment ex- related to the trauma, reduce avoidance around perts, including clinicians and researchers who have trauma-related cues and reminders, reformulate experience working with trauma survivors gener- feelings and thoughts about the event, and cope bet- ally and with SV survivors specifically. We provided ter with daily challenges. More information about them with results from the qualitative studies as the theory and development of CPT is available in well as a brief description of the context and types the manual developed for this study (available from of violence women may have been exposed to. The the developers at dkaysen@u.washington.edu on treatments with research evidence of their effective- request). ness for trauma-related symptoms among adults included prolonged exposure (PE), narrative expo- In this study, the CPT program was comprised of sure treatment (NET), and several different cogni- one individual meeting with study participants fol- tive-behavioral therapies. Included in this last group lowed by 11 weekly 2-hour group sessions with 6-8 was Cognitive Processing Therapy (CPT), which women per CPT group. NGO PSAs living in the was originally developed for survivors of rape and study villages provided the CPT intervention. The SV and has a strong evidence base. CPT has proven PSAs were employed by local NGOs partnering effectiveness for treating depression, anxiety, and with the IRC, and all had at least one year of previ- PTSD among SV survivors (Resick P et al, 1992, ous experience providing case management services 2008; Nishith P et al. 2005). The group format rep- for survivors. resented a cost-effective method for reaching large numbers of women. We used the Cognitive-Only 14 Training of PSAs and Intervention be  minimal.   Little mention of these additional Implementation services were reported in the regular weekly super- vision reports provided by the PSAs.  During the For the impact evaluation, the study villages were debriefing of the PSAs with the US-based trainers randomly allocated to offer additional access to in- in October 2012, the US-based trainers reported dividual support (IS) if survivors wished it (n=8 that although a few PSAs mentioned this happened villages) or to provide the new CPT program (n=8 they did not indicate it was a regular or frequent oc- villages). currence.  When IRC contacted the PSAs after the study was complete, the PSAs reported that seek- PSAs in all study villages had at least four years post- ing individual support happened occasionally with primary school education and 1-9 years prior expe- some, but not all, group members. According to rience providing psychosocial services to sexual vio- the PSAs, group members requested these sessions lence survivors. When they first were hired as PSAs mainly to discuss issues or problems that they did they received 5-6 day trainings by the IRC in case not feel comfortable discussing with the group. management and topic-specific trainings including counseling, family mediation, stress management, Supervision description clinical care of survivors, and HIV/sexually trans- mitted disease prevention, with refresher trainings PSAs at each IS site were continuously supervised PSAs regularly provided. This case management through monthly site visits by supervisors from and individual supportive counseling services make their own NGO, as well as by psychosocial technical up the usual care that all study participants received advisors (conseillères techniques – CTs) employed when they first accessed the PSA-provided services. by the IRC. Supervision was conducted through For this trial, which only included women who had observation during case management sessions us- previously accessed services from the PSAs and thus ing a checklist as well as one-on-one debriefing ses- were in their client files, the comparison services sions with each PSA to discuss the findings of the including access to general individual support (IS) checklist, observations made in terms of behavior which in this study included psychosocial counsel- and approach towards the survivor, as well as more ing and medical, legal and economic referrals. challenging cases. PSAs were also in touch with IRC staff and NGO supervisors over the phone as The PSAs who worked in the villages randomized needed when problems arose. to receive CPT participated in a two week in-person training from expert US-based CPT trainers based For the CPT program, supervision was provided on an adapted therapist manual for the eastern DRC through a multi-tiered supervision structure (details context and translated into French (available from on the content of the supervision provided below in Debra Kaysen dkaysen@u.washington.edu by re- the supervision section). The IRC CTs9 provided quest). The training, which was done in English direct supervision through weekly in-person meet- with simultaneous French translation, included ings or phone consultations with the PSAs. The didactic presentations of the components of CPT CTs were supervised by a US-trained clinical social as well as role play and practice sessions. Training- worker based in Bukavu through weekly CT meet- based quizzes and observation of skills by trainers ings during which the PSA and individual clients during role plays were used to evaluate the impact of progress were reviewed. The clinical social worker the training on PSA learning. was supervised by the US-based CPT trainers Women in the CPT villages had access to the PSAs through weekly phone/skype calls to provide ad- as desired outside of the therapy.  The frequency with which CPT participants utilized the PSAs outside of the group sessions was not monitored.    9  The IRC CTs who supervised the CPT intervention also went Given the time commitment required to receive through the 2-week CPT training with the US-trainers and were pro- vided with additional supervisory training during those two weeks. therapy and the busyness of the PSAs, our assump- In addition, they all co-led a CPT group during the pilot training tion  was  that the use of additional services  would period in order to get first hand experience with the intervention. Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 15 ditional support and quality assurance during the An implementation process issue learned from the implementation of the trial. pilot groups was that the amount of time needed for the PSAs to implement the three concurrent CPT CPT piloting groups, maintain the paperwork, and participate After participating in the 2-week in-person CPT in supervision was enough to take up most of their training, the PSAs and CTs led 4-person pilot work time over the course of the week. This made groups to practice implementing CPT and to deter- it difficult for them to provide ongoing services to mine if any adjustments to the intervention content non-study women and to be available to new wom- were needed. These seven pilot groups (one for each en who might come to the centers for services dur- PSA) were successfully completed using the super- ing the study period. In consultation with the IRC vision structure described above, with the conclu- and the local NGOs, the decision was made to hire sion being that the CPT trainers felt the PSAs were temporary PSAs to work in the villages where CPT ready to implement the CPT groups for the impact was being implemented for the 4-month study pe- evaluation study. The adaptations made to the CPT riod, thus ensuring that services for survivors not intervention based on the interactions and conver- involved in the study were maintained. The IRC sations during the in-person training and as a result trained the new PSAs in the basic case management of the pilot implementation are described in Appen- program to maintain quality services during the dix C. study. 16 STUDY METHODS Village selection and randomization naire that included demographic and trauma-related questions, assessments of social and task function- Sixteen villages were selected to participate in the ing, mental health signs and symptoms, and a com- study from the 23 villages served by the three col- plete economic battery. Two interviewers worked laborating Congolese NGOs. Selection was based in each study village, with interviewing continued on accessibility of the sites (road conditions, secu- until 28-30 eligible women were identified in each rity) and availability of the PSA from start to finish village. These interviewers were temporarily hired of study activities (mainly, some PSAs were preg- by the IRC specifically for this interviewing activ- nant or on maternity leave during this time which ity. The interviewers were identified based on their disqualified them from being in the study). prior interviewing (qualitative and/or quantitative) The 16 study villages, each with one PSA, were experience and their literacy in the local study lan- grouped into blocks of 2-4 villages based on prox- guages. Interviewers received a 1-week training in imity and shared language and randomized to CPT the consent procedures and the full study question- or to access to IS services. After CPT training, one naire, including didactic training and active role PSA (Katongo village) was dropped because of playing. The decision to use interviewers, rather competency concerns identified during training- than the PSAs, to implement the questionnaire was based oral quizzes and skill observation. The study made to reduce potential bias in how the respon- thus included 15 study villages (7 CPT; 8 IS). dents reported their symptoms and problems. Recruitment, baseline assessment Study eligibility included personally experiencing and eligibility and/or witnessing SV (translated locally as “rape”), a total symptom score of at least 55 (i.e., an average Recruitment of clients in the study villages occurred score of 1 for each of the 55 mental health signs and in December 2010. The PSAs worked with the symptoms from the questionnaire) and a functional study team to identify potentially eligible women impairment score of at least 10 (i.e., some dysfunc- through a review of current and previous client case tion on at least half of the tasks questions), as well as management files. Only women who had previously a reported age of 18 years or older. Study exclusion or were currently receiving services from the PSAs criteria included severe suicidality that the IRC and were invited to participate in the study; no new US-based clinical staff felt required immediate ser- clients were considered. Information on when the vices from the PSAs, which was provided with sup- cases first presented to the PSAs and when the SV port from the IRC CTs. occurred was not recorded. Women who the PSAs thought were currently suffering from mental health After questionnaire administration, all completed and psychosocial problems were invited by the PSA study instruments were brought back to the central to come to the NGO sponsored ‘listening center’ IRC office in Bukavu and reviewed by the impact (maison d’ecoute – the office at which the psycho- evaluation study team to review eligibility status for social services were provided) in their village where each respondent. Lists of eligible women were re- Congolese interviewers employed by the IRC in- turned to the PSAs to invite into the study. In the formed the women about the study and implement- CPT villages, the PSAs reviewed the lists and or- ed the consent process. If women consented, the dered them based on proximity to the NGO spon- interviewers administered the full study question- sored ‘listening center’ in order to prioritize women Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 17 who would have an easier time to regularly come the study, treatment fidelity was assessed by the US- for treatment. The counselors then invited women, based trainers through a review of checklists of key based on these lists, to participate in the program un- treatment elements and global ratings of treatment til they had 24 (up to eight for each of the three CPT knowledge and skills, as observed and reported by groups) women who had agreed or they reached the supervisors during group sessions. end of their lists. Remaining women (n=35) were informed that the program was full but that they IS program monitoring would be invited into any new group(s) started after Similar to the CPT intervention program, a simple the study period (four months) was complete. In program monitoring form was developed for the IS the IS villages, PSAs invited all eligible women to PSAs to be used each time a study participant came continue receiving services or return to services if in for services. Participants attended services ac- they wanted; four eligible women refused services and did not want to be part of the study. Sample size cording to their needs and wishes, and no specific limits were not required in the IS villages because number of meetings with PSAs were arranged. This the existing services could handle the larger num- form included the same 10 symptoms as the CPT bers as needed. form as well as a list of activities and services in the form of a service checklist that the IS PSAs had been Intervention monitoring system trained to provide. This form was used to monitor IS services the study participants received during The intervention period ran from April to July 2011 the study period. A copy of this form is included in in all study villages. PSAs in CPT and IS sites were Appendix D. trained on the case management protocols for high- risk cases, mainly suicide risk (see Appendix E). A Maintenance period service monitoring total of 29 cases of high suicide risk (not including the seven who were excluded from the study) were Following completion of the CPT treatment, wom- followed until they were no longer determined to be en in the CPT and IS villages entered a maintenance at risk. No incidents of suicide were reported. period (August-December 2011) during which they could access services provided by the PSA in their CPT Intervention monitoring village as needed. To monitor any services received, all PSAs (in the IS and CPT sites) used the simple To ensure intervention fidelity and to allow for on- IS monitoring form. Additionally, though not re- going supervision, a monitoring system was set up quired of them, some PSAs at CPT sites formed and that included forms that PSAs completed after each led new CPT groups with women who had not been group session as well as forms that supervisors com- invited into the study in order to maintain their own pleted after each supervision session with the PSAs. The PSA forms included information on the current skills and to meet the needs of other women in the symptom status on each group participant, infor- community. mation on the activities and topics covered during Follow-up Assessments the group session, plans for homework that the par- ticipant would complete during the week, and any Qualitative specific concerns about the group or any individual participant. For the current symptom status of each Following completion of the CPT intervention, a group participant, a summary score was generated brief post-intervention qualitative study was imple- based on 10-symptoms that were assessed at each mented in three of the CPT study villages (one from session. The summary score for each participant was each geographic area). The goal was to identify any recorded and shared with the IRC CTs, the clinical unexpected outcomes associated with the CPT in- supervisor, and the U.S. trainers to monitor signifi- tervention and to include questions about these cant improvements/declines that warranted special outcomes in the follow-up interviews (Bolton et attention. Copies of the CPT intervention monitor- al., 2007). This study utilized free listing interviews ing forms are included in Appendix D. Throughout with CPT participants to provide information about 18 unintended positive and negative effects of partici- Immediate post-intervention pating in CPT as perceived by CPT group partici- pants. The primary objective of this data collection was to re-interview all study women in the CPT and the Interviewers who were involved in the qualitative IS sites. A JHU graduate student, together with the study conducted prior to the initiation of the evalua- IRC M&E supervisor, trained 30 interviewers in tion study were contacted and those who were avail- the quantitative data collection protocol and instru- able and were literate in the local study languages ment. Most of these interviewers had been involved were invited to participate in this activity. Free list with the baseline quantitative data collection and interviewer training was held at the end of July 2011, were familiar with the process and the instrument, with data collection taking place the first week of which made the training more interactive as they August in three CPT villages (Lushebere, Bishange, could assist the new interviewers. Data collection and Luvungi). The goal was to interview 30 CPT was initiated in all 15 study villages (7 CPT, 8 IS) participants (10 in each site). For the interviews, re- during the same week – September 12-16 2011. spondents were asked two questions: Only one village, Bishange, needed to be revisited to follow-up with study women who had been missed 1. What are all the changes you and your fam- during the initial interview period. All of the inter- ily have experienced in the last 6 months? view forms were returned to the Bukavu IRC office and data were double entered, cleaned and sent to 2. What are all the changes you and your fam- JHU for analysis. ily have experienced in the last 6 months because of the CPT program? Six-month follow-up These two questions were selected to elicit informa- Having completed the maintenance period, a sec- tion on the unintended impact of the CPT. The inter- ond quantitative interview with all study women viewers were trained to probe for general changes as was implemented to provide some indication of the well as positive and negative changes. Each interview duration of any initial CPT effects. The same instru- was attended by the respondent, the interviewer and ment was used as for the post-intervention follow- a note-taker. The free list analysis was conducted by up. Once again, 30 interviewers working in pairs the interviewers and facilitated by JHU. Based on completed the interviews over the course of one the analysis and a review of supervision forms by the week. CTs and the research team, 28 questions on poten- tial unexpected changes and life events were added Analysis process to the quantitative instrument (Section G of the in- Sample Size Determination strument included as Appendix B). Assuming 20% drop-out, 180 participants in each Quantitative Follow-up: arm provided 80% power to detect at least a 0.5 Quantitative follow-up data were collected at two point difference in reduction in average symptom time points, within one month post-CPT comple- scores between the treatment arms, adjusting for a tion and approximately six months later. The follow- variance inflation factor of 2.0. After removing one up interview was conducted using the same instru- CPT village, we expected fewer than 180 recruit- ment as was used at baseline, with the addition of ments into the CPT arm. the questions generated from the post-intervention Mental Health and Function score creation qualitative assessment (described above). At each follow-up data collection, interviewers hired and Mental health symptom scores were generated us- trained by the IRC, working in pairs, spent one week ing average scores for each of the measures used in each village interviewing study women. The in- in this study: depression (HSCL-D), anxiety terviewers were blind to whether the village was a (HSCL-A), posttraumatic stress (PCL), the func- CPT or IS village. tionality tool (DRC), and a measure with only the Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 19 items from the qualitative study (Qual). In addi- dard, two sets of constructs were created based on tion, two composite scores were generated for each the economic variables of the study instrument. woman: An HSCL score, which included both the depression and anxiety measures, as well as an aver- The first set of constructs from section E of the study age total symptom score based on all 55 symptom instrument measures women’s participation in the questions. For each measure, an average of the re- labor market and consists of five distinct indicators: sponses for each question was generated rather than • Hours of paid economic work in the seven a total score. Using the average score allowed us to days preceding the interview standardize responses, keeping all measures on the same metric, with average scores ranging from 0-3. • Hours of unpaid economic work in the seven In addition to measuring mental health symptoms, days preceding the interview an average functional impairment score was calcu- lated for each woman by taking the average of her • Hours of total economic work (paid and un- responses to each of the 20 tasks. The average scores paid) in the seven days preceding the inter- could range of 0-4. view Mental Health cut-off score generation for ‘case- • Hours of domestic work in the seven days pre- ness’ ceding the interview To determine clinically significant levels of distress • Total hours of work (regardless of type) in the for depression and anxiety symptoms, we used a cut- seven days preceding the interview off of an average HSCL score of 1.75, established as Economic work is defined as all activities that have optimal when compared to the Composite Inter- direct material benefits for the woman and her national Diagnostic Interview (CIDI) (Sandanger household. This includes paid economic work such et al., 1998, 1999) and used with other conflict-af- as wage employment (either in cash or in kind) and fected populations (Mollica, Wyshak, de Marneffe, lucrative self-employment (e.g. small business, com- Khuon, & Lavelle, 1987)). For the PCL, we used merce of agricultural products), as well as unpaid also used cut-off of 1.75, which is the average of the economic work in family-run business and cultiva- standard cut-off score used to define PTSD caseness tion of the household’s fields. The distinction is that for the PCL (i.e. score of 30 divided by 17 items) paid economic work provides the woman with cash (Bliese et al., 2008). while unpaid economic work results in economic Social resource assessment benefits for the household, but does not result in any payment for the woman. Domestic work relates A preliminary analysis was undertaken to assess to a range of tasks typically carried out within the the impact of CPT on a few of the social resource home by women without any kind of remuneration, variables collected in this trial. For community and includes time spent cooking, fetching water and participation, we created a total community group firewood, cleaning the home and taking care of chil- participation score based on the number of different dren and elderly persons in the household. These groups a women reported being a member of (up to indicators are standard in the economic literature to 9 different types of groups were asked about). For measure women’s participation in the labor market the social activities, we took the average of 2 ques- in developing countries. tions asking women to report how often women visited others or had others visit them (0=never, The second set of constructs relates to household 1=rarely, 2=sometimes, 3=often). living standards and is based on section F of the study instrument. Two types of indicators were used Composite variables and scale creation for eco- to assess the economic situation of households. nomic outcomes To measure current short-run living standards we To measure economic functioning and living stan- calculated the monetary value of the household’s 20 food consumption during the seven days preceding Mental Health and Functionality Outcomes the interview. Consumption is a direct measure for living standards and is more accurate than income Intervention impact was calculated by comparing in a context where unpaid economic work is wide- average scores for women in CPT and IS villages at spread. Following common practice, we asked for each follow up. Analyses included all participants purchases and own-consumption of an extensive accounting for loss-to-follow up through a weight- itemized list of foodstuff most commonly consumed ing process. Missing values for any specific symp- in the region. Own-consumption (that is, consump- tom or function item were imputed based on mean tion of food the woman produced/grew herself) values for other items in the scale. Random effects was converted to monetary values by evaluating the models (xtmixed and xtmelogit) were used for all quantity consumed at current market prices. This impact analyses (Laird & Ware, 1982). As the data was added to purchases to arrive at the total mon- were clustered within therapy groups, villages and etary value of the foodstuff consumed during seven randomization block, multiple random effects were days. This amount was aggregated over all foodstuffs evaluated. Models with and without the random- and divided by household size to arrive at an esti- ization block, compared using the Hausman test mation of consumption expenditures that can be (Hausman, 1978), were not significantly different compared between households and across data col- (p=.99) so the three-level model was used which lection time points. incorporated the individual study participant mea- sured over 3 time points, the therapy group she par- To measure longer-run household living standards ticipated in if in the CPT condition, and the village we constructed a wealth index along the lines pro- in which the participant lived. Time and treatment posed by Filmer and Pritchett (2001). The idea of condition (CPT/IS access) were included as fixed the wealth index is to take all binary asset indicators effects. All tests were two-sided with statistical sig- included in our study instrument (e.g., materials nificance set at p < 0.05. used to build the home, ownership of assets and live- stock) and combine them into a weighted compos- Economic Outcomes ite variable (a wealth index). This approach can pro- To estimate the effects of participation in CPT on vide a convenient way to summarize an individual or economic outcomes we used the standard specifica- a household’s long-run economic status with a lim- tion below (McKenzie, 2012): ited amount of data. The weights are determined by the loading of each individual asset variable on the EOi,t=α+βEOi,0+ δCPTi+γBCi,0+εi (1) main component in a principal components analysis (PCA) including all asset variables. The PCA is the With EOi,t being the economic outcome of interest most commonly used method to construct wealth of woman (or household) I at time period t, EOi,0 indexes even if it suffers from an underlying lack of woman (or household) i’s baseline value of the eco- theory to motivate either the choice of variables or nomic outcome of interest, CPTi an indicator vari- the appropriateness of the weights. The wealth index able for treatment status and BCi,0 a vector of base- we constructed includes information on 16 individ- line variables to correct for baseline imbalances. ual asset variables. Specification 1 was estimated with t=1 (the immedi- Analyses ate post-assessment) and t=2 (the 6-month follow- up). This estimated the impact of CPT on economic Baseline characteristics were compared across study outcomes immediately after treatment and the lon- arms using chi-squared and t-tests. Factors associ- ger-run impact six months after the treatment had ated with loss-to-follow-up were identified using been completed, and shed light on the trajectory and logistic regression; those at p<0.20 were used to persistence of impacts. We also estimated specifica- generate weighting estimates to adjust for loss-to- tion 1 where the post intervention outcome value follow-up (N=135 (33%) were missing post-inter- is calculated as the average of both post-assessment vention; N=92 (23%) were missing at six months. outcomes values. Given the variability of many eco- Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 21 nomic indicators, averaging over multiple (in our Ordinary Least Squares (OLS) method. Plotting case, two) post-intervention measurements can lead the economic outcomes, however, shows heavily to more precise estimates (McKenzie, 2011). skewed distributions with fat tails. We therefore also estimated specification 1 using quintile median re- To take into account the fact that the randomization gression (which is more robust to outliers and ex- was done at the block level (i.e., with villages clus- tremes). tered into blocks of 2-4 villages), block dummies were added in the estimation of specification (1) All analyses were conducted using Stata version 12. and standard errors were clustered at the level of the More specific information about the analyses can be CPT group. obtained by contacting the authors (jbass@jhsph. edu for mental health analyses and Jeannie.annan@ Specification (1) was estimated by the standard rescue.org for economic analyses). 22 RESULTS Description of participation participant died near the end of the treatment due to a violent incident in the community. In the IS vil- A total of 494 women provided informed consent lages, 182 (73%) study participants utilized at least and were screened for eligibility (Figure 1). Of one session with the PSA, with 20 participants at- these, 440 (89%) met inclusion criteria; seven who tended 1-2 sessions; 45 participants attended 3-4 were excluded for severe suicidality (as determined sessions; 88 participants attended 5-6 sessions; 27 through a high risk protocol, Appendix E) received participants attended 7-8 sessions; and one partici- immediate assistance by PSAs and IRC staff. Of pant attending nine and one participant attended the 433 eligible women, 402 (93%) agreed to par- eleven sessions. Among those who utilized any of ticipate in the study. An additional four women who the PSA services, the average number of sessions did not meet the symptom cut-off criteria were mis- was five. PSAs in IS villages actively invited women takenly recruited in one of the CPT villages and are to continue to engage in available services (if they included in the analysis. After dropping one CPT were currently a client) or invited them back to re- participant due to paperwork errors, the final study ceive services (if they were a prior client) at the be- population included 405 women. ginning of the study and were available throughout Fifty-three women (13.1%) were unable to be re- the intervention period for women who sought their assessed at either the post-intervention or 6-month services. follow-up interview, 46 of whom lived in IS villages Despite regional instability, greater than two-thirds and 7 in CPT villages. Eighty-two (20%) women of women were living in the same area where they who missed the post-intervention assessment were were born. Comparing women in the CPT and IS found and assessed at the 6-month follow-up. In to- villages at baseline identified some significant dif- tal, 354 (87%) of the 405 women invited to partici- ferences in the make-up of the treatment conditions pate in the study completed at least one assessment (Table 1). Demographically, the women in the CPT (post-intervention, 6-month follow-up or both) and villages were on average nearly three years older 231 women (57%) completed both. Factors associ- and had a 16% greater prevalence of being married, ated with loss to follow-up included older age, being compared with women in the IS villages. In terms of in a IS village, being pregnant at baseline, and wit- symptoms and functional impairment, the women nessing and experiencing a wider range of traumas. in IS villages on average reported more functional The rate of follow-up differed by language that the impairment at baseline and more severe symptoms, interview was conducted in. Problems with secu- which resulted in a larger proportion meeting the rity and cases where the wrong women were inter- cut-off for clinically significant symptoms. Women viewed reduced follow-up numbers. in the CPT villages reported greater variety in types In the CPT villages, 141 (89%) were considered of different traumas experienced and witnessed treatment completers, having attended at least nine compared with women in the IS villages. There were of the 12 treatment sessions; the nine sessions did five different traumas a woman could have reported not need to be consecutive. Women in CPT groups experiencing and six different traumas a women who missed a session were visited by PSAs to iden- could have reported witnessing, thus the range of tify reason for absence and encouraged to rejoin. scores could be 0-5 and 0-6, respectively. Tables 2 Among the women who dropped out (i.e., attended and 3 provide the differences in demographics and fewer than nine sessions) most cited family obliga- total symptom and function scores separately by vil- tions and agricultural duties as reasons. One CPT lage. Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 23 Figure 1. Flow chart of study participants 16 villages randomized for study 1 CPT village excluded because of counselor capacity Allocated to IS (n=8 villages) Allocated to CPT (n=7 villages) 273 women assessed for eligibility 221 women assessed for eligibility 25 non-eligible 33 non-eligible 7 non-survivors 10 non-survivors 248 Eligible women 14 low symptoms 188 Eligible women 23 low symptoms or invited to participate or dysfunction dysfunction 4 actively suicidal 3 actively suicidal 32 eligible women not invited because group 158 women invited to size met participate 154 eligible + 4 ineligible 8 permanently lost to follow-up 1 id number not verified* 1 death 6 no information 156 (63%) completed 114 (73%) completed post-intervention post-intervention assessment assessment 175 (71%) completed 6- 138 (88%) completed 6- month follow-up month follow-up assessment assessment 248 included in analysis 157 included in analysis 129 (52%) completed post- 102 (65%) completed post- intervention and 6-month follow-up intervention and 6-month follow-up assessments assessments 73 (29%) only completed post-intervention 48 (31%) only completed post-intervention or 6-month follow-up assessments or 6-month follow-up assessments 46 (19%) completed only baseline 7 (4%) completed only baseline 25 * The sample was recruited from NGO clients lists serving sexual violence survivors we can assume 100% of the sample experienced rape. However, given that not all women will want to share this information, it was not surprising that a small proportion (N=22; 5%) reported witnessing but not experiencing rape. ** For one CPT participant treatment id could not be matched with a study id, therefore this participant could not be included in any analysis. 24 Baseline demographic, mental health, and functioning characteristics of the CPT and IS samples Table 1. Study Sample Characteristics at Trial Baseline (n=405) CPT IS Variable (n=157) (n=248) Demographic characteristics Age in years, Mean (SD)* 36.89 (13.44) 33.77 (12.43) Years of education completed, Mean (SD) 1.76 (2.76) 2.25 (3.14) Number of people living in home, Mean (SD) 7.41 (3.15) 6.81 (3.32) Number of children responsible for, Mean (SD) 3.96 (2.67) 4.06 (2.76) Marital Status, No. (%)* Single 20 (12.74) 35 (14.11) Married 93 (59.24) 107 (43.15) Divorced 1 (0.64) 11 (4.44) Separated 19 (12.10) 43 (17.34) Widowed 24 (15.29) 52 (20.97) Living in territory of origin, No. (%) 130 (82.80) 194 (78.23) Trauma Exposure Data Average typesa traumas experienced, Mean (SD)* 3.91 (1.08) 3.36 (1.36) Average typesa traumas witnessed, Mean (SD)* 5.20 (1.28) 4.06 (1.96) Functionality Outcome Average functional impairment score, Mean (SD)* 1.66 (0.69) 2.48 (0.82) Baseline Symptom Scale Score Average Total Symptom score, Mean (SD)* 1.91 (0.51) 2.20 (0.44) Indicators of Clinical Significance Average HSCL score greater than 1.75, No. (%)* 110 (70.97) 208 (83.87) Average PCL score greater than 1.75, No. (%)* 90 (58.06) 200 (80.65) Economic Indicators Food Expenditures per capita (CDR), Mean (SD)* 965.2 (91.4) 718.7 (73.9) Score on Asset Index, Mean (SD)* 0.114 (0.09) -0.204 (0.05) Hours of Economic Work per Week, Mean (SD)* 24.4 (1.8) 17.9 (1.5) Hours of Domestic Work per Week, Mean (SD)* 35.1 (2.2) 40.2 (1.6) *Between arm difference significant at the 0.05 level a Respondents were asked whether they had personally experienced 5 different types of traumas and/or witnessed 6 different types of traumas. Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 25 26 Table 2. Study Sample Characteristics in Individual support Villages at Trial Baseline (n=248) Buzunga Kiniezire Lusambo Makobola Mulengeza Nyabibwe Runingu Sange Kihavu Kihavu Kibembe Kifuliru Kihavu Kihavu Kifuliru Kifuliru Village/Language/NGO ADIF UEFA PSVS PSVS ADIF UEFA PSVS PSVS (n=19) (n=35) (n=32) (n=30) (n=30) (n=36) (n=38) (n=28) Demographic characteristics Age in years, Mean (SD) 35.11(13.2) 24.89 (6.68) 41.41 (13.46) 32.5 (7.52) 37.47 (14.79) 27.22 (9.62) 42.18 (11.83) 29.68 (7.92) Years of education completed, Mean 1.63 (2.97) 3.86 (3.65) 2.09 (2.80) 1.63 (3.20) 1.23 (2.53) 3.86 (3.78) 1.60 (2.38) 1.39 (2.17) (SD) Number of people living in home, 5.89 (2.85) 5.46 (3.99) 7.56 (3.97) 8.1 (3.38) 6.37 (2.68) 6.97 (3.13) 7.16 (3.06) 6.64 (2.44) Mean (SD) Number of children responsible for, 4.26 (1.91) 2.66 (2.42) 5.56 (3.29) 4.4 (3.06) 3.4 (1.71) 2.94 (2.16) 5.08 (3.11) 4.32 (2.37) Mean (SD) Marital Status, No. (%) Single 2 (10.53) 12 (34.29) 3 (9.38) 2 (6.67) 2 (6.67) 13 (36.11) 0 (0.00) 1 (3.57) Married 4 (21.05) 0 (0.00) 15 (46.88) 27 (90.00) 22 (73.33) 9 (25.00) 15 (39.47) 15 (53.57) Divorced 0 (0.00) 1 (2.86) 5 (15.63) 1 (3.33) 0 (0.00) 4 (11.11) 0 (0.00) 0 (0.00) Separated 5 (26.32) 13 (37.14) 1 (3.13) 0 (0.00) 4 (13.33) 4 (11.11) 9 (23.68) 7 (25.00) Widowed 8 (42.11) 9 (25.71) 8 (25.00) 0 (0.00) 2 (6.67) 6 (16.67) 14 (36.84) 5 (17.86) Living in territory of origin, No. (%) 19 (100.00) 31 (88.57) 24 (75.00) 21 (70.00) 23 (76.67) 22 (61.11) 29 (76.32) 25 (89.29) Trauma Exposure Data Average different traumas experienced, 4.32 (0.82) 4.49 (0.74) 2.88 (1.07) 3.30 (1.29) 3.13 (1.53) 4.03 (1.11) 2.66 (1.24) 2.29 (1.15) Mean (SD) Average different traumas witnessed, 5.63 (0.68) 5.34 (1.21) 4.16 (1.76) 3.77 (1.87) 4.27 (1.48) 2.64 (2.28) 4.16 (2.06) 3.11 (1.79) Mean (SD) Functionality Outcome Average functional impairment, Mean 2.29 (0.57) 2.64 (0.65) 1.15 (0.42) 2.36 (0.66) 2.47 (0.49) 3.09 (0.34) 2.88 (0.80) 2.76 (0.69) (SD) Baseline Symptom Scale Score Average Total Symptom score, Mean 2.00 (0.32) 2.44 (0.48) 1.90 (0.40) 2.00 (0.40) 2….10 (0.45) 2.36 (0.25) 2.40 (0.34) 2.20 (0.50) (SD) Table 3. Study Sample Characteristics in CPT Villages at Trial Baseline (n=157) Bishange Kiliba Lushebere Luvungi Mabingu Mantu Nyamukubi Kihavu Kifuliru Kihavu Kifuliru Mashi Mashi Kihavu Village/Language/NGO UEFA PSVS ADIF PSVS ADIF ADIF ADIF (n=23) (n=19) (n=24) (n=22) (n=21) (n=24) (n=24) Demographic characteristics Age in years, Mean (SD) 26.87 (9.22) 31.16 (12.81) 34.88 (10.21) 33.27 (10.27) 46.71 (10.68) 36.13 (14.98) 48.5 (10.86) Years of education completed, Mean (SD) 1.96 (2.08) 4.16 (3.98) 0.79 ( 1.41) 3.36 (3.32) 0.14 (0.65) 1.63 (2.70) 0.71 (1.90) Number of people living in home, Mean (SD) 5.74 (2.77) 8.42 (4.36)) 7.25 (2.23) 6.45 (2.81) 8.71 (2.85) 7.29 (2.79) 8.25 (3.34) Number of children responsible for, Mean 2.35 (2.14) 3.11 (2.60) 4 (2.25) 3.45 (2.18) 4.86 (2.41) 4.25 (3.19) 5.54 (2.70) (SD) Marital Status, No. (%) Single 8 (34.78) 6 (31.58) 0 (0.00) 2 (9.52) 0 (0.00) 3 (13.04) 0 (0.00) Married 8 (34.78) 6 (31.58) 18 (75.00) 15 (71.43) 11 (52.38) 15 (65.22) 19 (79.17) Divorced 0 (0.00) 0 (0.00) 1 (4.17) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) Separated 4 (17.39) 4 (21.05) 0 (0.00) 3 (14.29) 4 (19.05) 1 (4.35) 3 (12.50) Widowed 3 (13.04) 3 (15.79) 5 (20.83) 1 (4.76) 6 (28.57) 4 (17.39) 2 (8.33) Living in territory of origin, No. (%) 19 (82.61) 16 (84.21) 22 (91.67) 11 (52.38) 16 (76.19) 22 (95.65) 22 (91.67) Trauma Exposure Data Average different traumas experienced, 4.17 (0.94) 3.47 (1.47) 3.92 (0.97) 3.22 (1.27) 3.95 (0.92) 4.13 (0.80) 4.38 (0.82) Mean (SD) Average different traumas witnessed, Mean 4.87 (1.96) 4.74 (1.15) 5.63 (0.58) 4.45 (1.30) 5.71 (0.46) 5.67 (0.70) 5.21 (1.56) (SD) Functionality Outcome Average functional impairment score, Mean 1.54 (0.76) 1.33 (0.47) 2.03 (0.44) 1.22 (0.54) 1.25 (0.37) 1.87 (0.60) 2.15 (0.89) (SD) Baseline Symptom Scale Score In Eastern DRC with Cognitive Processing Therapy Addressing Sexual Violence Related Trauma Average Total Symptom score, Mean (SD) 1.58 (0.66) 1.86 (0.34) 1.76 (0.37) 1.91 (0.35) 2.06 (0.51) 2.00 (0.46) 2.18 (0.54) 27 Mental Health Outcomes Comparison of CPT to IS samples Although there were differences across villages at Table 4 below presents the comparison of women in baseline across the two treatment conditions, the CPT and IS villages across all of the mental health evaluation team concluded, through a review of the outcomes. For each outcome, average scores are randomization process and discussion with inter- provided from the baseline and follow-up assess- viewers and study staff, the differences were not due ments of those who completed the follow-up. The to any systematic bias (i.e., decision on the part of estimate of treatment effect is provided based on the program, researchers, or study interviewers to the longitudinal regression analysis that adjusts for specifically recruit and enroll participants different differences in the treatment arms at baseline and from those in other communities). Thus comparing weights for loss to follow-up. The treatment effect women in the CPT to IS is possible with the lon- is the estimated difference in amount of average gitudinal analytic methods accounting for baseline change experienced by the women in CPT com- differences across study conditions. pared with women with access to IS participants, to- gether with 95% confidence intervals. Confidence intervals that include a value of 0.0 would imply that the difference in average change between CPT and IS was not statistically significant. Table 4: CPT and IS symptom scores and impacts at each follow up* Estimated Observed Score % Change from baseline difference CPT IS CPT IS (95% CI)** Average Depression scores 1.90 2.16 Baseline 57% 23% 0.78 (0.45-1.12) 0.82 1.67 Post-Intervention 61% 30% 0.64 (0.28-1.02) 0.75 1.51 6-month follow-up Average Anxiety scores 2.04 2.23 Baseline 61% 25% 0.93 (0.60-1.26) 0.80 1.67 Post-Intervention 64% 32% 0.83 (0.46-1.21) 0.73 1.52 6-month follow-up Average Trauma scores 1.85 2.21 Baseline 59% 24% 0.96 (0.62-1.30) 0.75 1.67 Post-Intervention 62% 31% 0.84 (0.45-1.23) 0.70 1.53 6-month follow-up Average Qualitative scores 1.94 2.22 Baseline 61% 24% 0.88 (0.55-1.21) 0.75 1.68 Post-Intervention 63% 32% 0.75 (0.40-1.11) 0.71 1.52 6-month follow-up Average HSCL-25 scores 1.97 2.20 Baseline 59% 24% 0.86 (0.53-1.19) 0.81 1.67 Post-Intervention 62% 31% 0.74 (0.38-1.11) 0.74 1.52 6-month follow-up Average Total Symptoms 1.91 2.20 Baseline 61% 25% 0.86 (0.53-1.19) 0.75 1.65 Post-Intervention 63% 32% 0.74 (0.38-1.11) 0.71 1.50 6-month follow-up *Data presented based on observed rates; probable caseness was defined using cut-off scores of 1.75 on the HSCL-25 **Regression analyses used all available data and incorporated adjustment for variables that were statistically significantly different comparing women in CPT with women in IS villages at baseline and related to change in symptoms over time: age, pregnancy status, marital status (married yes/no), language, range of time living in this village, total number of people living in the home, number of children responsible for, range of traumas witnessed and experienced, as well as random effects for village, treatment group within village, and the individual participant level indicators. 28 Based on the results above (Table 4), CPT partici- the HSCL combined depression and anxiety scales pants had significantly greater change in average and the trauma symptoms as measured using the symptoms across all outcomes compared with those PCL measure are presented graphically in Figure 2. with access to IS. At the post-intervention assess- ment, the percent change was twice as great among Table 5 presents a comparison of women in CPT CPT participants compared with the percent change with IS villages on percent of probable caseness for among those with access to IS across all outcomes. depression/anxiety and PTSD. This analysis repre- At the 6-month follow-up, the difference was re- sents an alternate way to examine the data compared duced a very small amount, indicating that initial in- with the previous analysis of change in symptom se- tervention effects were maintained. The results for verity. In this analysis, we are looking specifically Figure 2 : Average scores on the combined depression/anxiety scales using the Hopkins Symptom Checklist (HSCL-25) and the trauma scale using the PTSD Checklist (PCL) across the trial assessment points. Average scores on the HSCL-25 and PCL range from 0 to 3 with scores higher than 1.75 consistent with clinically significant levels and depression/ anxiety and PTSD     Legend Dark Blue: 2IS Depression/Anxiety Dark Purple: IS Posttraumatic Stress Light Blue: CPT Depression/Anxiety Light Purple: CPT Posttraumatic Stress Table 5: Probable cases of depression/anxiety and PTSD and impacts at each follow up* Relative Risk CPT IS (95% CI; p-value)** Probable Depression/Anxiety cases 111 (70.7) 206 (83.1) Baseline, N (%) 11 (9.7) 82 (52.6) 7.3 (3.4 - 16.8; <0.001) Post-intervention, N (%) 12 (8.7 73 (41.7) 4.6 (2.1 - 11.1; <0.001) 6-month follow-up, N (%) Probable PTSD cases 94 (59.9) 205 (82.7) Baseline, N (%) 9 (7.9) 85 (54.5) 12.3 (5.2 - 30.5; <0.001) Post-intervention, N (%) 12 (8.7) 73 (41.7) 5.5 (2.5 - 13.2; <0.001) 6-month follow-up, N (%) * Data presented based on observed rates; probable caseness was defined using cut-off scores of 1.75 on the HSCL-25 (depression/anxiety cases) and on the PCL trauma measure (PTSD cases). **Regression analyses used all available data and incorporated adjustment for variables that were statistically significantly different comparing women in CPT with IS villages at baseline and related to change in symptoms over time: age, pregnancy status, marital status (married yes/no), language, range of time living in this village, total number of people living in the home, number of children responsible for, range of traumas witnessed and experienced, as well as random effects for village, treatment group within village, and the individual participant level indicators. Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 29 Figure 3 - Box plot of HSCL and PCL scores with the dark horizontal line indicating the 1.75 cut-off* 3 Scale Score 1 0 2 Control CPT 1 hscl 1 trauma 2 hscl 2 trauma 3 hscl 3 trauma *1 hscl and 1 trauma reference the baseline HSCL-25 and PCL scores by treatment arm (IS/CPT). 2 hscl and 2 trauma reference the respective scores at the post-intervention follow-up. 3 hscl and 3 trauma reference the respective scores at the 6-month follow-up assessments. at the rate at which participants in each group who Function and Social Resource met our criteria for a clinical case of disorder (i.e., Outcomes had scores of greater 1.75) went into remission – which basically means they no longer met criteria Comparison of CPT to access to IS women as a clinical case. For both outcomes, women with Table 6 below presents the results of the analysis access to IS were at significantly greater risk of re- comparing average functional impairment scores of maining a probable case of Depression/Anxiety and women in CPT villages with women in access to IS PTSD compared with those in the CPT arm at the villages. Functional impairment was assessed with post-intervention assessment and at the 6-month a series of 20 tasks and activities of daily living. As follow-up. Figure 3 further shows that the remission with the symptom outcomes above, the women in rates are not due to cases simply ‘dipping’ below the CPT villages showed significantly greater improve- cut-off score of 1.75; rather, a review of the box plots ment compared with women in the access to IS vil- lages. shows that among the CPT participants, the major- ity have had their symptom severity scores signifi- Table 7 presents a comparison of CPT to IS samples cantly reduced. across 2 domains of social resources: participation 30 Table 6: CPT and IS function scores and impacts at each follow up* Observed % Change from baseline Effect Estimate CPT IS CPT IS (95% CI)* Average Function scores 1.65 2.48 Baseline 0.82 1.92 50% 23% 1.08 (0.63-1.53) Post-Intervention 0.88 1.77 47% 29% 0.90 (0.41-1.39) 6-month follow-up * Data presented based on observed rates. **Regression analyses used all available data and incorporated adjustment for variables that were statistically significantly different comparing women in CPT with women in IS villages at baseline and related to change in symptoms over time: age, pregnancy status, marital status (married yes/no), language, range of time living in this village, total number of people living in the home, number of children responsible for, range of traumas witnessed and experienced, as well as random effects for village, treatment group within village, and the individual participant level indicators. Table 7: CPT and IS social resource ratings and impacts at each follow up* Observed % Change from baseline Effect Estimate CPT IS CPT IS (95% CI)* Average number of groups participating in 3.04 2.69 Baseline 3.68 3.23 21% 20% 0.09 (-1.18, 1.35) Post-Intervention 3.96 2.85 30% 06% 0.88 (-0.28, 2.05) 6-month follow-up Average frequency of visiting with others** 1.20 1.14 Baseline 1.69 1.43 41% 25% 0.11 (-0.37, 0.58) Post-Intervention 1.72 1.34 43% 18% 0.24 (-0.19, 0.66) 6-month follow-up * Data presented based on observed rates. The range of possible numbers of groups is 0-9; frequency of visitation value is based on reporting the average frequency of visiting others/having others visit you: 0=never, 1=rarely, 2=sometimes, 3=often **Regression analyses used all available data and incorporated adjustment for variables that were statistically significantly different comparing women in CPT with women in IS villages at baseline and related to change in symptoms over time: age, pregnancy status, marital status (married yes/no), language, range of time living in this village, total number of people living in the home, number of children responsible for, range of traumas witnessed and experienced, as well as random effects for village, treatment group within village, and the individual participant level indicators. in community groups and frequency of visiting with better than that of IS women: Per capita expendi- others. There were no statistically significant dif- tures on food were higher for treatment (CDF 965.2 ferences between the treatment conditions, though or 2.17 PPP USD10) than for IS women (CDF the trends show greater increases among women in 718.7 or 1.61 PPP USD) and their score on the asset the CPT compared with women in the access to IS index-a composite indicator of household wealth- arms. was substantially higher. In line with this, treatment women performed on average more economic work Economic Outcomes (24.4 hours per week) than IS women (17.9 hours per week). Women in the IS villages on average per- As with the mental health outcomes, the random- ization of villages into CPT and IS conditions did not produce a good balance on baseline economic 10  We used the last purchasing power parity conversion factor variables. As shown in Table 1 above, the economic available for private consumption: $444.84 in 2008. Source: http:// situation of CPT women at baseline was on average data.worldbank.org/indicator/PA.NUS.PRVT.PP Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 31 Table 8: Baseline Characteristics for lost to follow-up and completed at least one follow-up interview Loss to follow-up Completed follow-up Mean Diff (N=53) (N=352) Food Expenditures per Capita 961.3 (280.3) 792.3 (51.4) -169 (170.9) (CDF), Mean (SD) Score on Asset Index, Mean (SD) -0.107 (0.104) -0.076 (0.050) -0.03 (0.135) Hours of Economic Work 15.8 (2.8) 21.1 (1.3) -5.3 (3.4) (Week), Mean (SD) Hours of Domestic Work 40.2 (3.7) 38 (1.4) 2.2 (3.9) (Week), Mean (SD) formed more domestic work. participants may represent a less privileged part of the original CPT sample. Exploring baseline dif- Table 8 below shows the baseline economic charac- ferences between CPT and IS women after loss to teristics for women who were re-interviewed after follow-up, however, suggests that this is unlikely to the intervention and women who were not (lost be a problem, as the CPT group is still better-off to follow-up). We did not see any significant differ- than the IS group even considering loss to follow- ences regarding their economic outcomes. Baseline up. Women in the CPT group had higher food ex- per capita food expenditures were somewhat higher penditures, a higher score on the asset index, and for women who did not complete a follow-up in- performed more hours of economic work and less terview than for women who completed a least one hours of domestic work. post-intervention assessment, asset holdings of lost to follow-up women were somewhat lower at base- Table 10 shows the means of the economic out- line and these women also performed fewer hours of comes at baseline, post-intervention and 6-month economic work. None of the differences is however follow-up for the CPT and IS participants. Between statistically significant. baseline and post-intervention, the hours of eco- nomic work performed (both paid and unpaid) in- It is also important to examine whether attrition creased for CPT women and stayed approximately among CPT participants differs systematically from the same for IS women. At the 6-month follow-up attrition among the IS participants, which would however, economic work in the CPT group had jeopardize the comparability of the randomized fallen back to baseline levels. Per capita food expen- groups. To highlight the patterns of attrition, Table ditures increased in both the CPT and IS groups. 9 shows baseline characteristics of CPT and IS lost The magnitude of the increase was exactly the same to follow-up. The seven CPT lost to follow-up wom- for CPT and IS women (average increase of 66%). en were better off in economic terms than were the While the score on the asset index (a standardized IS lost to follow-up women: their average per capita variable) dropped for CPT women, it increased for food expenditures (CDF 1,810 or 4.1 PPP USD) IS women. These descriptive statistics give us a first were more than double than those of the IS lost to sense of the evolution of economic outcomes in follow-up (CDF 832.2 or 1.87 PPP USD) and their both groups but a proper empirical analysis is need- score on the asset index was higher (statistically sig- ed to provide a rigorous impact assessment. nificant at p<0.05). Table 11 shows the estimated impact of CPT on the The observation that participants lost to follow-up different economic outcomes (estimates of in in the CPT condition were better-off than IS lost to specification 1) compared with IS. The first row in follow-up may point to a possible underestimation Table 12 reports the estimates of the immediate im- of CPT’s economic impact. Since wealthier women pact (at post-intervention), the second row presents dropped out of the CPT group, the remaining CPT the longer-run impact (at 6-month follow-up) and 32 Table 9: Baseline Characteristics of CPT and IS Lost to Follow-Up CPT Lost to Follow- IS Lost to Follow-Up Up Mean Diff (N=46) (N=7) Food Expenditures per Capita 1810 (1087) 832.2 (279) 977.8 (824.8) (CDF), Mean (SD) Score on Asset Index, Mean (SD) 0.524 (0.321) -0.203 (0.104) 0.727 (0.294)** Hours of Economic Work 21.3 (5.0) 15 (3.1) 6.3 (8.3) (Week), Mean (SD) Hours of Domestic Work (Week), 40.1 (10.5) 40.2 (3.9) -0.1 (10.9) Mean (SD) ** indicates significance at the 0.05 level. the third row reports the estimated impacts using Focusing on the 6-month follow-up, we find that all the average of the two post intervention assessments effects had become smaller or had subsided. We still as unique follow-up measurement. The analysis re- find a statistically significant effect on the number veals positive impacts of CPT participation on the of hours of paid economic work per week (three ex- number of hours of economic work performed per tra hours for the CPT women compared to the IS week (both paid and unpaid). At the post-interven- women), though the impact on unpaid economic tion assessment CPT women performed on average work is small and insignificant. The positive impact 6.3 hours more paid economic work and 7.7 hours on per capita food expenditures is still observed at more unpaid economic work per week than IS wom- the 6-month follow-up. The estimated coefficients en. The estimates are statistically significant at the are smaller compared to the immediate post-inter- 1% level. We also find a positive impact on per capi- vention assessment but still significant when using ta expenditures on food11. At the post-intervention quantile regression. The difference in asset holdings assessment median food consumption expenditures is not statistically significant. The last row in table were 354 CDF (or 0.8 PPP USD) higher for CPT 11 presents the estimates using the average of the than for IS women. Finally, we find a small negative post-intervention assessments as unique post mea- effect on assets; however, the magnitude is insignifi- surements. Overall the estimates suggest a modest cant from both an economic and statistical point of positive economic impact of CPT compared to IS. view. Overall, we find a positive impact of CPT compared to IS on economic work and to a lesser extent on food expenditures. However, these effects decrease or disappear after 6-months. 11  the coefficient is only statistically significant when using quintile regression (which estimates the conditional median instead of the conditional mean) Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 33 Table 10: Descriptive Statistics for CPT and IS Participants at Baseline and Follow-Ups CPT SI Average Hours Paid Economic Work Baseline (SD) 14.66 (16.37) 10.81 (17.52) Post-Intervention (SD) 15.74 (12.93) 8.66 (9.54) 6-month follow-up (SD) 13.78 (13.77) 8.71 (9.87) Average Hours Unpaid Economic Work Baseline (SD) 10.67 (13.49) 7.37 (13.29) Post-Intervention (SD) 14.75 (11.86) 8.57 (11.86) 6-month follow-up (SD) 12.33 (9.97) 9.96 (9.98) Average Hours Total Economic Work Baseline (SD) 25.26 (23.91) 17.91 (23.37) Post-Intervention (SD) 30.48 (20.41) 17.05 (15.99) 6-month follow-up (SD) 25.24 (17.96) 18.87 (14.71) Average Hours Domestic Work Baseline (SD) 35.1 (27.8) 40.2 (25.5) Post-Intervention (SD) 37.7 (19.8) 54.9 (28.0) 6-month follow-up (SD) 38.6 (21.1) 46.1 (26.8) Per Capita Food Expenditures Baseline (SD) 965.2 (1144.7) 718.7 (1161.8) Post-Intervention (SD) 1148.1 (1923.4) 728.7 (1000.5) 6-month follow-up (SD) 1604.4 (1609.3) 1193.6 (1251.9) Score on Asset Index Baseline (SD) 0.114 (1.11) -0.204 (0.75) Post-Intervention (SD) 0.013 (1.05) -0.024 (0.96) 6-month follow-up (SD) 0.043 (0.99) -0.063 (1) Note: All regressions control for baseline demographic variables such as age, age-squared, years of education, household size, and marital status. Analyses also include dummy variables for identifying the village block used for randomization. 34 Table 11: Estimated Impact of CPT on Economic Outcomes Unpaid Economic Food Paid Economic Work Asset Index N Work Expenditures Post Intervention OLS 6.3*** 7.7*** 494.5 -0.044 270 [SD] [1.54] [1.05] [360.3] [0.153] QR 5.7*** 8.8*** 354.4*** -0.065 270 [1.73] [1.7] [86.6] [0.142] 6-month Follow-Up OLS 2.9** 1.0 362.2 0.103 311 [SD] [1.3] [1.4] [239.3] [0.117] QR 2.7* 1.9 260.2** 0.108 311 [1.4] [1.4] [125.5] [0.125] Average Follow-Up OLS 4.9*** 3.4*** 388.0* 0.049 350 [SD] [1.3] [1.1] [225.7] [0.116] QR 5.0*** 3.4*** 292.0*** 0.040 350 [1.2] [1.2] [100.3] [0.104] Note: ***, **, and * indicate significance at the 1, 5, and 10 percent levels respectively. Two specifications are presented for each of the three rows: Ordinary Least Squares (OLS) and Quintile Median Regression (QR). Qualitative follow-up results Luvungi site. Participants in Lushebere mentioned how they are no longer abandoning themselves. Qualitative interviews They used this term to refer to how they now care The sample of CPT participants interviewed during for themselves and their children. Participants in the post-intervention qualitative study spoke about Lushebere also spoke about how they reestablished positive and negative changes in the free list exer- their physical state, don’t hate men, don’t underesti- cise. The most commonly mentioned changes in the mate themselves, and have power now. lives of participants across all three sites were hav- When asked about changes specifically due to the ing harmony with others and having strength. Some program, participants mentioned many of the same changes were mentioned more frequently in one or changes that they had identified in the prior ques- two sites but not all three. While some participants in Bishange mentioned having no more fear and not tion and some new changes. Being in harmony with having a lot of thoughts, more people in Luvungi others was the most commonly mentioned change and Lushebere mentioned these two changes. In and was mentioned in three field sites. In Luvungi, Luvungi and Bishange, participants spoke about participants spoke about having stability or peace. changes in poverty status (positively and negatively) In Luvungi and Bishange, participants mentioned as well of the problem of lack of mutual comprehen- not having fear and reduced poverty in relation to sion with family members. Participants in Lushe- participating in the program, even though in gen- bere and Bishange spoke about not being ashamed, eral they did say it was a problem in response to not being discriminated against anymore and feeling the first question. In Lushebere, participants spoke free, but these changes were not mentioned in the about not being discriminated against, being ill, hav- Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 35 Table 13. Report of amount of change from baseline to post-intervention Post-Intervention IS (n=155) CPT (n=114) Worse Same Better Worse Same Better Harmony: G1 Harmony with husband 30% 5% 32% 12% 7% 48% G2 Harmony with children 23% 12% 62% 7% 8% 77% G3 Harmony with neighbors 23% 15% 61% 5% 11% 86% G4 Harmony with family 21% 23% 53% 2% 8% 89% Strength: G5 Strength to do work 34% 21% 44% 9% 7% 83% G6 Strength to go to market 26% 18% 49% 12% 9% 76% Positive feelings: G7 Having good thoughts 30% 15% 53% 9% 5% 85% G8 Not ashamed in front of others 32% 19% 47% 5% 4% 88% G11 Peaceful environment in home 34% 16% 49% 4% 3% 93% G12 Peaceful environment in 28% 30% 50% 5% 2% 93% community Negative feelings: G9 Hatred against men 39% 20% 37% 19% 8% 68% G10 Discriminated against by others 32% 21% 45% 6% 4% 83% Care of self: G13 Wearing clean clothes and shoes 29% 28% 43% 10% 18% 72% G14 Taking baths 20% 11% 69% 4% 6% 88% G15 Wearing makeup 25% 12% 36% 7% 15% 67% G18 Thinking about how food affects 25% 27% 41% 12% 32% 63% your body Care for family: G16 Making sure your children look 20% 12% 66% 3% 6% 87% clean G17 Cooking food for family 19% 14% 65% 4% 8% 88% G19 Thinking of having more children 33% 17% 29% 26% 18% 32% * data are presented as percentages; results may not sum to 100% due to missing data and/or responses indicating that the questions were not relevant. 36 Table 14. Report of amount of change during maintenance period 6-month Follow up IS (n=175) CPT (n=138) Worse Same Better Worse Same Better Harmony: G1 Harmony with husband 25% 7% 27% 13% 8% 43% G2 Harmony with children 21% 9% 70% 4% 12% 81% G3 Harmony with neighbors 22% 12% 66% 7% 10% 83% G4 Harmony with family 25% 13% 61% 15% 9% 76% Strength: G5 Strength to do work 37% 12% 51% 14% 9% 76% G6 Strength to go to market 29% 15% 53% 12% 15% 70% Positive feelings: G7 Having good thoughts 32% 19% 49% 9% 5% 86% G8 Not ashamed in front of others 29% 18% 53% 2% 7% 91% G11 Peaceful environment in home 27% 14% 59% 6% 9% 75% G12 Peaceful environment in 22% 16% 62% 6% 6% 88% community Negative feelings: G9 Hatred against men 37% 18% 45% 12% 7% 77% G10 Discriminated against by others 33% 18% 48% 7% 11% 82% Care of self: G13 Wearing clean clothes and shoes 28% 19% 52% 10% 12% 76% G14 Taking baths 18% 9% 74% 2% 2% 96% G15 Wearing makeup 20% 21% 42% 12% 10% 77% G18 Thinking about how food affects 25% 26% 45% 25% 15% 59% your body Care for family: G16 Sure your children look clear 19% 10% 70% 3% 4% 88% G17 Cooking food for family 21% 10% 68% 3% 12% 85% G19 Thinking of having more children 45% 23% 28% 33% 22% 33% * data are presented as percentages; results may not sum to 100% due to missing data and/or responses indicating that the questions were not relevant. Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 37 ing many thoughts and death. In both Luvungi and to reflect on whether they felt this had gotten worse Lushebere, participants spoke about being cured. In over the prior six months (a score of 0 ‘a lot worse’ Bishange, participants spoke about feeling free. or 1 ‘a little worse’), whether they felt this had not changed at all (a score of 2), or whether they felt this Preliminary analysis of quantitative items had gotten better over the prior six months (a score from items added based on qualitative of 3 ‘a little better’ or 4 ‘a lot better’). Tables 13 and study 14 present the results in terms of the percent of re- Based on the frequently mentioned changes from spondents reporting changes. Across all outcomes the qualitative study, a series of additional questions and both follow-ups, the majority of CPT partici- were added to the quantitative interview to reflect pants reported that these outcomes had gotten bet- possible unexpected changes due to participation in ter. For what is listed in the table as negative feelings CPT. By including them in the interview and ask- it should be understood that respondents were not ing the questions to both CPT and IS participants, saying that they felt them more often, but rather that we can explore whether these differences may be these feelings got better. That is, the CPT partici- due to the CPT program or to factors common to pants reported high rates of feeling less hatred and both groups (CPT and IS). For each type of change discrimination, or their hatred and discrimination (e.g., harmony with family), we asked participants were less strong, compared with IS participants. 38 DISCUSSION Mental health Outcomes ed to come to as many sessions as they themselves wanted. PSAs in the CPT condition may also have This study found that while the average symptom been more motivated and engaged than those in IS scores improved over time in both treatment con- because they were implementing a new service and ditions, CPT was more effective in improving reported high satisfaction with the treatment man- function and reducing symptoms of distress regard- ual and guidance provided through the supervision less of how it was assessed (i.e., depression, anxiety, system set up for this trial. trauma, combined depression/anxiety and PTSD) compared with individual support alone among From the program perspective, in a review of their female survivors of SV with high levels of mental experience, while the CPT PSAs acknowledged the health symptoms in eastern DRC. The benefits were importance of some of the non-content differences large and maintained six months post-intervention. between CPT and IS for achieving these outcome CPT participants were significantly less likely to results (such as group vs. individual, or fixed dates meet criteria for probable depression/anxiety and vs. meeting as needed), they also felt that the con- PTSD. Our findings are consistent with trials in tent of the therapy was essential in achieving these high-income countries of cognitive behavioral in- results. The PSAs reported that the CPT training terventions generally (Olatunji, 2010) and of CPT provided them with useful tools and guidance to ad- specifically (Resick, 2002; Cloitre, 2010) for studies dress deeper issues in clients’ thoughts and feelings among SV survivors. that current case management does not address. The PSAs also noted that it provided them with a more Prior research has suggested short-term therapies structured and organized system of therapy with a may not be effective for populations exposed to clear end, which made offering effective services ongoing or multiple severe traumas (Cloitre, 2010; easier for the PSAs with less experience, intuition, Dorrepaal, 2010). In this study, all villages reported or capacity, compared to case management, where at least one major security incident during the trial services are provided based on the client’s needs and including attacks, displacement due to fighting, and which depends heavily on the capacity and skills of robbery by armed groups. There were also sug- the PSA to engage with the client in identifying and gestions that providing therapy to mostly illiterate addressing these specific needs. clients would be challenging. Our findings suggest that despite illiteracy and ongoing conflict, this ev- The level of supervision the CPT PSAs received was idence-based treatment can be appropriately imple- greater than that for IS counselors due to the nature mented and effective. of introducing a more specific manualized program (CPT) that required significant (i.e., weekly) su- Differences in how CPT and IS were provided may pervision because of the minimal mental health affect our conclusions. Since CPT, but not IS, was background training of the PSAs. Prior studies have provided in groups, it is unclear how much of the found increased quality and quantity of clinical su- impact was due to group context. The difference pervision can explain some treatment effect (Sho- in how study participants were motivated to par- lomskas 2005; Stewart 2009). CPT participants also ticipate in sessions also differed by study arms. CPT had on average a greater number of treatment ses- participants were also actively encouraged to come sions compared with IS participants. Overall CPT to ongoing sessions while IS participants were invit- effects must therefore be taken as program effects, Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 39 which include the therapy itself, number of sessions, are exposed to other survivors struggling with simi- group process and supervision systems. lar experiences. CPT may also have provided a way of building self-efficacy for participants as they Individuals who are illiterate have traditionally been helped each other acquire skills through listening excluded from research trials of trauma-focused to group members discuss practice assignments, cognitive behavioral therapies. To deal with the lit- participating actively in the group and helping each eracy issues, modifications to CPT (see Appendix other generate alternative cognitions. C for a complete list of treatment modifications) were made to simplify treatment materials and rely The task-sharing model utilized in this trial was on memorized rather than written homework. This based on an apprenticeship model (Murray et al., suggests that trauma-focused interventions may be 2011) of service provision with lay-level counselors able to be used with populations that have tradition- receiving brief (2-week) training (experiential and ally been excluded from care where literacy or access didactic) and then ongoing supervision through a to written materials is problematic. multi-tiered support system of local and internation- al mental health staff. Although the initial training Some service providers and researchers assume that was important, the majority of learning for the CPT populations exposed to multiple severe traumas PSAs occurred during the pilot phase and through- such as refugees, survivors of child sexual abuse, out the implementation of the trial. The regular and or those exposed to ongoing war either cannot tol- consistent supervision from both local IRC supervi- erate or will not respond to short-term trauma-fo- sory staff and US-based expert trainers was essential cused cognitive behavioral therapies (Cloitre et al., in ensuring uptake and fidelity to the treatment. This 2010; Dorrepaal et al., 2010). Insecurity continued was evidenced by documented notes of challenges in CPT and IS sites during the implementation of and questions by local staff requiring input from the trial.  Of the seven CPT sites, all reported at least supervisory structure on the implementation of the one incident of insecurity during the intervention therapeutic model. IRC-based supervisors (CTs) period.  Reports of general attacks and pillage on the and the US-trained clinical social worker were able whole village occurred in two villages, and outbursts to get support from the US-based CPT experts for of military fighting in three, causing displacement of both ongoing and complex questions regarding the populations into the forest.  In three villages, there treatment and to then provide real-time feedback were reports of specific attacks and robbery by mili- and support directly to the PSAs in the field. tary or bandits at individual homes, a commercial truck, religious convents, a health center and one Function and Social Outcomes of the ‘listening centers’.  Our findings suggest that On average, the CPT participants reported signifi- despite exposure to extensive previous trauma, as cantly less difficulty in engaging in their daily tasks well as ongoing conflict, treatment of mental health compared with IS participants. Unlike many func- symptoms can be both well-tolerated and effective. tion assessment instruments, ours did not differ- entiate between functional impairment specifically The group format of treatment has several advantag- related to health problems versus dysfunction due to es over individual treatment that were considered in any cause (including lack of resources or assistance). selecting this model of intervention. Group can be This is important in contexts where dysfunction is more resource-efficient; a single therapist can treat common and due to multiple causes. Moreover, more women in the same period of time (Beck, Cof- the tasks assessed were those identified by women fey, Foy, Keane, & Blanchard, 2009). This is an espe- similar to those in the study as being particularly im- cially vital benefit when working in settings where portant to them. Therefore a large improvement in specially trained professionals and resources are lim- the ability to do these tasks could significantly affect ited. Another advantage to group treatment is that community welfare and development. it can potentially provide a means of reducing inter- nalized stigma around rape itself and around mental We did not find any significant differences in two health symptoms (Classen, et al., 2011), as women social resource indicators we analyzed: number of 40 groups participating in or amount of visiting with indicate an important time-period for introducing others. This may an artifact of there being a limited economic services that can support the women’s number of groups in each village (i.e., not all types of increases in work hours and economic potential. groups existed in each village). Further analysis on Where the social drift hypothesis states that increas- data collected related to participation in the groups es in mental health problems can place individuals is warranted in order to determine whether there at risk for ‘drifting’ into poverty, the preliminary re- are more nuanced differences. For the frequency of sults from this trial provide initial evidence that this visiting the trends show CPT participants reporting trend can be reversed; improving individual’s mental somewhat greater average frequency compared with health and thereby improving their economic out- IS, though the differences were not statistically sig- comes. nificant. Regardless, the average frequency of par- ticipation was relatively low across both groups, with However, it needs to be recognized that our evalu- both groups staying between the rarely and some- ation is limited by our lack of information on stan- times amount of visitation. dards for each community and changes that may have occurred at the community level over the course of Although results of the questions added to the ques- the trial. Climate and conflict-related factors should tionnaire based on the post-intervention qualitative be explored at the macro level to determine whether assessment showed consistent improvements across there were village-level issues that may have impact- all the domains of family and community compar- ed economic outcomes (i.e. reductions in agricultur- ing CPT to IS participants, initial analysis of a few of al production, changes in purchasing power, access the social resource outcomes did not find as clear re- to economic activities). sults. Further exploration of this data is needed. For example, there may be a limited number of groups Limitations available in certain communities, limiting the upper Limitations include symptom severity differences threshold for this measure, or it may be the quality of across study arms that may limit comparability. Ran- group participation (being more active in the same domization was done within blocks of 2-4 villages groups) or visits (having longer visits) that changed, grouped together based on language and proximity, rather than the number of groups or visits. Further with the assumption that villages close to one anoth- analysis will explore potential changes in social re- er would be similar; however this assumption was not sources through other measures. empirically confirmed. The small number of village Economic Outcomes clusters (n=6) made randomization less likely to re- sult in comparability. The recruitment process relied Relative to IS women, women who participated on PSAs in the villages reviewing their files to iden- in the CPT sessions performed more paid and un- tify women that were currently under treatment or paid economic work per week. Taken together, CPT who had previously been in treatment they thought women spent about one day more per week than IS might be appropriate for the intervention trial based women on economic work (adding the coefficients on the criteria we gave them (i.e., significant trauma of paid and unpaid economic work results in an over- symptoms and impairment in tasks of daily living). all impact of eight hours, about a day’s work). We There may have been biases in recruitment that re- also find a positive impact on per capita food expen- sulted in higher average symptom scores in IS vil- ditures, weakly statistically significant (at the 10% lages because PSAs recruiting patients knew ahead level) using OLS and strongly using quantile regres- of time whether they would be providing CPT or IS. sion. We do not find impacts on assets. To assess if higher IS baseline scores biased results, we performed sensitivity analyses restricted only to These economic results add to the limited evidence- women with baseline HSCL-25 scores greater than base that mental health programs can have second- 2.0 (CPT N=84; IS N=171), and found effect sizes ary benefits on economic functioning. The prelimi- remained greater than 1.0. nary results show that the strongest impacts were in the immediate post-intervention period, which may An additional limitation is the lack of locally-validat- Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 41 ed measures for specifically identifying depression, both measuring the same underlying distress. anxiety, and posttraumatic stress disorder. Data from the preliminary qualitative study indicated A final limitation is use of measures of unknown that rather than specific disorders, SV survivors in validity for identifying clinical cases of combined these villages experienced more generalized dis- depression/anxiety and PTSD. Since symptoms of tress, presenting with symptoms from all three dis- these disorders could be nonpathological reactions orders (depression, anxiety and PTSD), as well as a to extreme circumstances, it is unclear what pro- range of other symptoms of distress unrelated to any portions of participants actually meet clinical crite- one specific disorder. A brief validation study con- ria. While the clinical meaning of standard cut-off firmed these results, with our study team either find- scores is therefore uncertain, the score itself can still ing women with lower levels of symptoms or higher be meaningfully interpreted: 1.75 means women are levels of symptoms, but not women meeting specific reporting that symptoms occur, on average, nearly a criteria for any one of these disorders. This may help ‘moderate’ amount of the time (a score of 2.0). CPT explain why the results using the HSCL-25 and the participants’ scores dropped, on average, to lower PCL are quite similar. That is, it may be that while than ‘a little bit’ for the average response (a score of we have separated the measures into different disor- 1) while IS participants’ scores remained closer to a der constructs, the reality in the field is that they are ‘moderate amount’. 42 CONCLUSIONS AND RECOMMENDATIONS T his trial provides evidence of effectiveness of a with this type of therapy can be both well tolerated mental health intervention for SV survivors in and effective. a low-income conflict setting. The results indi- cate that with appropriate training and supervision, The group format of treatment has several advan- psychotherapeutic treatments such as cognitive tages over individual treatment that were con- processing therapy can be successfully implement- sidered in selecting this model of intervention. ed and show impact in settings with few specially Group can be more resource-efficient; a single ther- trained mental health professionals. To meet the apist can treat more women in the same period of goal of identifying low-cost and scalable interven- time. This is an especially vital benefit when working tions for this population and context, a cost-impact in settings where specially trained professionals and analysis is needed. As the supervision costs for this resources are limited. Another advantage to group trial, in terms of human and economic resources, treatment is that it can potentially provide a way of were relatively high, it may also be beneficial to de- reducing internalized stigma around rape itself and termine the level of ongoing supervision needed for around mental health symptoms, as women are PSAs to continue to implement CPT once they have exposed to other survivors struggling with similar been trained and completed several groups. experiences. CPT may also have provided a way of building self-efficacy for participants as they helped CPT may be used with populations that have tra- each other acquire skills through listening to group ditionally been excluded from care where litera- members discuss practice assignments, participat- cy or access to written materials is problematic. ing actively in the group and helping each other gen- Individuals who are illiterate or who are potentially erate alternative cognitions. exposed to ongoing violence have traditionally been excluded from research trials of trauma-focused cog- This study demonstrates that with a task-sharing nitive behavioral therapies. To deal with the literacy approach, which includes training and supervi- issues, modifications to CPT were made to simplify sion structures that support the counselors and treatment materials and rely on memorized rather local supervisors, evidence-based treatments than written homework. Based on our findings these such as CPT can be implemented with fidelity. factors did not limit the impact of CPT. The task-sharing model utilized in this trial was based on an apprenticeship model (Murray et al., CPT may be used with populations exposed to 2011) of service provision with lay-level counselors multiple severe traumas and who are exposed receiving brief (2-week) didactic training and then to ongoing trauma. There is often an assumption ongoing supervision through a multi-tiered support that populations exposed to multiple severe traumas system of local and international mental health staff. such as refugees, victims of child sexual abuse, or Although the initial training was important, the ma- those exposed to ongoing war either cannot tolerate jority of learning for the CPT counselors occurred or will not respond to short-term trauma-focused during the pilot phase and throughout the imple- cognitive behavioral therapies (Cloitre et al., 2010; mentation of the trial. The regular and consistent su- Dorrepaal et al., 2010). Our findings suggest that pervision from both local IRC-supervisory staff and despite the high degree of trauma experienced by US-based expert trainers was essential in ensuring many of the study women and the context of ongo- uptake and fidelity to the treatment. IRC-based su- ing conflict, treatment of mental health symptoms pervisors and the US-trained clinical social worker Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 43 were able to get support from the US-based trainers JHU and the IRC to further inform the discussion for both ongoing and complex questions regarding about the initial and continued costs of the program the treatment and to then provide real-time feed- in relation to the outcomes. JHU is also working back and support directly to the counselors in the independently on a situational analysis to map the field. NGO, UN, Ministry of Health and other agency programs that provide mental health and psychoso- PSAs from CPT sites expressed that they were ini- cial services in the region. This will inform further tially worried that CPT would be too difficult for recommendations of how CPT could be integrated them to implement, though with the help of support from the CTs, they adapted to using CPT and found into existing systems of care. that it was not as difficult as they initially expected. Recommendations One possibility for potential future CPT interven- tions may be to integrate CPT and case management Program recommendations skills to ensure that PSAs can still offer services to women who cannot participate in CPT, and be able In DRC: to refer safely and appropriately to other services as • The strong findings that CPT was successful per the case management model. in reducing symptoms and increasing func- Increased costs related to the initiation and im- tioning suggests that CPT should be made plementation of CPT are comparable to those more widely available for women survivors associated with a randomized controlled trial. of SV with high levels of symptoms and im- The costs associated with implementing CPT in this paired functioning within eastern DRC. study were in part due to the nature of introducing a new program, particularly one with a learning curve • An integrated model of CPT delivered in tan- that requires weekly supervision in a region where dem with other services (such as case manage- logistics, for example getting to villages on a weekly ment, health and other SV services) should basis, can be quite difficult and sometimes impos- be developed and tested in order to better sible because of security issues. But in considering understand whether combining systems of su- the costs, one needs to also consider the reduction pervision and program monitoring can reduce in costs that is realized once the counselors are human and economic resource costs. more fully trained and experienced. In the case of this study, once the trial was complete, the counsel- Globally: ors continued to provide services to new groups of • CPT can be used with populations that have women and received monthly, rather than weekly, traditionally been excluded from care where supervision from the IRC-based supervisors. This literacy or access to written materials is prob- monthly supervision is in line with standard prac- lematic. It can also be used with populations tices for many NGO-based psychosocial services who have been exposed to multiple severe and thus does not add additional costs relative to traumas, including SV. Given that this is the standard services. first evaluation showing CPT works with Next steps include a cost-impact analysis and a these populations, future programs should mapping of mental health services in the region. still be accompanied with rigorous evaluations The cost-impact analysis is being planned jointly by to measure effectiveness. 44 REFERENCES Analysis: New laws have little impact on sexual violence in DRC. (2011, June 7).IRIN News. Retrieved from http://www.irinnews.org/Report.aspx?ReportID=9292 Baelani, I., & Dünser, M. W. (2011). Facing medical care problems of victims of sexual violence in Goma/ Eastern Democratic Republic of the Congo. Conflict and health, 5(1), 2. doi:10.1186/1752-1505-5-2 Bartels, S., Kelly, J., Scott, J., Leaning, J., Mukwege, D., Joyce, N., & Vanrooyen, M. (2012). Milita- rized Sexual Violence in South Kivu, Democratic Republic of Congo. Journal of interpersonal violence. doi:10.1177/0886260512454742 Bass, J., Robinson, C., & Cole, G. (2010). Qualitative Assessment of Psychosocial Needs of Survivors of Gender- Based Violence in Eastern DRC. Beck, J. G., Coffey, S. F., Foy, D. W., Keane, T. M., & Blanchard, E. B. (2009). Group cognitive behavior therapy for chronic posttraumatic stress disorder: an initial randomized pilot study. Behavior therapy, 40(1), 82–92. doi:10.1016/j.beth.2008.01.003 Betancourt, T. S., Borisova, I. I., de la Soudière, M., & Williamson, J. (2011). Sierra Leone’s child soldiers: war exposures and mental health problems by gender. The Journal of Adolescent Health: Official Publication of the Society for Adolescent Medicine, 49(1), 21–28. Bliese, P. D., Wright, K. M., Adler, A. B., Cabrera, O., Castro, C. A., & Hoge, C. W. (2008). Validating the pri- mary care posttraumatic stress disorder screen and the posttraumatic stress disorder checklist with soldiers returning from combat. Journal of Consulting and Clinical Psychology, 76(2), 272–281. 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., Bass, J., Murray, L., Lee, K., Weiss, W., & McDonnell, S. M. (2007). Expanding the scope of hu- manitarian program evaluation. Prehospital and disaster medicine, 22(5), 390–395. 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 Booth, B. M., Mengeling, M., Torner, J., & Sadler, A. G. (2011). Rape, sex partnership, and substance use consequences in women veterans. Journal of Traumatic Stress, 24(3), 287–294. Campbell, R., Dworkin, E., & Cabral, G. (2009). An Ecological Model of the Impact of Sexual Assault On Wom- en’s Mental Health. Trauma, Violence, & Abuse, 10(3), 225 –246. Casey, S. E., Gallagher, M. C., Makanda, B. R., Meyers, J. L., Vinas, M. C., & Austin, J. (2011). Care-seeking behavior by survivors of sexual assault in the Democratic Republic of the Congo. American journal of public health, 101(6), 1054–1055. Center for Health Services and Outcomes, Stony Brook University, Research Brief, May 2011. If Numbers Could Scream: Estimates and determinants of sexual violence in the Democratic Republic of the Congo. http://www.stonybrookmedicalcenter.org/system/files/INCS_Congo_Brief_r6%20%281%29.pdf. Chambless, D. L., & Hollon, S. D. (1998). Defining empirically supported therapies. Journal of consulting and clinical psychology, 66(1), 7–18. Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 45 Chard, K. M. (2005). An evaluation of cognitive processing therapy for the treatment of posttraumatic stress disorder related to childhood sexual abuse. Journal of consulting and clinical psychology, 73(5), 965–971. Chen, L. P., Murad, M. H., Paras, M. L., Colbenson, K. M., Sattler, A. L., Goranson, E. N., Elamin, M. B., et al. (2010). Sexual abuse and lifetime diagnosis of psychiatric disorders: systematic review and meta-analysis. Mayo Clinic Proceedings. Mayo Clinic, 85(7), 618–629. Chivers-Wilson, K. A. (2006). Sexual assault and posttraumatic stress disorder: A review of the biological, psychological and sociological factors and treatments. McGill Journal of Medicine : MJM, 9(2), 111. Classen, C. C., Palesh, O. G., Cavanaugh, C. E., Koopman, C., Kaupp, J. W., Kraemer, H. C., Aggarwal, R., et al. (2011). A comparison of trauma-focused and present-focused group therapy for survivors of childhood sexual abuse: A randomized controlled trial. Psychological Trauma: Theory, Research, Practice, and Policy, 3(1), 84–93. Cloitre, M., Stovall-McClough, K. C., Nooner, K., Zorbas, P., Cherry, S., Jackson, C. L., Gan, W., et al. (2010). Treatment for PTSD related to childhood abuse: a randomized controlled trial. The American journal of psy- chiatry, 167(8), 915–924. Cohen J. (1988) Statistical power analysis for the behavioral sciences. Hillsdale, New Jersey: Lawrence Erl- baum Associates. Conybeare D, Behar E, Solomon A, Newman MG, Borkovec TD. (2012) The PTSD Checklist-Civilian Ver- sion: Reliability, Validity, and Factor Structure in a Nonclinical Sample. J Clin Psychol, 68(6):699–713. Dorrepaal, E., Thomaes, K., Smit, J. H., van Balkom, A. J. L. M., van Dyck, R., Veltman, D. J., & Draijer, N. (2010). Stabilizing group treatment for Complex Posttraumatic Stress Disorder related to childhood abuse based on psycho-education and cognitive behavioral therapy: a pilot study. Child abuse & neglect, 34(4), 284– 288. Duroch, F., McRae, M., & Grais, R. F. (2011). Description and consequences of sexual violence in Ituri prov- ince, Democratic Republic of Congo. BMC international health and human rights, 11, 5. Filmer, D., & Pritchett, L. H. (2001). Estimating wealth effects without expenditure data--or tears: an applica- tion to educational enrollments in states of India. Demography, 38(1), 115–132. Foa, E. B., Keane, T. M., & Friedman, M. J. (2010). Effective Treatments for PTSD, Second Edition: Practice Guidelines from the International Society for Traumatic Stress Studies. Guilford Press. Hausman JA. (1978) Specification tests in econometrics. Econometrica;46(6):1251-1271. Hesbacher PT, Rickels K, Morris RJ, Newman H, Rosenfeld H. (1980) Psychiatric illness in family practice. J Clin Psychiatry;41(1):6–10. Inter-Agency Standing Committee (IASC) (2007). IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. Geneva: IASC. http://www.humanitarianinfo.org/iasc Johnson, K., Scott, J., Rughita, B., Kisielewski, M., Asher, J., Ong, R., & Lawry, L. (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: The Journal of the American Medical Association, 304(5), 553–562. Kaysen, D., Lindgren, K., Sabir Zangana, G.A., Murray, L., Bass, J., & Bolton, P. (2011). Adaptation of Cog- nitive Processing Therapy for Treatment of Torture Victims: Experience in Kurdistan, Iraq. Psychological Trauma: Theory, Research, Practice, and Policy. Nov 7 [Epub ahead of print] Kohli, A., Makambo, M. T., Ramazani, P., Zahiga, I., Mbika, B., Safari, O., Bachunguye, R., et al. (2012). A Congolese community-based health program for survivors of sexual violence. Conflict and health, 6(1), 6. Laird NM, Ware JH. (1982) Random-effects models for longitudinal data. Biometrics;38(4):963–74. Lockett, D., & Bolton, P. (2009). Victims of Torture Fund Evaluation of the IRC Gender Based Violence Program 46 in the Democratic Republic of Congo Final Report. USAID. Loncar, M., Medved, V., Jovanović, N., & Hotujac, L. (2006). Psychological consequences of rape on women in 1991-1995 war in Croatia and Bosnia and Herzegovina. Croatian medical journal, 47(1), 67–75. McKenzie, D. (2012). Beyond baseline and follow-up: The case for more T in experiments. Journal of Devel- opment Economics, 99(2), 210–221. Loi numero 06/018 du 20 juillet 2006 modifiant et completant le decret du 30 janvier 1940 portant Code penal congolais (2006). Mollica, R. F., Wyshak, G., de Marneffe, D., Khuon, F., & Lavelle, J. (1987). Indochinese versions of the Hop- kins Symptom Checklist-25: a screening instrument for the psychiatric care of refugees. The American Journal of Psychiatry, 144(4), 497–500. Murray, L. K., Dorsey, S., Bolton, P., Jordans, M. J., Rahman, A., Bass, J., & Verdeli, H. (2011). Building ca- pacity in mental health interventions in low resource countries: an apprenticeship model for training local providers. International journal of mental health systems, 5(1), 30. Murray L, Bass J, Bolton P (2006). Qualitative study to identify indicators of psychosocial problems and func- tional impairment among residents of Sange District, South Kivu, Eastern DRC. USAID http://pdf.usaid.gov/ pdf_docs/pnadi610.pdf Nishith P, Nixon RDV, Resick PA. Resolution of trauma-related guilt following treatment of PTSD in fe- male rape victims: a result of cognitive processing therapy targeting comorbid depression? J Affect Disord 2005;86(2-3):259–65. Olatunji, B. O., Cisler, J. M., & Deacon, B. J. (2010). Efficacy of cognitive behavioral therapy for anxiety disor- ders: a review of meta-analytic findings. The Psychiatric clinics of North America, 33(3), 557–577. Ougrin D. (2011) Efficacy of exposure versus cognitive therapy in anxiety disorders: systematic review and meta-analysis. BMC Psychiatry;11:200. Peterman, A., Palermo, T., & Bredenkamp, C. (2011). Estimates and determinants of sexual violence against women in the Democratic Republic of Congo. American journal of public health, 101(6), 1060–1067. Population Council and UNFPA. (2007). The Adolescent Experience In-Depth: Using Data to Identify and Reach the Most Vulnerable People (p. 19). Resick, P. A. (1993). The Psychological Impact of Rape. Journal of Interpersonal Violence, 8(2), 223–255. Resick PA, Galovski TE, O’Brien Uhlmansiek M, Scher CD, Clum GA, Young-Xu Y. (2008) A randomized clinical trial to dismantle components of cognitive processing therapy for posttraumatic stress disorder in female victims of interpersonal violence. J Consult Clin Psychol;76(2):243–58. Resick, P. A., Nishith, P., Weaver, T. L., Astin, M. C., & Feuer, C. A. (2002). A comparison of cognitive-pro- cessing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. Journal of Consulting and Clinical Psychology, 70(4), 867–879. Resick, P. A., & Schnicke, M. K. (1992). Cognitive processing therapy for sexual assault victims. Journal of Consulting and Clinical Psychology, 60, 748–756. Resick, P. A., Williams, L. F., Suvak, M. K., Monson, C. M., & Gradus, J. L. (2012). Long-term outcomes of cognitive-behavioral treatments for posttraumatic stress disorder among female rape survivors. Journal of consulting and clinical psychology, 80(2), 201–210. Roberts, B., Ocaka, K. F., Browne, J., Oyok, T., & Sondorp, E. (2008). Factors associated with post-traumatic stress disorder and depression amongst internally displaced persons in northern Uganda. BMC psychiatry, 8, 38. Ruggiero KJ, Del Ben K, Scotti JR, Rabalais AE. (2003) Psychometric properties of the PTSD Checklist- Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 47 Civilian Version. J Trauma Stress;16(5):495–502. Sandanger, I., Moum, T., Ingebrigtsen, G., Dalgard, O. S., Sørensen, T., & Bruusgaard, D. (1998). Concor- dance between symptom screening and diagnostic procedure: the Hopkins Symptom Checklist-25 and the Composite International Diagnostic Interview I. Social Psychiatry and Psychiatric Epidemiology, 33(7), 345– 354. Sandanger, I., Moum, T., Ingebrigtsen, G., Sørensen, T., Dalgard, O. S., & Bruusgaard, D. (1999). The mean- ing and significance of caseness: the Hopkins Symptom Checklist-25 and the Composite International Diag- nostic Interview. II. Social Psychiatry and Psychiatric Epidemiology, 34(1), 53–59. Scott, J., Polak, S., Kisielewski, M., McGraw-Gross, M., Johnson, K., Hendrickson, M., & Lawry, L. (2012). A mixed-methods assessment of sexual and gender-based violence in eastern Democratic Republic of Congo to inform national and international strategy implementation. The International Journal of Health Planning and Management, n/a–n/a. Sholomskas, D. E., Syracuse-Siewert, G., Rounsaville, B. J., Ball, S. A., Nuro, K. F., & Carroll, K. M. (2005). We don’t train in vain: a dissemination trial of three strategies of training clinicians in cognitive-behavioral therapy. Journal of consulting and clinical psychology, 73(1), 106–115. Stewart, R. E., & Chambless, D. L. (2009). Cognitive-behavioral therapy for adult anxiety disorders in clinical practice: a meta-analysis of effectiveness studies. Journal of consulting and clinical psychology, 77(4), 595–606. Tjaden, P., & Thoennes, M. (2006). Extent, Nature, and Consequences of Rape Victimization: Findings From the National Violence Aginst Women Survey. Special Report. Washington, DC: National Institute of Justice and the Centers for Disease Control and Prevention. Tol WA, Stavrou V, Greene MC, et al. (in Press) Mental health and psychosocial support interventions for survivors of sexual and gender-based violence during armed conflict: a systematic review. World Psychiatry Tsutsumi A, Izutsu T, Poudyal AK, Kato S, Marui E. (2008) Mental health of female survivors of human traf- ficking in Nepal. Soc Sci Med;66(8):1841–7. Ventevogel P, De Vries G, Scholte WF, et al. (2007) Properties of the Hopkins Symptom Checklist-25 (HSCL-25) and the Self-Reporting Questionnaire (SRQ-20) as screening instruments used in primary care in Afghanistan. Soc Psychiatry Psychiatr Epidemiol;42(4):328–35. Vickerman, K. A., & Margolin, G. (2009). Rape treatment outcome research: empirical findings and state of the literature. Clinical Psychology Review, 29(5), 431–448. Weathers FW, Litz BT, Huska JA, Keane TM. (1994) PTSD Checklist—Civilian version. Boston: National Center for PTSD, Behavioral Science Division Winokur A, Winokur DF, Rickels K, Cox DS. (1984) Symptoms of emotional distress in a family planning service: stability over a four-week period. Br J Psychiatry;144:395–9. 48 APPENDICES Appendix A: Design Framework Appendix B: Questionnaire Appendix C: Adaptation of CPT Appendix D: Intervention Monitoring Forms Appendix E: High Risk Protocol Appendix A Design Framework Impact Evaluation Framework An evaluation of the impact of community-based initiatives to promote improved functioning among survivors of sexual violence in South Kivu, Eastern DRC: assessing mental health and social-economic programming Jeannie Annan, Ph.D. Director, Research & Evaluation, IRC Judy Bass, Ph.D. Assistant Professor, Johns Hopkins University Dalita Cetinoglu, M.A. Director, GBV Programs IRC-DR Congo Gabrielle Cole, B.A.H. VSLA Manager, IRC-DR Congo Karin Wachter, M.Ed. Senior Technical Advisor, IRC Revised – Oct 2011 50 Appendix A: Design Framework Introduction S exual violence has grave physical and psychological consequences, including injuries, poor reproduc- tive health, mental health and psychosocial problems, and associated dysfunction. In communities af- fected by armed conflict, women may be exposed to both violent conflict and violence in the home and the neighborhood, and consequences can be compounded when sexual violence by armed groups results in rejection from families and communities. Much remains unknown about how to prevent violence against women and how to treat its various mental health and psychosocial effects. This applies to all forms of violence, including sexual violence resulting from armed conflict, by other community members and intimate partner violence in places where gender inequity is pervasive and where social norms and barriers to justice sustain violence against women. In areas where survivors of sexual violence are also faced with extreme poverty and bear the burden of social stigma, there is currently little information on effective interventions for alleviating psychological symptoms, increasing social capital and improving economic status. The International Rescue Committee (IRC) implements programming to respond to violence in the Demo- cratic Republic of Congo (DRC) and is committed to growing the evidence-base about what programs are the most effective, why they work, and for whom. Eastern Congo is still embroiled in conflict with armed groups committing high rates of sexual violence and survivors often facing significant stigma within their own families and the wider community. IRC also observes increases in reported incidents of violence perpetrated by civilians and that minors constitute a substantial percentage of the survivors seeking services. The overall objective of the evaluation is to identify effective and scalable interventions for the response to sexual violence in areas affected by armed conflict by evaluating innovative approaches to socio-economic programs. The project in DRC will evaluate the impact of both a savings and loans association and a mental health intervention on improving the mental, social, physical and economic functioning of survivors of sexual violence. This evaluation offers a significant contribution to the field of gender-based violence programming. Background and significance of the evaluation The Democratic Republic of the Congo (DRC) has become synonymous with sexual violence by armed groups within the last 2 decades. Reportedly, tens of thousands of women and girls have been raped, sexually assaulted, attacked and abducted in Eastern Provinces including North and South Kivu, targeted by armed groups with unparalleled levels of brutality. Renewed hostilities between armed groups led to a spike in vio- lence in late 2008 with fighting taking place in both North and South Kivu. The breakdown of the security system in the region, combined with societal attitudes toward women and the absence of a functioning ju- dicial system, have created conditions in which violence against women and girls persists with alarming fre- quency after periods of active fighting have ended. Access to services in North and South Kivu—both emergency and longer term care—remains a major chal- lenge. Limited services as well as the potential stigma of seeking services mean that many survivors have never received adequate care. Results of a preliminary study by the IRC and Johns Hopkins University found many survivors have substantially reduced ability to function, including reduced ability to perform basic tasks and activities related to earning, self care, caring for family, and contributing to their communities. These survivors also describe high rates of mental health and social problems including mood disorders, anxiety, Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 51 withdrawal, and stigmatization and rejection by family and community. The rates of mental problems and dysfunction are significantly higher than those found in other violence-affected populations in other parts of Africa and elsewhere. With IRC’s training and support, case managers from local NGOs have been providing psychosocial ser- vices to these survivors and preliminary study results show that psychosocial care is associated with increased functioning and decreased mental health symptoms. However, case managers report the need for more skills to address the large number of clients and their multiple needs. In other areas, community-based programs have been providing social support and advocating for women at village level; however, they have no viable options for referring clients who have more severe symptoms and need to higher level care. Across commu- nities and services, IRC has also seen the great need for increased access to economic resources for women who have been sexually assaulted because of their reduced function and frequent alienation from family and community. While social and economic development in conflict affected areas like DRC relies on populations who are ready and able to work, the psychological effects of conflict may mean that a percentage of the population living in these low-resource areas are less able to engage in economic opportunities even when they are avail- able. However, there is little data on the best strategy to deal with this. One approach is to treat mental health problems in order to reduce symptoms and improve functioning with the hope that people will then seek out and take advantage of opportunities. Another option is to provide new ways to encourage participation in economic activities as a way of addressing both mental health issues and dysfunction and thereby con- solidating continued participation. A third option is to combine the two approaches: first providing a mental health intervention and then providing new economic opportunities. Currently, it is not known which of these approaches is the most effective, since little is known about how improvements in mental health impact economic development, and conversely, how economic programs impact mental health. IRC GBV Programming IRC is introducing two new and innovative programs for survivors of sexual violence in South Kivu who have high symptoms of distress and who are having difficulty with daily functioning: 1. Economic Program: The Village Savings and Loan Associations (VSLA) model was developed to provide a system of community savings for people who cannot access banks or microfinance institu- tions. Self-selected groups of 15-25 members form independent associations where each member saves and contributes to a common pool of money. Members can apply for loans from the pool and pay back with interest. At the end of a cycle (usually about 1 year), group members cash out and re- ceive their savings plus interest earned. IRC has implemented VSLAs in several programs and have found the results promising. A model based on trust among the members, IRC sees VSLAs as an important tool with which to promote solidarity and social cohesion amongst women and contrib- ute to the social reintegration of survivors This evaluation will investigate its potential for providing socio-economic support and improving the mental health and functioning of survivors of sexual violence, which has not been done previously. 2. Mental Health Program: Group Cognitive Processing Therapy (CPT), a structured group therapy that research has shown to be effective used to assist trauma survivors and can improve a variety of symptoms related to depression, anxiety and posttraumatic stress disorder, will be adapted to fit the cultural context. Local Psychosocial Assistants (PSAs) will be trained by expert US-based CPT trainers and will provide the therapy to groups of 6-8 women. The PSAs will be provided with direct supervision and assistance with problem solving as issues arise, with remote supervision and quality assurance provided by the US-based CPT trainers. This evaluation will investigate the fea- 52 Appendix A: Design Framework sibility and impact of implementing CPT by local counselors for improving the mental health and functionality of survivors of sexual violence. Impact Evaluation The central evaluation questions include: 1. What is the impact of a mental health intervention on social, psychological, physical and eco- nomic functioning? 2. What is the impact of a socio-economic intervention on social, psychological, physical and eco- nomic functioning? 3. What is the combined impact of a mental health intervention followed by a socio-economic program on social, psychological, physical and economic functioning? Based on these questions, the evaluation has the following objective and aims: Study Objective: To identify cost effective and scalable interventions that demonstrate improvements in the psychological, social, physical and economic functioning of survivors of sexual violence living in Eastern DRC. Specific Aims: 1. What is the impact of IRC’s mental health intervention (Cognitive Processing Therapy- CPT) on social, psychological, and economic functioning? 2. What is the impact of IRC’s socio-economic intervention (Voluntary Savings and Loans As- sociations – VSLA) on social, psychological, and economic functioning? Exploratory Aims: What is the sequential impact of IRC’s mental health intervention followed by a socio-econom- ic program on social, psychological, and economic functioning? Does improving mental health prior to implementing an economic program improve the uptake and utilization of the economic program? Evaluation hypotheses The proposed research project is based on the hypothesis that participation by survivors of sexual violence with high levels of psychological symptoms and functional impairment in VSLA groups or in CPT groups will lead to an increase in psychological, social, physical and economic functioning compared to similar wom- en (controls) who did not participate in these interventions. The specific hypotheses of the evaluation are: VSLA Study 1. Women participating in the VSLAs will have increased household assets and consumption com- pared to control. 2. Women participating in the VSLAs will report improved social support compared to control. 3. Women participating in VSLAs who report improved social support and increased assets will report Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 53 decreased psychological symptoms compared to control. Mental Health Study 4. Women participating in the CPT intervention will report improved social support compared to control. 5. Women participating in the CPT intervention will report decreased psychological symptoms com- pared to control. 6. Women participating in the VSLA program after first having participated in the CPT intervention will have increased household assets and consumption compared to women who only participated in CPT or in the control condition. Both Studies 7. Women participating in the mental health intervention and/or the VSLA program will have an in- crease in their functionality, as assessed through measures of daily functioning, compared to control women. Program and Evaluation Strategy The study will be two parallel randomized impact evaluations to investigate the impacts of the different inter- vention strategies. The first study will focus on the impact of the VSLA compared to a wait-control sample. The VSLA impact evaluation study will be conducted in communities served by 9 IRC’s CBO partners. The second study will focus on the impact of the mental health intervention followed by the VSLA program compared to a wait-control sample. This study will be conducted in communities served by 3 of IRC’s NGO partners currently providing psychosocial support. The design of this second study will allow us to look at the independent impact of the CPT intervention and to explore the effect of receiving the CPT intervention on the rates of retention in VSLA and the impact of the VSLA program. Phase 1: Formative Research During the first phase, qualitative research will be conducted among 3 major language groups (Swahili, Mashi, Kifuliro) in South Kivu, to learn how the psychological and social problems resulting from sexual violence vary in their presentation and impacts. This information will be used to refine existing measures from a previ- ous study and design a suitable instrument for use across these populations to assess these problems and their effects on functioning. Once developed, this assessment tool will be validated in 2 communities among 2 dif- ferent language groups and cut-off scores determined for identifying women with high rates of mental health problems and functional impairment. This cut-off score will be used to determine eligibility for both studies, along with the more general criteria of being exposed to sexual violence and being over age 18. Exclusion criteria will include very low functioning (cut off determined during phase 1), high suicidality, and substance dependence. Participation in all phases of the studies will be completely voluntary. Phase 2: Training, Recruitment and Program Implementation VSLA Study In 9 areas with community based organizations, trained interviewers will work with CBOs to identify com- munities most affected by GBV and violence.  Within these communities, the CBO management committee 54 Appendix A: Design Framework and members of other local NGOs who work with survivors of GBV will assist IRC in identifying women to be screened for eligibility into the study.  These women will also be asked to identify other women who have similar problems, using a snowball sampling method to identify eligible women. The women who meet criteria in the screening will be invited to an introductory meeting in which the VSLA methodology will be described and they will be encouraged to return to a second meeting along with 2-3 friends they would be interested in joining a group with. At the end of the meeting, participants would be asked to go out and form into groups of 15-25 women interested in being a part of VSLA. A third meeting would be held with all the potential groups, and at this time groups would submit their membership lists as an application. IRC staff will review all of the applications and select those groups that contain approximately 6-8 women who meet the study eligibility.  These applications will then be randomized into treatment and wait-list control conditions.  The aim in each community is to have eight VSLA groups—4 treatment groups and 4 waitlist control. All of the groups will be formed at the same time, but the control groups will not re- ceive VSLA training until year 2, when the intervention group has completed the program. As per standard practice, the selected groups will meet on a weekly basis during the first several months to learn about the process through 7 IRC led modules, make decisions as to how they want to implement the savings program, and select a management committee to assist with the running of the program and start the savings activities.  The next period (approximately months 3-12) will cover the actual running of the savings and loans program, when members save money on a weekly basis and apply for loans.  The first round of the program is complete when the share-out is provided, typically starting in months 9-11.  The waitlist control applications will then be invited to participate in the VSLA program, with the training being provided by women from the initial VSLA groups. Mental Health followed by VSLA Study Training for the adapted mental health intervention will be done at the beginning of Phase 2. There are 16 psychosocial assistants (PSAs) working with the 3 collaborating NGOs. Each PSA provides services at a designed office that serves several villages. The 16 PSAs will be randomized to either receive training in the CPT intervention or to continue providing treatment as usual. At the end of the study, if CPT is found to be effective, the control PSAs will receive training in order to be able to provide it to the control participants. Recruitment for participation in the study will be the same whether the PSA is an intervention or control service provider. A variety of methods will be used to identify eligible participants including: • PSAs will review their old beneficiary files and identify women who did not significantly improve from their usual services and who may still be in need of additional services and these women will be invited to be screened for the study; • PSAs will invite current beneficiaries to be a part of this new activity and these women will be invited to be screened for the study; • The community educators (CEs) that are paired with each PSA will adopt a community education messaging for a period of time, focusing it more on symptoms that survivors might be experiencing that are indicative of higher distress. The messaging will include an invitation to be screened for pos- sible eligibility into the program. Care will be taken to not mobilize more women than the PSAs can accommodate to mitigate any negative effects on the NGOs reputation. In the 8 locations designated to receive the adapted mental health intervention, the PSAs will put eligible women into 3 groups of up to 8 women. The women will be grouped by where they live to minimize the distance they have to travel for the weekly sessions. The treatment will include two introductory individual Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 55 meetings followed by 12 regular weekly meetings. The total treatment will last approximately 4 months, followed by a maintenance period during which PSA will meet with study participants as requested by the participant. During this time period, the PSAs in the CPT and control communities will monitor any ser- vices used by the study participants. This maintenance period will allow us to evaluate whether there is any post-intervention sustenance of any initial reduction in symptoms and improvement in functioning. After the maintenance period is complete, the CPT participants will be invited to participate in a VSLA pro- gram. Similar to the VSLA study described above, the women will be invited to an introductory meeting in which the VSLA methodology will be described and they will be encouraged to return to a second meeting along with other community members who they would like to join their VSLA group. At the end of the sec- ond meeting, the women will be asked to submit their membership lists, each including 15-25 women, as an application. IRC staff will review all of the applications and select those groups that contain approximately 6-8 women of the treatment participants. As per standard practice, the selected groups will meet on a weekly basis during the first several months to learn about the process through 7 IRC led modules, make decisions as to how they want to implement the savings program, and select a management committee to assist with the running of the program. The next period (approximately months 3-12) will cover the actual running of the savings and loans program, when people give money on a weekly basis and apply for loans. The program is complete when the pay-out is provided, typically starting in months 9-11. The PSAs who did not originally receive the adapted mental health training and who provided services to the waitlist control condition will be provided with the training once the maintenance data has been reviewed. After receiving the training, any control study women who still want services will be invited to participate in the group therapy. Data Collection There are 4 designated data collection points: 1. Baseline Quantitative Assessment – prior to initiation of any of the intervention strategies. If we assume that approximately 75% of the women assessed will meet eligibility criteria and will agree to participate in the study, we will assess approximately 500 women within the 16 PSAs areas and 480 women in the 9 VSLA locations. This will allow us to meet our goal of 360 study women in the VSLA program (40 women per location; 180 intervention; 180 control) and 380 study women in the mental health program (24 women per PSA; 180 intervention; 180 control). 2. Qualitative Post-program – after approximately 10-11 months, following the pay-out period for the VSLA program and the end of the treatment period for the mental health treatment, a brief qualita- tive assessment will be done to identify any unexpected outcomes. The study questionnaire will then be amended to include questions related to these unexpected outcomes. 3. First Mental Health Quantitative Follow up – approximately 1 month following completion of the CPT intervention, all intervention and control participants will be assessed with the amended as- sessment tool, to allow for investigation of immediate intervention effects. 4. First VSLA Quantitative Follow up – approximately 2-4 weeks after the pay-out period is complete, all women who were eligible and originally agreed to participate in the VSLA programming will be assessed with the amended assessment tool. 5. Second Mental Health Quantitative Follow up – after the 6-7 month maintenance period is com- plete, and before the VSLA program is initiated in the CPT communities, all intervention and con- trol participants will again be assessed with the amended assessment tool to allow for investigation 56 Appendix A: Design Framework of longer term treatment effects. 6. Second VSLA Quantitative Follow up – approximately 8-10 months after the first round of VSLA groups are completed, a final assessment will be conducted of all study participants to investigate longer term maintenance of the VSLA program. 7. Third Mental Health Quantitative Follow up - approximately 2-4 weeks after the pay-out period is complete for the VSLA program in the CPT communities, all women who were eligible and origi- nally agreed to participate in the VSLA programming will be assessed with the amended assessment tool. This will allow us to explore the impact of the combined CPT and VSLA program. Outcomes and measures The primary outcomes of interest include the psychological, social, physical and economic functioning of the women involved in the programs. To assess these domains, the study will use the assessment tool developed in phase 1 to assess mental health and functioning. The function assessment will cover both social and eco- nomic functioning, including indicators of social capital, social cohesion, and income/consumption. The measures will be developed to capture outcomes at the level of the individual, family and community. Assess- ments will be conducted at baseline and at regular intervals described above. Primary Outcomes • Psychological Well-Being • Physical and Social Functioning • Economic functioning Secondary Outcomes • Family Functioning • Cost effectiveness Monitoring Over the course of the implementation of both the VSLA and mental health program, IRC will systematically monitor the outputs and outcomes of each program. We will monitor progress of the project on two levels: individual-level and group-level. 1. VSLA Program: IRC staff will make regular monitoring visits to each VSLA group. During these visit they will collect the following quantitative data for monitoring purposes: attendance rate, drop- out rate, accumulated value of savings, number and value of current loans, and the value of cash not in circulation. This data will be inputted and analyzed in the standard VSLA Monitoring Infor- mation System. The frequency of monitoring visits will be determined by the phase of the VSLA. During the intensive phase, groups will be monitored on a weekly basis at every meeting. After a period of approximately 4 months, each group will be evaluated and, if successful, will progress to the development phase where monitoring visits will be reduced to every 2-3 weeks. Four months after this, another evaluation will take place and the group will progress to the maturity phase. Dur- ing this 4-month phase, groups may only be monitored 3-4 times before the end of the cycle. 2. Mental Health Program: The CPT therapy groups will meet weekly. Following each session, the PSAs will fill out a monitoring form for each group participant as well a form summarizing what Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 57 was covered during the group session and any challenges that may have arisen. These forms will be reviewed weekly with an IRC supervisor who will in turn review each group, and each client, with a Mental Health technical advisor and US-based trainers. The control PSAs will maintain monitoring forms for all control participants indicating if/when a participant came to see them and what services were provided. IRC supervisors will contact control PSAs monthly to review monitoring procedures and ensure forms are being filled out. During the maintenance period, when the CPT program is complete, the CPT PSAs will fill out the standard monitoring form (same one used by control PSAs) any time a study participant visits them for additional services. The control PSAs will continue to fill out the monitoring forms on control study participants during this period as well. Evaluation Outputs The formative research and program evaluation will be carried out over the three years of the project. Below are the projected dates for key outputs which will be developed and led by the JHU team, with collaboration from IRC. Outputs Timeline Qualitative study and situation analysis report – complete draft August 31, 2010 Instrument development and validation – complete draft November 31, 2010 Baseline Quantitative data analysis – complete draft December 15, 2011 Qualitative Post-program analysis for Mental Health and VSLA programs May 31, 2012 – complete draft First Mental Health and VSLA quantitative assessment and monitoring April 30, 2012 – complete draft Second Mental Health and VSLA quantitative assessment and April 30, 2013 monitoring – complete draft Preliminary impact evaluation report – based on completion of first April 15, 2012 round Final Quantitative and impact evaluation report submitted to World June 30, 2013 Bank Output Descriptions The JHU team will have primary responsibility for generating each of these reports, with collaboration from IRC. Qualitative study report: The data from the qualitative studies and the additional situation analysis infor- mation will be summarized to provide a picture of the relevant psychosocial problems and functional impair- ments currently experienced by the target population, GBV survivors. The report will also highlight any differences identified across the three language groups in which the qualitative studies were done. Instrument development and validation report: This report will provide information on the selection, adaptation and validation of the mental health and psychosocial assessments and will present the complete instrument to be used for all subsequent quantitative data collections. Baseline Quantitative data report: The baseline report will provide background characteristics of the wom- en in the evaluation; detailed information about the pre-intervention status of the main outcomes that the 58 Appendix A: Design Framework programs aim to improve and an analysis of whether or not there are systematic differences between treat- ment and control individuals. Qualitative Post-program report: This report will provide data on any unexpected outcomes associated with participating in the programs and information about how these outcomes will be incorporated into the subsequent quantitative assessments. First Mental Health and VSLA Quantitative report: This report will provide preliminary analyses of the data from each intervention program (VSLA and Mental Health) comparing participants to waitlist controls on the primary outcomes of interest. Second Mental Health and VSLA Quantitative report: This report will provide preliminary analyses of the maintenance data from each intervention program (VSLA and Mental Health) comparing participants to waitlist controls on the primary outcomes of interest. Preliminary impact evaluation report: This report will follow up the previous report by providing a more in depth investigation and complete analysis as to the impact of each intervention program on the primary and secondary outcomes. Final Quantitative and impact evaluation report: The final report will provide a final analysis of the pro- gram impact, including data from the combined mental health and VSLA programs and longer-term follow up of the VSLA only participants. The report will answer the main questions and hypotheses described in this document. Communication plan Involvement of stakeholders at beginning of evaluation (see Annex for communication documents). IRC will communicate the evaluation plan to the following stakeholders at multiple levels: • Community: CBOs, NGO partners, GBV staff, INGOs for GBV, Provincial Commissioner, univer- sities (IRB), local authorities, territorial-level authorities, psychiatric hospital, media • National: social protection meeting subgroup, university (IRB), Ministry of Gender, and donors community in DRC Ministry of Health, media • International: current and potential donors, InterAction, GBV Area Of Responsibility, Harvard Hu- manitarian Initiative, Columbia University, Women’s Refugee Commission, media, academic and practitioners forums Dissemination of findings Community-level: At the end of the evaluation, IRC will hold meetings with IRC GBV staff, partner NGOs and CBOs to discuss preliminary findings and to engage them in discussions about the findings. These discus- sions will inform the final report. Final reports will also be provided to local government officials and other community stakeholders. National level: The results of the final evaluations will be disseminated to key stakeholders in the govern- ment, private sector and non-governmental agencies. IRC will hold presentations in Bukavu and Kinshasa and disseminate copies of the reports. International level: JHU researchers and IRC will present findings in New York and Washington, D.C. to do- nors, NGOs, UN agencies, and other international agencies working in microfinance and GBV programming. The reports will also be widely disseminated. The evaluation will be published in both policy and academic Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 59 journals for wide dissemination among both communities. Ethical and Safety Considerations Standard ethical procedures for data collection and research will be used to ensure that participation in the study will minimize any potential distress or harm. The evaluation protocol and questionnaires will be re- viewed by an external board at Johns Hopkins University and a Congolese review board at the Kinshasa School of Public Health. 60 Appendix A: Design Framework Annex 1 Communication Points for the Impact Evaluation of a Socio-Economic Program and a Mental Health Program for Survivors of Sexual Violence • IRC is committed to providing good programming. We do this, in part, by designing programs based on existing research and by conducting rigorous evaluations to figure out what is effective program- ming. • We are introducing two new and innovative programs for survivors in South Kivu who suffer from the psychological and social consequences of sexual violence (i.e. who have high symptoms of distress and who are having difficulty with daily functioning): 1. Economic Program: The Village Savings and Loan Associations (VSLA) model was developed to provide a system of community savings for people who cannot access banks or microfinance institu- tions. Self-selected groups of 15-25 members form independent associations where each member saves and contributes to a common pool of money. Members can apply for loans from the pool and pay back with interest. At the end of a cycle (usually about 1 year), group members cash out and receive their savings plus interest earned. IRC has implemented VSLAs in several programs and have found the results promising. A model based on trust among the members, IRC sees VSLAs as an important tool with which to promote solidarity and social cohesion amongst women and contribute to the social reintegration of survivors. This evaluation will investigate its potential for providing socio-economic support and improving the mental health and functioning of survivors of sexual violence, which has not been done previously. 2. Mental Health Program: Cognitive Processing Therapy (CPT) is a structured group therapy that research has shown to be effective on the major problems and symptoms that were identified through both program experience and qualitative research. The CPT group therapy will be adapted to fit the cultural context. • These programs will be implemented together with the national NGOs and CBOs that we work closely with in South Kivu • For the evaluation of both programs, we are partnering with Professor Judy Bass and Dr. Paul Bolton from Johns Hopkins University Mental Health Department • Through this evaluation, we will learn about the impact of both the group mental health intervention and socio-economic program on the social, psychological and economic functioning of survivors. Understanding the impact will help us to identify effective interventions. • Funding for the evaluation is provided by the World Bank and the USAID Victims of Torture Fund and IRC contributes through funding the program components. Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 61 Appendix B Questionnaire Numero d’Enqeuteur ________ Code du participant: ____ _____ _________ Date du Jour DD/MM/YY: Langue : _________________ Uko na miaka ngapi? Quel est votre âge -What is your age: _______ Miaka Années/years Iyi Fasi unaishi sasa njo territoire kwenye ulizaliwaka ? Est-ce que l’endroit que vous habitez actuellement votre territoire d’origine? - Is where you are living now your territory of origin? ___Ndiyo Oui ___Apana Non Uko wa kabila gani? Quel est votre group ethnique - What is your ethnicity _____________ Kabila, Group ethnique - ethnicity Ulishaka olewa? Quel est votre statut _____Haya olewa Single, Célibataire matrimonial What is your Marital status _____Ameolewa Marrié Married _____Wame acana Divorcé Divorced _____ Wame tenganaSeparée Separated _____ MujaneVeuve Widowed Kama ulishaka olewa, izi siku unaishi na bwana ko?Si Marrié, est ce que vous habitez actuellement avec votre mari? If married, currently living with husband ___Ndiyo Oui ___ Apana Non Ulimalizaka miaka ngapi ku masomo ? Combien d’années d’études avez- ____ Miaka Nombre d’annees number of years vous terminé How many years of education did you complete Zaidi ya shule la msingi? Plus que le primaire? More than primary education? ___Ndiyo Oui ___ Apana Non 62 Appendix B: Questionnaire Kwa sasa,ni batu ngapi njo ___ Idadi ya watu nombre de personnes banaishi mu mwako (mu nyumba yako)? Combien de personnes vivent actuellement dans votre propre maison , c’est à dire sous votre proper toit- How many people are currently living in ___ (plus de 18 ans) Wanaume Hommes your own house, by house we mean under your own roof ___ (plus de 18 ans) Wana wake Femmes ___ (annees 12-17) Vijana Adolescents Andika idadi kwa kila aina ya watu ___ (annees 4-11) Watoto Enfants Ecrire le nombre pour chaque type de personnes Write in the number of each type of person ___ (annees 0-3) Watoto wacangaNourrissons / bébés Una pashwa lea watoto ngapi ? Vous avez la responsabilité de vous occuper ____ # (miaka /annees 0-17) de combien d’enfants? How many children you responsible for care of? Uko muja muzito hizi siku ? Etes vous enceinte actuellement  - Are you currently ____ Ndiyo Oui ___ Apana Non pregnant Ni tangu wakati gani unaishi ___ 0 - 5 Mwezi mois hapa ? ___ 6 - 11 Mwezi mois ___ 1 - 4 Mwaka années Depuis combien de temps vous habitez ici  ___ 5 – 9 Mwaka années ___ 10 + Mwaka années How long have you lived here _____ Vita/Uasi Guerre/ Rebelles - Rebels/war _____ Ndoa Marriage - Marriage _____ Afia/kuwa karibu ya kituo ca afiaSanté Kama ni cini ya miaka tano, _____ Mavuno mabaya Mauvaise récolte ulihamaka sababu gani ? (caguwa _____ mengine Autre - Other moja). Si c’est moins de 5 années, pourquoi vous avez déménagé (choisissez un) If less than 5 years, why did you move (choose one): Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 63 SECTION A- Evaluation des Fonctions Assessment of Function Nita soma makazi fulani fulani. Ni kazi ambazo wengine wana wake ambao wanaishi huku walituambiya ni za muhimu kufanya. Kwa kila kazi,nita nitakuomba uniamabiye kiasi ya magumu unapataka kwa kuifanya. Utaniambiya kama haupatake hata shida moja,ao shida kidogo,ao kiasi ya shida kwa kadiri,ao shida nyingi,ao mara na mara shida ni nyingi hata hauwezi kufanya ile kazi. Je vais lire une liste de tâches et d’activités. Ce sont des tâches et des activités que d’autres femmes autour d’ici nous ont dit qu’il était important pour elles de pouvoir accomplir. Pour chaque tâche ou activité, je vais vous demander comKbien de difficultés en plus vous rencontrez. Vous devriez me dire si vous avez aucune difficulté, un peu de difficulté, un nombre modéré de difficulté, beaucoup de difficulté, ou vous ne pouvez souvent pas faire cette tâche. Kusudi uelewe vema zaidi,niko na picha,na kila picha inaonesha kiasi fulani ya shida. Pour rendre cela beaucoup facile à comprendre, j’ai une carte ici avec des images. Chaque image représente un bon nombre de difficulté. Montrer au participant la carte illustrant les niveaux de difficultés. Pointez sur chaque image en même temps que vous la décrivez. Picha ya kwanza,inaonesha mutu ambaye hana shida yoyote. Picha ya pili inaonesha mutu ambaye ana shida kidogo. Picha ya tatu inaonesha mutu ambaye ana kiasi ya shida kwa kadiri. Picha ya ine inaonesha mutu mwenye kuwa na shida nyingi na picha ya mwisho inaonesha mutu mwenye kuwa na shida mingi na hata hawezi kufanya hiyo kazi. Kwa kila kazi ama shurti,nitakuomba ushote kidole kwa kuonesha picha ambayo ina ambatana na shida unayo kwa kufanya ile kazi ama shurti. La première image montre quelqu’un qui n’a aucune difficulté. La deuxième image montre quelqu’un qui a un peu de difficulté. La troisième image montre quelqu’un qui a un nombre modéré de difficulté. La quatrième image montre quelqu’un qui a beaucoup de difficulté et la dernière montre quelqu’un qui a tellement de difficultés qu’il ne peut même pas faire la tâche. Pour chaque tâche ou responsabilité, je vais vous demander de pointer sur l’image qui montre combien de difficultés vous avez en faisant cette tâche ou activité. Tuseme sasa kama pamoja na nyuma ya kila kazi ama shurti: Munamo juma mbili zilizo pita ,haukupata hata shida yoyote,shida kidogo, shida kwa kiasi ya kadiri ,shida nyingi,ao ulipata shida nyingi hata huwezi kufanya hiyo kazi. Wakati una shota kidole kwa kila picha na kusema hii maneno,uandike jibu kwa nafasi ambayo ina ambatana na kila kazi ama shurti. Disons maintenant qu’avec chaque tâche, et après chacune d’elle dire: Au courant des deux semaines passées, est ce que vous avez eu aucune difficulté, un peu de difficulté, un nombre modéré de difficulté, beaucoup de difficulté, ou avez-vous autant de difficulté que vous ne pouvez souvent pas faire la tache ?, En pointant sur chaque image en le disant. Enregistrez la réponse en entourant le numéro dans la boite appropriée à côté de l’activité ou de la tâche dans le tableau ci-dessous. 64 Appendix B: Questionnaire DRC GBV Psychosocial Evaluation Questionnaire February 9, 2012 Pour chaque tâche dites: Swahili-French-English Mu juma mbili zilizo pita ni shida za kiasi gani uli pata kwa kufanya hii kazi____:   Pour chaque tâche dites: Mu juma mbili zilizo pita ni shida za kiasi gani uli pata kwa kufanya hii kazi____: Dans les 4 dernières semaines, combien de difficulté avez-vous eu pour faire In the last 4 weeks, how much difficulty have you had doing Dans les 4 dernières semaines, combien de difficulté avez-vous eu pour faire In the last 4 weeks, how much difficulty have you had doing Kiasi ya shida kwa kufanya hiyo kazi Quantité de difficulté en faisant la tâche/l’activité Amount of difficulty doing the task/activity Kazi Hakuna Kidogo Kiasi ya Mingi Mara na mara Non applicable not applicable tâches/activités aucune Un peu kadiri Beau hata hawezi tasks/activities None Little coup Quantité a lot kufanya ile kazi modérée Souvent ne peut pas moderate faire amount often cannot do A01. Mulimo cultivation/agriculture - 0 1 2 3 4 9 cultivating/farming A02. Ucuruzi ao ingine njia ya kupata pesa/franka 0 1 2 3 4 9 commerce ou autres moyens de gagner l’argent - trading or other making money A03. Kupiga cakula Cuisine – 0 1 2 3 4 9 Cooking A04. Ku lea watoto 0 1 2 3 4 9 s’occuper des enfants looking after children A05. Ku shauriya wengine wana memba wa jamaa 0 1 2 3 4 9 Donner des conseils aux membres de la famille - giving advice to family members A06. Ku shauriya wengine wana memba wa jamii Donner des conseils aux autres membres 0 1 2 3 4 9 de la communauté giving advice to other community members A07. Kubadirisha mafikiri na watu wengine échanger des 0 1 2 3 4 9 idées avec les autres exchanging ideas A08. Kufuga wa nyama 0 1 2 3 4 9 élever des animaux raising animals A09. Kazi zingine za mikono Tout autre type de travail 0 1 2 3 4 9 manuel any other types of manual labor A10. Kujiunga na wengine wanamemba wa jamii kwa kufanya kazi kwa faida ya jamii S’unifier avec d’autres membres de 0 1 2 3 4 9 la communauté pour accomplir des tâches pour la communauté/uniting with other community members tasks for community A11. Kujiunga na wengine wanamemba wa jamaa kwa kufanya kazi kwa faida ya jamaa ’unifier avec d’autres membres 0 1 2 3 4 9 de la famille pour accomplir des tâches pour la famille - uniting with other family members to do tasks for the family; 3 Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 65 DRC GBV Psychosocial Evaluation Questionnaire February 9, 2012 Swahili-French-English Kazi Hakuna Kidogo Kiasi ya Mingi Mara na mara Non applicable not applicable tâches/activités aucune Un peu kadiri Beau hata hawezi tasks/activities None Little coup Quantité a lot kufanya ile modérée moderate kazi amount Souvent ne peut pas faire often cannot do A12. Kujiunga na wengine ndani ya jamii Socialiser avec les 0 1 2 3 4 9 autres dans la communauté - socializing with others in the community. A13. Kulomba/ku pokea msaada kutoka watu ao shirika wakati wa mahitaji 0 1 2 3 4 9 Demander/Obtenir de l’aide des gens ou des organisations quand vous en avez besoin - asking/getting help from people or organizations when you need it A14. Ku cukuwa uamzi wenye muhimu kuhusu maisha ya kila siku. Prendre 0 1 2 3 4 9 des decisions importantes sur la vie quotidienne Making important decisions about daily life A15. Ku shiriki kwa kazi za jamaa ao matukiyo prendre part 0 1 2 3 4 9 aux activités familiales ou aux événements/ taking part in family activities or events A16. Ku shiriki kwa kazi za jamii ao matukiyo. Prendre part 0 1 2 3 4 9 aux activités de la communauté ou aux événements taking part community events A17. Ku jifunza ufundi ao akili mpya Apprendre des nouvelles 0 1 2 3 4 9 techniques ou du savoir learning new skills A18.kujiusisha sana kwa kazi ao mapashwa yako Se concentrer sur ses tâches 0 1 2 3 4 9 responsabilités - concentrating on your tasks/responsibilities A19. Kujadiliana ao kushirikiyana na watu ambao haufahamuCommuniquer 0 1 2 3 4 9 ou établir une relation avec les gens que vous ne connaissez pas interacting or dealing with people you do not know A20. Kwenda kanisani ao muskitini kama kawaida aller à l’église ou à la mosquée comme 0 1 2 3 4 9 d’habitude - attending church or mosque as usual Fanya esabu ya ma jibu zote zime patikana Kwa ma ulizo A01-A20 (Bila Kufanya hesabu ya 9): Total_______ Sum up all the scores for questions A01-A20 (Ignore the 9’s): TOTAL : _______ 4 66 Appendix B: Questionnaire SECTION B: Instrument de symptômes Symptom Assessment Instrument Nitasoma shida fulani fulani. Nita ku uliza mara ngapi kila shida Ili kusumbuwa munamo juma ine zilizo pita hadi leo. Nina penda kuelewa kama hiyo shida haiku kusumbuwa hata kidogo, kidogo, kwa kiasi ya kadiri ao sana (Tuna weza uliza ivi: Munamo juma ine zilizo pita hadi leo, ni mara ngapi uli lemewa na shida hiyo? Je vais vous lire une liste de problèmes. Pour chacun, je vais vous demander combien ce problème vous a tracassé ces quatres dernières semaines, y compris aujourd’hui. Je veux savoir si ce problème ne vous a pas dérangé du tout, un peu, d’une quantité modérée, ou beaucoup. (Alternativement, nous pouvons demander : «  Combien chacune des catégories suivantes a été un problème pour vous au courant de ces quatres dernières semaines) Rudilia kila maneno na mwisho ujiulize kama mutu unaye zungumuza naye alijisikiyaka vile vile munamo juma ine zilizo pita. Déclarez chaque rapport, et après chacun, se demander si le participant s’est souvent senti comme ca lors de ces quatres dernières semaines. Répétez les catégories aprés chaque déclaration et laissez le participant en choisir une. Enregistrez la réponse en entourant le numéro dans la boite appropriée à côté du symptôme. Pour chaque symptome dites: Munamo juma ine zilizo pita, ni kwa kiasi gani ulipata shida ya __________ Dans les 4 dernières semaines, à quelle fréquence avez-vous eu le problème de In the last 4 weeks, how often have you experienced the problem of DRC GBV Psychosocial Evaluation Questionnaire February 9, 2012 Swahili-French-English Shida Akuna Kidogo Kiasi ya Mingi Problèmes hata Un peu a little bit kadiri Beaucoup a lot Problems siku Une quantité modérée moja moderate amnt: Pas du tout not at all B01. Kujisikiya hauna nguvu Sentir peu 0 1 2 3 d’énergie, au ralenti Feeling low in energy, slowed down (H) B02. Kuji shitaki sababu ya mambo fulani Se blamer pour des choses Blaming self for things 0 1 2 3 (H,Q) B03. Mwepesi kuliya/Kuliya kwepesi 0 1 2 3 Pleurer facilement Crying easily (H,Q) B04. Kupoteza faida ao furaha katika kitendo ca ndoa Perte d’intérêt ou de plaisir 0 1 2 3 sexuel - Loss of sexual interest or pleasure (H) B05. Kukosa hamu ya kula 0 1 2 3 Manque d’appétit - Poor appetite (H,Q,D) B06. Shida kwa kupata busingisi ao kubaki una lala Difficulté à s’endormir, à rester 0 1 2 3 endormi - Difficulty falling asleep, staying asleep (H,Q,D) B07. Kujisikiya mwenye kukosa matumaini kuhusu maisha ya kesho 0 1 2 3 Se sentir désespéré au sujet du futur - Feeling hopeless about the future (H, Q,D) B08. Kujisikiya mwenye huzuni 0 1 2 3 Se sentir triste Feeling sad (H,Q) B09. Kujisikiya unabaki peke yako. 0 1 2 3 Se sentir seul - Feeling lonely (H,Q) B10. Kufikiriya ku ji uwa 0 1 2 3 Penser à se suicide - Thoughts of ending your life (H,Q,D) Fanya esabu ya ma jibu zote zime patikana Kwa ma ulizo B01-B10 Total_______ Sum up all the scores for questions B01-B10: TOTAL : _______ Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 67 DRC GBV Psychosocial Evaluation Questionnaire February 9, 2012 Swahili-French-English Shida Akuna Kidogo Kiasi ya Mingi Problèmes hata Un peu a little bit kadiri Beaucoup a lot Problems siku Une quantité modérée moja moderate amnt: Pas du tout not at all B11. Kujisikiya ndani ya mtego ao ku naswa. Se sentir piégé ou attrapé - Feeling of being 0 1 2 3 trapped or caught (H) B12. Kujiuzunisha sana sababu ya vitu Trop s’inquiéter sur des choses - Worrying too much 0 1 2 3 about things (H,Q) B13. kusikiya kukosa faida ajili ya vitu/faida kidogo ku elekeya kazi za kila siku Sentir aucun intérêt pour des choses/ moins 0 1 2 3 d’intérêt pour les activités quotidiennes - Feeling no interest in things/less interest in daily activities (H, P, Q, D) B14. Kusikiya sawa ku fanya kila kitu yoyote ni kujikaza Sentir que tout est un effort - 0 1 2 3 Feeling everything is effort (H) B15. Kujisikiya mwenye kukosa mafia/maana Sentiment de dévalorisation/ avoir 0 1 2 3 aucune valeur - Feelings of worthlessness- no value (H,Q) B16. kujisikiya pale pale mwenye oga bila sababu Soudainement effrayé sans aucune 0 1 2 3 raison - Suddenly scared for no reason (H) B17. Kujisikiya mwenye oga 0 1 2 3 Se sentir peureux - Feeling fearful (H,Q,D) B18. Uzaifu, kizungu zungu ao uregevu Faiblesse, vertige ou fragilité - Faintness, 0 1 2 3 dizziness or weakness (H Q) B19. Ukali ao kutetemeka kindanindani Nervosité ou tremblement à l’intérieur 0 1 2 3 - Nervousness or shakiness inside (H) B20. Kuwa na moyo wa kupiga piga 0 1 2 3 Coeur battant ou palpitation Heart pounding or racing (H,Q) B21. Kutetemeka 0 1 2 3 Trembler - Trembling (H) B22. Kujisikiya mwenye kutetemeka 0 1 2 3 Se sentir tendu ou surexcité Feeling tense/ keyed up (H,Q) B23. Maumivu ya kichwa 0 1 2 3 Maux de tête/Headaches (H,Q) B24. Wakati wa woga sana 0 1 2 3 Moments de terreur ou de panique Spells terror/panic (H,Q) B25. kujisikiya mwenye bisirani hata hawezi kubaki fasi moja 0 1 2 3 Se senir nerveuxt, ne peut pas rester sur place - Feeling restless, can’t sit still (H) Fanya esabu ya ma jibu zote zime patikana Kwa ma ulizo B11-B25 Total____ Sum up all the scores for Questions B11-B25: TOTAL: _______ 7 68 Appendix B: Questionnaire DRC GBV Psychosocial Evaluation Questionnaire February 9, 2012 Swahili-French-English Shida Akuna Kidogo Kiasi ya Mingi Problèmes hata Un peu a little bit kadiri Beaucoup a lot Problems siku Une quantité modérée moja moderate amnt: Pas du tout not at all B26. Mawazo iko inakurudilia ao kukumbuka ile wakati ya mambo mazito ao ya oga uliyo pitiya. 0 1 2 3 Pensées récurrentes ou des souvenirs des événements les plus durs ou les plus terrifiants - Recurrent thoughts or memories of the most hurtful or terrifying events (P, D, Q) B27. Kusikiya sawa vile ungali ndani ya ile wakati ya mambo mazito ao ya oga uliyo pitiya Sentir comme si les événements 0 1 2 3 durs ou terrifiants se passent encore - Feeling as though the hurtful or terrifying event is happening again (P) B28. Ndoto mbaya za kurudiliya Cauchemars récurrents (sur un événement) - Recurrent 0 1 2 3 nightmares (about the event) (P) B29. Ku jisikiya mwenye kutengwa ao kubaguliwa na wengine. 0 1 2 3 Se sentir détaché ou exclus des autres - Feeling detached or withdrawn from others (P,Q,D) B30. Kujisikiya hauwezi sikiya uwepo ndani Incapable de sentir des 0 1 2 3 émotions/Unable feel emotions (P) B31. Kujisikiya mukali ,ku camuka ao kuwaka upesi Se sentir nerveux, sursaute 0 1 2 3 facilement - Feeling jumpy, easily startled (P) B32. Magumu kuweka akili fasi moya. 0 1 2 3 Difficulté pour se concentrer - Difficulty concentrating (P) B33. Ku jisikiya sawa mwenye iko ku zamu. Se sentir en garde - Feeling on guard (P) 0 1 2 3 B34. Mwepesi kwa kuwaka ao kucamuka na bisirani sana 0 1 2 3 Se sentir irritable ou avoir des excès de colère - Feeling irritable or having outbursts of anger (P,Q) B35. Kuepuka ma kazi zenye zina weza kumbusha wakati mbaya mtu alipitiyaka Eviter des activités qui rappellent les 0 1 2 3 événements durs ou traumatiques - Avoiding activities that remind of the traumatic or hurtful event (P, Q) B36. Kushindwa ku kumbuka vipindi vya wakati ya magumu sana na ya kuogopesha uliyo pitiya. Incapacité de se 0 1 2 3 souvenir des parties des événements les plus durs ou terrifiants - Inability to remember parts of the most traumatic or hurtful events (P) Fanya esabu ya ma jibu zote zime patikana Kwa ma ulizo B26-B36 Total_______ Sum up all the scores for questions B26-B36: TOTAL: _______ 8 Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 69 DRC GBV Psychosocial Evaluation Questionnaire February 9, 2012 Swahili-French-English Shida Akuna Kidogo Kiasi ya Mingi Problèmes hata Un peu a little bit kadiri Beaucoup a lot Problems siku Une quantité modérée moja moderate amnt: Pas du tout not at all B37. Kusikiya sawa hauna maisha ya mbele/kesho Se sentir comme si vous n’avez pas 0 1 2 3 de futur Feeling as if you don’t have a future (P,Q) B38. kuepuka mawazo yenye kuamabatana na vipindi vigumu ulivyo vi pitiya Eviter des pensées qui sont 0 1 2 3 associées aux événements durs ou traumatiques - Avoiding thoughts of feelings associated with the traumatic or hurtful events (P) B39. Vitendo vya mbiyo biyo/haraka vya kimafikiri ao vya kimwili wakati bana kukumbusha ile vipindi vigumu sana uliyo pitiya.Réaction soudaine, 0 1 2 3 émotionnelle ou physique quand on n’est rappelé des événements les plus durs ou les plus traumatiques - Sudden emotional or physical reaction when reminded of most hurtful/traumatic events (P) B40. Kujisikiya mwenye makosa. 0 1 2 3 Se sentir coupable - Feeling guilty (P,D) B41.kuwa na boga ya kukamatika na magonjwa. Avoir peur d’ être infecté par la maladie - 0 1 2 3 Being afraid to be infected by disease (D,Q) B42. Kujisikiya mwenye kutendewa vibaya na wanamemba wa jamaa. 0 1 2 3 Se sentir maltraité par les membres de la famille Feeling badly treated by family members (D,Q) B43. Kujisikiya mwenye kutendewa vibaya na wanamemba wa jamii. 0 1 2 3 Se sentir maltraité par les membres de la communauté Feeling badly treated by community member (D,Q) B44. Kujisikiya haya. 0 1 2 3 Se sentir honteux - Feeling shame (D,Q) B45. kujisikiya mwenye kutupiliwa na watu wote. Se sentir rejeté par tout le monde - 0 1 2 3 Feeling rejected by everybody (D,Q) B46. Kujisikiya mwenye kushotwa vidole na kubaguliwa. Se sentir stigmatisé - 0 1 2 3 Feeling stigma (D,Q) B47. Kuwaza sana ju ya mambo iliyo kufikiya. Trop penser à ce qui t’est arrivé -Thinking too 0 1 2 3 much about what happened to you (D,Q) Fanya esabu ya ma jibu zote zime patikana Kwa ma ulizo B37-B47 Total_______ Sum up all the scores for questions B37-B47: TOTAL: _______ 9 70 Appendix B: Questionnaire DRC GBV Psychosocial Evaluation Questionnaire February 9, 2012 Swahili-French-English Shida Akuna Kidogo Kiasi ya Mingi Problèmes hata Un peu a little bit kadiri Beaucoup a lot Problems siku Une quantité modérée moja moderate amnt: Pas du tout not at all B48. kuwaza sana ju ya mambo mengine iliyo kubabaisha. 0 1 2 3 Trop penser à d’autres choses qui t’ont bouleversé - Thinking too much about other things that upset you (D,Q) B49. kuwaza kujilumiza. 0 1 2 3 Penser à se blesser - Thinking about hurting yourself (D,Q) B50. kutafuta kuepuka watu wengine ao kujifica. Vouloir éviter les autres gens ou se 0 1 2 3 cacher Wanting to avoid other people or hide (D, Q) B51. Mawazo mengi sana. 0 1 2 3 Trop de pensées - Too many thoughts (Q) B52. Kuwa mwenye baridi 0 1 2 3 Etre froid/timide -To be cold/shy (Q) B53. Kukosa amani 0 1 2 3 Elle manque de paix - She lacks peace (Q) B54. Hasira ndani ya roho 0 1 2 3 Colère au Cœur - Anger in the heart (Q) B55. Vidonda vya ndani 0 1 2 3 Blessures intérieures - Inward wounds (Q) Fanya esabu ya ma jibu zote zime patikana Kwa ma ulizo B48-B55 Total_______ Sum up all the scores for questions B48-B55: TOTAL: _______ TOTAL SCORES: Fanya hesabu ya ma jibu zote za mashida za ki maisha kawaida(Page4)Total_____ Total Score for Function Problems (page 4) : TOTAL : _______ Fanya hesabu ya ma jibu zote simepatikana ku husu vitendo vinavio onekane kuwa shida kwa mtu (hesabu majibu za page 5-9) : Total : __________ Total Score for Symptom Problems (add up scores from bottom of pages 5-9) : TOTAL : _______ 10 Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 71 SECTION C. Se Debrouiller et L’Usage des Services Coping and service usage; Tuna penda sasa kuelewa zaidi kuhusu mambo ambayo wana wake wanafanyaka kwa kujisaidiya ku kuwa vema zaidi. Nitakuuliza maulizo fulani fulani ku husu ma kazi mbali mbali, na tena nita kuuliza kwa kiasi gani unafanyaka zile kazi ajili ya kujisaidiya wakati una jisikiya vibaya.Kwa kila kazi,uta tuambiya kama hauyifanyake hata kidogo ,ao unaifanyaka mara haba,ao una ifanyaka saa zimoja zimoja,ao una ifanyaka mara mingi kwa kujisaidiya kujisikiya vizuri zaidi Maintenant, nous voulons apprendre sur ce que les femmes font pour les aider à se sentir mieux. Je vais vous poser des questions sur les différentes activités, et je vais demander à quelle fréquence vous faites ces activités pour s’en sortir lorsque vous vous sentez mal. Pour chacune des activités, Dites-nous si vous ne le faites pas du tout, avez-vous a le faire rarement, faites-vous quelquefois, ou faites-vous souvent pour vous aider à vous sentir mieux Hata Mara Mara moja Mara kidogo haba moja mingi Pas du tout Rarement Quelque fois Souvent Not at all Rarely Sometimes Often C01. Kuzungumuza ku husu magumu ao shida zangu pamoja na marafiki na wana 0 1 2 3 memba wa jamaa yangu. Discuter mes problèmes avec les amis ou les membres de ma famille - Talk about your problems with friends or family members C02. Kuzungumuza kuhusu magumu yangu pamoja na wengine wa mama walio pitiya shida ya ubakaji 0 1 2 3 Discuter mes problèmes avec d’autres femmes qui ont vécu des choses similaires Talk about your problems with other women who have experienced similar traumas C03. Kusali /kujihusisha ndani ya kazi za kanisa. 0 1 2 3 Prier/ Participer dans les activités de l’église - Pray/ participate in church activities C04. Kutumika 0 1 2 3 Travailler – Work C05. Najifungiyaka mu nyumba Je m’enferme dans la maison 0 1 2 3 I shut my self up in the house C06. Kunywa pombe 0 1 2 3 Boire de l’alcool - Drink alcohol C07. Kuimba 0 1 2 3 Chanter – Sing C08. Kubakiya na wengine rester avec les autres - Spend time with 0 1 2 3 others 72 Appendix B: Questionnaire Tunataka sasa kuelewa kwa jumla kuhusu ma kazi mbali mbali ambazo mulitumika mu miezi sita (6) iliyo pita. Kwa kila aina ya kazi, nita kuuliza kama muli ifanya mu miezi sita (6) iliyo pita. Maintenant, nous voulons apprendre plus généralement sur les différents types de services que vous avez utilisés au cours des 6 derneir mois. pour chaque type de service, je vais vous demander si vous l’avez utilisé dans les 6 derniers mois Now we want to learn more generally about the different types of services you may have used in the past 6 months. For each type of service, I will ask whether you have used it in the past 6 months Apana Ndiyo Non Oui No yes C09. Ulienda ku kituo ca afya sababu ya shida za afya? Vous êtes allé à la clinique à cause de vos problèmes de santé. 0 1 - Have you gone to the health clinic for your own health problems. C10. Je,ulipataka musaada kimafikiri na kijamii. Est –ce que vous avez reçu une assistance psycho-sociale - Did you recieve 0 1 psychosocial services C10a. Kama ndio, ulipataka msaada wa aina gani na nani alikusaidiyaka? Si oui, qu’est-ce que vous avez reçu et de qui? If yes, what did you receive and from whom C11. Je,ulipataka msaada usiyo kuwa wa pesa (nyama za kufuga,vifaa vya mulimo) Est-ce que vous 0 1 avez reçu une assistance non-monétaire (ex: animaux, matériel agricole) - Have you received any non-money assistance (e.g. animal, farm materials) C11a. Kama ndio,ulipataka nini? Si oui, qu’est-ce que vous avez reçu? - If yes, what did you receive C12. Je, uko na pesa zako binafsi zenye unaweza tumikisha kama vile unataka ? 0 1 Avez-vous de l’argent que vous pouvez utiliser à votre gré? Do you have any money of your own that you alone can decide how to use? C13. Je, uko mwana memba wa vikundi vya mikopo ? Participez-vous à des activités de prêt actuellement? 0 1 Are you currently participating in any loan activities? C13a.Kama ndiyo,ni tangu wakati gani uko ndani ya vikundi hivyo ? Si oui,depuis quand participez-vous dans ces activités? If yes, how long have you been participating in these activities? _____ miezimois months _____ miakaannees years C13b. kama ndio,ni mkopo wa kiasi ao samani gani ulipewa huu mwaka? Si oui,quelle est la valeur total des prêts que vous avez eu cette annee? If yes, what is the total value of the loans you have taken out this year __ Cini ya $5 __ $5-$10 __ $10-$20 __ yulu ya $20 moins de plus que Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 73 SECTION D. Groupes et Réseaux groups and networks Nita ku uliza sasa unizungumuziye kuhusu vikundi, shirika, na miungano ambayo wewe ni mwanamemba. Inaweza kuwa ni shirika halali ao vikundi vya watu wenye ku kusanyika karibuni kila mara kwa ajili ya kazi fulani ao ajili ya kuzungumuza ku husu mambo mbali mbali. Nita soma aina za vikundi mbali mbali na utaniambiya zile ambazo una shiriki kama vile mwanamemba. Kama ndiyo, nita kuomba uni ambiye kama unakuwaka unashiriki kwa kucukuwa uamzi ndani ya ile kundi. maintenant vous demander de me parler de groupes, organisations et les réseaux auxquels vous appartenez. Ceux-ci peuvent être les groupes formellement organisés ou des groupes de personnes qui s’assemblent régulièrement pour une activité ou pour parler de choses. Je vais vous lire une liste des groupes et vous allez m’indiquer ceux-la auxquels vous appartenez. Si oui, dites moi si vous participez activement à la prise de décision de ce groupe. - I am now going to ask you about groups, organizations and networks to which you may belong. These could be formally organized groups or just groups of people who get together regularly to do an activity or talk about things. As I read the list of groups, please tell me if you belong to such a group. If yes, please tell me if you actively participate in the group’s decision making. Aina ya shirika ao kundi Una Mara ngapi unakuwaka una Type d’Organisation ou Groupe kuwaka shiriki ndani ya ile kundi? Type of organization or group Combien de fois participez-vous dans ce ndani ya groupe iyi kundi? 3= Kila mukutano Chaque reunion Appartenez-vous à ce groupe 2= Kwa wingi wa mikutano Pendant la plupart des reunions 0= Apana Non/no 1= Mara moja moja ila si zaidi Quelquefois, mais pas souvent 1= Ndiyo 0= Hata moja Pas du tout Oui/yes D01. Vikundi vya mulimo/ vikundi vya hakiba ao vingine vya kuzaa matunda.Groupe Agricole/ 1 0 3 2 1 0 coopérative ou d’autre groupe de production - Farming cooperative or other production group D02. Vikundi vya kuceza kiasili Groupe de danse folklorique 1 0 3 2 1 0 Folkloric dance group D03. Shirika za dini ao za kiroho- Groupe religieux ou spiritual 1 0 3 2 1 0 Religious or spiritual group D04. Vikundi ao shirika za mila Groupe ou association culturel - Cultural group or 1 0 3 2 1 0 association D05. Muungano wa afya 1 0 3 2 1 0 Mutuelle de santé - Health groups D06. Vikundi vya kusaidiyana Groupe mutuelle de solidarité, 1 0 3 2 1 0 Solidarity group D07. Vikundi vya kujifunza kusoma na kuandika 1 0 3 2 1 0 Groupe d’alphebetisation/Education D08. Vikundi visivyo kuwa vya kutegemea serikali 1 0 3 2 1 0 Groupe ONG/OCB/ou autre groupe civique NGO or other civic group3 74 Appendix B: Questionnaire D09. Miungano ya wana wake. 1 0 3 2 1 0 Association de femmes. Women’s group ApanaNon NdiyoOui D10. Je,una shirikianaka na wana memba wa jamaa yako,hata ile jamaa yako ya inje? Ëtes-vous régulièrement en 0 1 contact avec les membres de votre famille, y compris la famille élargie? - Are you in regular contact with members of your family, including extended family? Si le répondant dit oui, continuez. Si le répondant dit non, passez à la partie D14. If respondent says yes, continue on. If respondent says no, go to next section (D14). Nita ku uliza maulizo ku fuatana na ushirika kati yako na wanamemba wa jamaa yako ya inje. Ninge hitaji uniambiye kama masemi haya mara mingi,wakati moja moja,ao mara haba,ao hata kamwe ni ya kweli. Je vais vous posez des questions à propos des relations que vous entretenez avec les membres de votre famille élargie. J’aimerai que vous me disiez si les déclarations suivantes sont vraies souvent, parfois, rarement, ou jamais - I am going to ask you about relationships with extended family members. I’d like you to tell me if these things are true often, sometimes, rarely, or never UShirika na wanamemba wa jamaa ya Hata Mara Wakati Mara inje kamwe haba moja mingi Relations avec les membres de votre famille élargie Jamais Rarement Extended Family Relationships never rarely moja Souvent Often Parfois sometimes D11. Ni mara ngapi una kuwaka mu mangovi /fujo na wana memba wa jamaa yako ya inje?À quelle fréquence avez-vous des disputes 0 1 2 3 avec, ou de l‘hostilité envers un (des) membre(s) de votre famille élargie? – How often do you have quarrels or hostility with member(s) of your extended family? D12. Ni mara ngapi una cangiyaka mawazo na manunguniko yako na wanamemba wa jamaa yako ya inje? 0 1 2 3 À quelle fréquence partagez-vous vos pensées et vos soucis avec les membres de votre famille élargie? - How often do you talk with extended family members about your thoughts and troubles? D13. Ni kwa kiasi gani wanamemba wa jamaa yako ya inje wana kusaidiyaka,kwa mufano wakati wa magonjwa,wakati wa shida za watoto,wakati hauko nyumbani,ao kwa kazi za shamba? 0 1 2 3 À quelle fréquence les membres de votre famille élargie vous aident-ils par example, quand vous êtes malade, avec les enfants, quand vous êtes absente, ou avec les travaux champetres ? - How often do you receive practical help from your extended family, like help when you are sick, child care when you are away, or help with garden work? Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 75 Nina taka ku ku uliza kuhusu ushirika wako na wanamemba wa jamii (wale wasiyo kuwa wanamemba wa jamaa yako) Je vais vous posez des questions à propos des relations que vous entretenez avec les membres de votre communauté (qui ne font pas partis de votre famille). I am going to ask you about relationships with people in the community who are not in your family. Hata Mara Wakati Mara kamwe haba moja mingi Jamais Rarement souvent Never Rarely moja Often Quelque fois Sometimes D14. Katika mwezi uliyo pita,ni kwa kiasi gani watu wali kutembeleya ? 0 1 2 3 Pendant le mois dernier, à quelle fréquence est-ce que les gens vous ont rendu visite chez-vous? In the last month, how often have people visited you in your home? D15. Katika mwezi uliyo pita,ni kwa kiasi gani uli tembeleya watu nyumbani kwao? Pendant le mois dernier, à quelle 0 1 2 3 fréquence avez-vous rendu visite aux gens chez-eux ? In the last month, how often have you visited people in their home? D16. Kama una pata hitaji ya pesa kidogo haraka haraka,kwa Idadi mufano pesa ya kusaidiya jamaa yako muda wa juma moja,ni watu wangapi wa roho mwema una weza kimbiliya kuomba ile pesa? Si Nombre tout d’un coup vous avez besoin d’une petite somme d’argent, par example, assez pour soutenir votre foyer pendant une semaine, vous aurez recours à combien de personnes de bonne volonté pour demander Number cet argent? - If you suddenly needed a small amount of money, for example like enough to pay for your household for one week, how many people could you turn to who would be willing to provide? D17. Kama mara moja una jikuta ndani ya hitaji ya mbiyo mbiyo Idadi tena ya kudumu,kama vile kilio,mavuno mabaya,una weza kimbiliya watu ngapi wa roho mwema na ambao wata kuwa tayari Nombre ku kutolea msaada? Si tout d’un coup vous vous retrouvez face à une urgence à long terme, comme, telle qu’un décès ou une mauvaise récolte; vous aurez recours à combien de personnes de bonne Number volonté qui seront prêtes à vou aider? - If you suddenly faced a long-term emergency, such as a family death or harvest failure, how many people could you turn to who would be willing to assist? 76 Appendix B: Questionnaire DRC GBV Psychosocial Evaluation Questionnaire February 9, 2012 Swahili-French-English SECTION E. Economics L’EMPLOI SALARIE E01. E02. E03. E04. Je, ulifanya Je, ulifanya Munamo siku 7 Malipo uli lipiwaka kwa ile kazi ni ya samani gani ? kazi ya kulipwa kazi ya kulipwa zilizo pita, uli Na muda wa ile kazi ni wakati gani? L’EMPLOI SALARIE mushahara mushahara tumika saa [Kama ulipewaka vitu kama vile malipo, ao ulipewaka munamo siku munamo miezi ngapi kama vile franka na vitu pamoja, ufanye jumla ya yote pamoja. saba 7 zilizo 12 iliyo pita ? mutu mwenye pita (kutumikiya kutumikiya Quelle est (était) la valeur des paiements que vous avez recu pour ce travail ? Spécifiez la période de référence ! [si le répondent est payé en nature, demandez au SECTION E. Economics (kutumikiya mutu na kisha mushahara wa répondent d’estimer la valeur de ces paiements en nature;en cas de paiement en mutu na kisha akulipe pesa ao vitu ? espèce et en nature, demandez au répondent d’estimer la valeur du paiement en nature et de l’ajoutez au paiement en espèce] akulipe mushahara wa Dans les 7 derniers 1 Saa HEURE 5 Mwezi MOIS mushahara wa pesa ao vitu) jours, combien d’heures 2 Nusu ya siku DEMI-JOURNE 6 Miezi tatuTRIMESTRE pesa ao vitu) ? Avez-vous fait un travail avez-vous travaillé en salarié pendant les 12 tant que employée (entre 4-5 heures) 7 Miezi sita SEMESTRE derniers mois ? (i.e salariée (payée en Avez-vous fait un travail 3 Siku JOUR 8 Mwaka AN travailler pour quelqu’un nature ou en espèces)? salarié pendant les 7 qui vous paye un salaire 4 Juma SEMAINE derniers jours (i.e ou qui vous paye en travailler pour quelqu’un nature) qui vous paye un salaire ou qui vous paye en nature) (►E05) Saa/HEURES / Kiasi ya Pesa/MONTANT Muda PERIODE DE REFERENCE 0 Apana 0 Apana Non Non 1 Ndiyo 1 Ndiyo Oui (►3) Oui In Eastern DRC with Cognitive Processing Therapy Addressing Sexual Violence Related Trauma 16 77 78 DRC GBV Psychosocial Evaluation Questionnaire February 9, 2012 Swahili-French-English L’EMPLOI INDEPENDENT E05. E06. E07a. E07b. E08. E09. E10. Je,ulitumika Je,ulitumika Munamo Muda ya siku Ndani ya Munamo miezi JUMLA YA ndani ya ndani ya siku 7 zilizo saba zilizo pita, jamaa,ni nani 12 iliyo pita ,ni FAIDA ya kazi shirika /ao shirika /ao pita,ni saa franga ngapi ndiye mwenyeji muda wa miezi ulizo zi fanya Appendix B: Questionnaire ulifanya ulifanya ngapi uliweza pata wa kazi hiyo ? ngapi njo munamo miezi biashara ao biashara ao ulitumika kupitiya kazi za ulifanya hiyo 12 iliyo pita ni Qui dans le ménage est kazi ingine ya kazi ingine ya ndani ya uchumi, ma propriétaire de cette kazi ? (Idadi ya ngapi ? kupata faida kupata faida shirika kazi ya kuzala entreprise? miezi iyo kazi ili Quel était le REVENU TOTAL NET (le bénéfice) kwa jamaa kwa jamaa /ucuruzi/kazi franga ? endeshwa) de votre entreprise(s) yako pekee yako pekee zingine za Tafazali, 1 Mimi/ Moi Combien de mois au pendant les 12 derniers des 12 derniers mois ? munamo siku munamo ku leta unaweza 2 Mume wangu/ Mari cours mois avez-vous exploité 7 zilizo pita, miezi 12 iliyo faida ? kudirisha faida 3 Baba/ Pere cette entreprise ? (Nombre de mois Kama mutu zingine kazi pita, zingine za ile kazi mu 4 Mama/ Mere l’entreprise était en Dans les 7 derniers 5 Kaka/ Frere activité) unaye kuacha kazi kuacha jours, combien muda za siku kulima ? kulima ? d’heures avez-vous saba zilizo pita. 6 Dada/ Soeur zungumuza Avez-vous exploité travaillé dans cet 7 Mwanangu/ Fils Kama mutu naye hajuwi, une Avez-vous exploité entreprise / Dans les 7 derniers 9 wengine/ Autres unaye andika «99 » entreprise/commerce une entreprise/ commerce / activité jours, combien d’argent (a preciser) zungumuza Si le répondent ne sait ou effectué une commerce ou effectué génératrice des avez-vous gagne a pas, notez « 99 » activité génératrice de une activité revenus ? naye hajuwi, travers des activites de revenus pour le génératrice de cet entreprise/ andika «99 » compte de votre revenus pour le commerce/ activité propre ménage compte de votre génératrice des Si le répondent ne sait pendant les 7 derniers propre ménage revenus ? SVP essayez pas, notez « 99 » jours, autres que pendant les 12 d’estimer le benefice de cultiver vos champs? derniers mois, autres cette activite dans les 7 que cultiver vos derniers jours. champs? Francs Si plusieurs 0 ApanaN 0 Apana Saa personnes, notez Miezi Franka on Non (►11) Heures Mois Francs deux codes en 1 Ndiyo 1 Ndiyo Oui (►7) Oui (►8) maximum : 17 DRC GBV Psychosocial Evaluation Questionnaire February 9, 2012 Swahili-French-English Si les deux réponses sont “Non” (0), Réponse Question 1 : |___| Réponse Question 5 : |___| continuez avec question 11. Sinon, continuez avec question 15. Chomage E11. E12. E13. E14. Ni sababu gani hauku kuwa na Ya mara mwisho ulitumikia Je ,ulikuwa tayari muda na kuwa tayari ku tumika Je, ulijaribu kutafuta kufanya kazi ya kazi ya kulipwa mushahara ao faida fulani ilikuwa ni munamo siku saba(7) zilizo wakati gani ? kulipwa pita ? mushahara munamo Quand est la dernière fois ou vous avez travaillé pour un mushahara ama juma ine (4) zilizo salaire ou pour un profit ? yenye kuleta Pourquoi n’étiez-vous pas disponible et prête à pita ? travailler pendant les 7 derniers jours? [Marquez '0 / 0' si le répondent n’a jamais travaillee pour un faida munamo salaire/un profit] Avez-vous essayé de trouver un siku saba (7) 1 Masomo/ A l’école travail rémunéré pendant les 4 zilizo pita ? 2 Kufungwa na kazi za dernières semaines ? nyumbani /Trop occupée par les Etiez-vous disponible et taches ménagères prête à travailler pour un 3 Miaka kidogo sana/ Trop jeune salaire ou un profit pendant les 7 derniers 4 Kuzeheka sana/ Trop âgée jours? 5 Magonjwa/kuumia/ Maladie/blessure physique 6 Magonjwa ya kichwa /Maladie mentale 7 Ulemavu/ Handicapée 9 Mengine / Autres (à préciser) 0 Apana Non (►14) 0 Apana Non _____ Mwezi Mois 1 Ndiyo Oui 1 Ndiyo Oui _____ Mwaka Annee (►13) In Eastern DRC with Cognitive Processing Therapy Addressing Sexual Violence Related Trauma 79 18 DRC GBV Psychosocial Evaluation Questionnaire February 9, 2012 80 Swahili-French-English TRAVAIL NON-REMUNERE E15. E16. E17. E18. E19. E20. Ni saa ngapi Munamo siku Munamo siku Ni saa ngapi Ni saa ngapi Ni saa ngapi ulitumiya kwa zingine saba (7) zilizo pita saba (7) zilizo ulitumiya kwa ulitumiya kwa ulitumiya kwa kazi za nyumbani ,ni muda wa saa pita ,ni muda kupiga cakula ya kutafuta kuni za kushota maji kwa jana, sawa vile ku Appendix B: Questionnaire ngapi ulitumika wa saa ngapi nyumba yako kupiga cakula faida ya jamaa safisha nyumba, sawa vile ulitumika (bila jana ? jana ? jana ? kushugulikiya mutumishi asiye kulipwa) kazi Combien d’heures avez- Combien d’heures avez- Combien d’heures avez-vous watoto,… ? kuwa na za mulimo vous consacré hier à la vous consacré hier à la consacré hier à la collecte de Combien d’heures avez-vous mushahara katika kwa faida ya cuisson- préparation de la collecte de bois pour la l’eau pour le ménage ? consacré nourriture pour le cuisine (ou des autres hier aux autres taches ménagères, kampuni /shirika nyumba yako ménage ? combustibles) comme nettoyer la maison, lisilo kuwa la (kazi prendre soin des enfants, etc...? mulimo ? shamabani),uf Dans les 7 derniers jours, ugo na uvuvi [Kama hakuna, combien d’heures avez-vous pamoja [Kama hakuna, andika 0] [ANDIKA MUDA WA [Kama hakuna, travaillé en tant que andika 0] KWENDA NA andika 0] travailleur non-rémunéré Dans les 7 derniers KURUDI] dans une entreprise non- jours, combien [SI AUCUNE, NOTEZ '0'] [NOTEZ LE TEMPS ALLER- agricole ? d’heures avez-vous [SI AUCUNE, NOTEZ '0'] RETOUR] consacré (non- [SI AUCUNE, NOTEZ '0'] rémunéré) aux activités agricoles du ménage (travail sur les [Kama hakuna, [Kama hakuna champs), y compris andika 0] l’élevage et la pêche? ,andika 0] [SI AUCUNE, NOTEZ '0'] [SI AUCUNE, NOTEZ '0'] [Kama hakuna Saa Heures ,andika 0] [SI AUCUNE, NOTEZ '0'] Saa Heures Saa Dakika Saa Dakika SaaHeures Dakika SaaHeures Dakika Heures Minutes Heures Minutes Minutes Minutes 19 BIENS ET BETAIL E21.Je, wewe ao mwengine Kama Apana ao Kama ndio, mwanamemba wa nyumba yako,muna HAJUWI, endelea na kitu ngapi kuwaka na : inayo fuata. Si Non ou NSP, (wanamemba Est-ce que vous ou un autre membre du ménage continuez avec le prochain bien wote wa possède: 0 = Apana Non nyumbani)? 1 = Ndio Oui Si Oui, combien (tous les membres 8 = Hajuwi NSP du ménage) ? [A]RADIO/Une Radio [B] simu ya mukononi/Une téléphone portable [C] SAA YA KU KIBAMBAZI Pendule [D] KINGA/Une Bicyclette [E] PASI/Un Fer a Repasser [F] MASHINI YA KUSHONA/Une Machine a Coudre E22. PAA YA NYUMBA YAKO /Majani ya mingazi/ 1 Nyasi INAJENGWA NA NINI ? Quel est le mugomba Chaume feuille de palmier principal matériel de toit de votre maison ? 2 Mbao Planches de bois 3 Manjanja Tôles 9 Mengine Autre (à préciser) E23. VIBAMBAZI VYA NYUMBA 1 Udongo/Matope Terre/boue YAKO VINA JENGWA NA NINI ? 2 MbaoPlanches de bois/shingles Quel est le principal matériel des murs de 3 Matofali Briques votre maison ? 9 Mengine Autre (à préciser) E24. NYUMBA AMBAYO UNAISHI NDANI,JE NI 0 Apana Non YAKO PEKEE ? Est-ce que vous êtes propriétaire de la 1 Ndio Oui maison ou vous habitez ? 8 Hajuwi NSP E25. WEWE AO MWENGINE MWANAMEMBA 0 Apana Non NDANI YA NYUMBA YAKO, MUNA MASHAMBA ZA 1 Ndio Oui KULIMA ? Est-ce que vous ou un autre membre du ménage 8 Hajuwi NSP possède des terres pour cultiver? E26. JE , NYUMBANI MWAKO MUNA MIFUGO IFUATAYO ? Est-ce que le ménage possède le bétail suivant? IDADI YA MIFUGO Si oui, notez le nombre de têtes. Si non, notez « 0 » Nombre de têtes [A] NGOMBE Bovins [B] KONDOO/MBUZI Moutons/Chèvres [C]NGURUWE/Porcins [ D] KUKU/ Volaille [E] SUNGURA/ Lapin [F] DENDE/ Cobailles Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 81 82 F. CONSOMMATION ALIMENTAIRE – 7 DERNIERS JOURS F01 JAMAA , F02 JAMAA, F03 MULI LIPA F04 MUNAMO SIKU F05 MUNAMO SIKU 7 F06 KAMA JAMAA INGE Ligne PRODUIT ILI TUMIA ILI NUNUA NGAPI KWA 7 ZILIZO PITA, MULI ZILIZO PITA , NI KIASI UZISHA MAVUNO AMBAO MUNAMO MUNAMO KUNUNUA TUMIA VITU GANI YA MAVUNO INA ANDIKWA KWA ULIZO SIKU 7 ZILIZO SIKU 7 ZILIZO VITU MUNAMO AMBAVYO (MAVUNO BINAFSI YA 1.7 INGE PATA PESA/ PITA ? PITA ? SIKU 7 ZILIZO VLIVUNWA NA JAMAA)JAMAA ILI FRANKA NGAPI KU SOKO LE MENAGE A-T-IL LE MENAGE A-T-IL PITA ? JAMAA (MAVUNO TUMIYA ? YA HAPA MJINI ? SI LE CONSOMME ACHETE COMBIEN AVEZ- YENU PEKEE) MENAGE AURAIT VENDU SUR LE (PRODUIT) (PRODUIT) VOUS PAYÉ POUR DANS LES 7 DERNIERS DANS LES 7 DERNIERS JOURS, MARCHE LOCAL LA QUANTITE DU PENDANT LES 7 PENDANT LES 7 L’ACHAT DE JOURS, AVEZ-VOUS QUELLE QUANTITE DE (PRODUIT) MENTIONNEE DANS DERNIERS Appendix B: Questionnaire DERNIERS JOURS? (PRODUIT) PENDANT CONSOMMÉ DE (PRODUIT) (PRODUIT) (QUI VIENT DE LA QUESTION F05, COMBIEN AURAIT-IL JOURS? LES 7 DERNIERS QUI A ÉTÉ RÉCOLTÉ PAR LE PROPRE PRODUCTION) LE REÇU ? JOURS ? MÉNAGE (PROPRE MENAGE A-T-IL CONSOMME ? PRODUCTION)? NOTEZ UNITE ET QUANTITE ! 0. Apana Non 0. ApanaNon Munamo franka 0. ApanaNon A. Unite B. Quantite Munamo franka za 1. Ndio Oui 1. Ndio Oui za kikongomani 1. Ndio Oui kikongomani 8. Hajuwi NSP 8. HajuwNSP francs congolais 8. Hajuwi NSP Francs Congolais Si Non ou NSP, Si Non ou NSP, Si le répondent ne Si Non ou NSP, Si le répondent ne sait pas, continuez avec le continuez avec sait pas, notez continuez avec le notez « 99» prochain produit q.F4 « 99» prochain produit MIHOGO A MANIOC TUBERCULE BUNGA YA MIHOGO B FARINE DE MANIOC C MIHINDI/MAIS D MCHELE/RIZ E VIAZI/PATATES DOUCES F MAHARAGI/HARICOTS VIAZI/BIRAI G POMMES DE TERRE H NDIZI/BANANES I NYAMA/VIANDE F. CONSOMMATION ALIMENTAIRE – 7 DERNIERS JOURS DAGAA J KAVUSAMBAZA SECHE/ DAGAA – K MBICHI/SAMBAZA FRAIS ZINGINE SAMAKI/ L AUTRES POISSONS M MAZIWA/LAIT 21 LOCALES   KILOGRAMME..........1 LITRE...............2 PANIER..............3 REGIME..............4   UNITES   TAS.................5 PIECE...............6 NAMAHA..............7 PETITE BOUTEILLE....8 GRANDE BOUTEILLE....9 GOBELET.............10 BUMBA..............11 PLANTE DE MANIOC...12 VERRE..............13 GUIGOZ.............14 MORCEAU............15 AUTRES (PRECISEZ)..99 Sasa tunataka kuuliza ma swali fulani fulani ku husu namna gani una tosheka na vitu mbali mbali vya maisha yako. Ni kwa kiasi gani una tosheka na tena kwa kiasi gani hautosheki  ku husu Maintenant, nous aimerions vous poser quelques questions sur votre niveau de satisfaction avec les différents composants de votre vie Quel est votre niveau de satisfaction-insatisfaction concernant Hautosheki Hautosheki Hakuna Kutosheka Kutosheka sana kidogo kutosheka kidogo sana Très Un peu na hakuna Un peu Très insatisfait insatisfait kuto satisfait satisfait kutosheka Ni satisfait ni insatisfait F07. Afia yako 0 1 2 3 4 Votre santé F08. Hali yako kiucumi/ 0 1 2 3 4 Pesa Votre situation financière F09. Nyumba 0 1 2 3 4 Votre logement F10. Maisha yako kwa jumla 0 1 2 3 4 Votre vie en général Section G Please tell me whether these feelings have gotten worse, gotten better or stayed the same in the last 6 months Svp dites nous quels des ces sentiments ont empirés, sont améliorés ou sont restes les mêmes dans les derniers 6 mois. Tafazali una weza ku tu eleza vitendo gani avikubadirika, zile zili badirika, wala zila zilibaki vilele kisha mwezi 6 kupita Now I am going to ask you about any changes you have made in some behaviors in the last 6 months. For each one, please tell me if you are now doing it less often, about the same, or more often than you were doing it 6 months ago. Maintenant nous allons vous demander a propos de tout changements dans vos comportement produits dans les derniers 6 mois. Pour chacun svp dites moi si vous le faites moins souvent, également ou plus souvent que vous le fassiez il y a 6 mois. Sasa tuta sumuliya ku usu ma badiriko yote ku usu namna yako ya ku ishi mu mwezi sita zilizo pita. Na kwa kila moja tafazali u tueleze kama una ifanya sana ao mara kwa mara wala ku ifanya mara mingi kwa ngisi ili zoweya ku i fanya mu mwezi sita Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 83 In the past 6 months, have any of the following happened to you: Dans le derniers 6 mois, quelqun de ces faits vous est-il arrive? Kwa mwezi sita ku pita ku na kitu kili ku fikiya ? Got a lot Got a little No change Got a little Got a lot Not worse worse Pas de better better Applicable Beaucoup Un peu changemen Un peu Beaucoup Non empire t améliore amélioré applicable empiré HAKUN MAGUM MABADIL MABADIL HAIKU MAGUM A U ZAIDI IKO KIASI IKO ZAIDI HUSU U KIASI MABADI LIKO G01. Feeling harmony with your husband Se sentir en harmonies avec son Mari 0 1 2 3 4 9 Kujisikiwa kuwa sawa na bwana yako G02. Feeling harmony with your children Se sentir en armonie avec les enfants 0 1 2 3 4 9 Kuji sikiya kuwa sawa na watoto? G03. Feeling harmony with your neighbors Se sentir en harmonie avec les voisins 0 1 2 3 4 9 Kuji sikiya kuwa sawa na majirani? G04. Feeling harmony with your family Se sentir en armonie avec sa propre famille 0 1 2 3 4 9 Kuji sikiya kuwa sawa na jama yako? G05. Having strength to do work (go to the field, harvest, other) avoir la force pour travailler (aller au champ, faire la récolte, autre) 0 1 2 3 4 9 Kuwa na ngufu ya ku tumika (kuenda ku shamba, ku vuna na mengine) G06. Having strength to go to the market Avoir la force pour aller au marche 0 1 2 3 4 9 Kuwa na ngufu ya ku enda ku soko 23 84 Appendix B: Questionnaire G07. Having good thoughts avoir des bonnes pensées 0 1 2 3 4 9 Kuwa na mawazo mazuri G08. Feeling not ashamed in front of people N’avoir pas honte devant d’autres personnes 0 1 2 3 4 9 Kuto kuwa na haya mbele ya watu wangine G09. Feeling hatred against men Sentir de la haine envers les hommes 0 1 2 3 4 9 Ku sikiya chuki kwa ku ona wanaume G10. Feeling discriminated against by other people Sentir de la discrimination de la part d’autres personnes 0 1 2 3 4 9 Ku sikiya ku ku baguliwa na mengine G11. Feeling a more peaceful environment in the home Sentir une ambiance de paix a la maison 0 1 2 3 4 9 Ku jisikiya kuwa na amani nyumbani G12. Feeling a more peaceful environment in the community Sentir une ambiance de paix dans sa propre communauté 0 1 2 3 4 9 Kujisikiya kuwa na amani ndani ya jamaa 24 Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 85 A lot less A little less About the A little more A lot more Not Applicable often often same often often Non Beaucou Un peu A peu pres Un peu Beaucoup applicable p moins moins le meme plus plus HAKUNA souvent souvent KARIBUNI souvent souvent JIBU ZAIDI MARA SAWA KIDOGO MARA MARA MOJA VILE KILA MINGI KIDOGO MOJA MARA ZAIDI G13.Wearing clean clothes and shoes Porter des habits et des chassures propres 0 1 2 3 4 9 Ku vaa mavazi na viato vyaku takata G14.Taking baths Prendre un Bain 0 1 2 3 4 9 Ku koga G15 Wearing makeup Vous maquiller 0 1 2 3 4 9 Ku ji podowa G16. Making sure your children look clean Faire attention a que les enfants soient propres 0 1 2 3 4 9 Kufanya angalisho ju ya usafi ya watoto G17. Cooking food for your family Préparer la nourriture pour la famille 0 1 2 3 4 9 Ku piga chakula ju ya watoto G18. Thinking about what you eat and how it affects your body Penser a propos de ce que vous mangeait et quel effet ceci a sur votre corps. 0 1 2 3 4 9 Ku waza ju chakula una kula na madiriko gani una leta mwilini mwako G19. Thinking about having more children Penser d’avoir plus d’enfants 0 1 2 3 4 9 Kuwaza kuzala watoto mingi Yes No Oui Non Ndiyo Hapana G20. Had a baby 1 0 Avoir un bebe Ku zala mtoto G21. Lost a baby or child died 1 0 Avoir fait un avortement ou avoir perdu son propre fils ou fille 25 Mimba ku toka wala ku fisha G22. Had a seriously ill child mtoto wako bi nafsi 1 0 Avoir un enfant très malade? Kuwa na mototo mugonjwa ? 86 Appendix B: Questionnaire G23. Had a close family member die 1 0 Avoir le décès d’un parent très proche? Kufisha mzazi wa karibu ? G24. Had a close friend die 1 0 Avoir le décès d’un ami intime? Ku fisha rafiki wa karibu ? G25. Been seriously ill yourself 1 0 Etre serieusement malade vous même? Kuwa mgojwa sana ? G26. Had a seriously ill family member 1 0 Avoir un membre de la famille gravement malade? Kuwa na mtu wa jama ? G27. Been seriously injured yourself 1 0 Etre gravement blesse (vous même)? Ku lumiya sana? G28. Had a seriously injured family member 1 0 Avoir un membre de la famille gravement blessé Kuwa na mtu wa jama mwenyi kuwa mgonjwa ? SECTION T: Experiences Traumatiques Tuna penda kuelewa aina za vitendo ao vipindi vya hatari na vya kuogopesha ambavyo ulivipitiya kwa jumla. Nita kuambiya aina mbali mbali tulisikiya kwa wanawake wenye wali pitiya shida zile. Ina wezekana ulipitiya shida zimoja zimoja wewe binafsi ao uliona mutu mwengine ana zipitiya. Kama vile ingine maulizo, uki jisikiya haupendi ao haufurahishwi kujibu izi maulizo,tuna weza zirudiliya wakati mwengine ao unaweza kataa kuzijibu zote. Kwa kila aina ya shida,nita kuuliza kama uli ipitiya binafsi ao uliona mutu mwengine ana ipitiya. Nous voulons comprendre quels sont les types d’expériences traumatiques générales que vous avez vécues ? Je vais vous citer les différents types d’expériences que nous avons entendu des femmes qui ont été victimes. Vous pouvez avoir vécu certains des eux personnellement ou que vous avez vu quelqu’un d’autre l’expérience de ce traumatisme. Comme avec toutes les questions, si vous ne vous sentez pas à l’aise de répondre à ces questions, nous pouvons y revenir plus tard ou vous pouvez convenir de ne pas répondre à toutes. Pour chaque type de traumatisme, je vous demanderai de me dire si vous avez vécu le traumatisme ou vu cela se produire à quelqu’un d’autre. Dans les 6 derniers mois…. Je,hiyo shida Je, ulionaka ile ilikufikiya binafsi/ shida ina fikiya mtu wewe mwenyewe? mwengine? Avez-vous personnellement Avez-vous vu cela arriver a vécu - Have you personally quelqu’un d’autre - Have you seen experienced this happen to someone else 0 apana 1 ndiyo T01. Ubakaji 0 apana 1 ndiyo Non Oui Violence sexuelle - Sexual violence Non Oui T02. Mauwaji 0 apana 1 ndiyo Meurtre – Murder Non Oui Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 87 T03. Kushambuliwa na budunki, mupanga ao zingine silaha ao ingine ujehuri kali 0 apana 1 ndiyo 0 apana 1 ndiyo kama vile kupigwa. Attaque par fusil, machete ou autre munitions Non Oui Non Oui ou autre violence severe comme etre tabasse- Attack with a gun, machete or other weapon or other severe violence like beatings T04. Kunyanganywa/ Kuporwa ao kulunguziwa manyumba ao vitu 0 apana 1 ndiyo 0 apana 1 ndiyo vingine. Pillage ou bruler les maisons ou autre propriete Non Oui Non Oui Looting or burning of home or other property T05. kuachiliwa/kufukuzwa 0 apana 1 ndiyo 0 apana 1 ndiyo Abandon/chassée - Abandoned/thrown out Non Oui Non Oui T06. Kubebwa (mahali pasipo 0 apana 1 ndiyo 0 apana 1 ndiyo julikana). Etre enleve - Being abducted Non Oui Non Oui 88 Appendix B: Questionnaire Appendix C Adaptation of CPT Text S4: Cognitive Processing Therapy Adaptation Process We adapted the existing Cognitive Processing Therapy group manual and training materials (Resick, Mon- son, & Chard, 2008; Chard, Resick, Monson, & Kattar, 2008) to be both culturally appropriate and useable by local psychosocial assistants. The adaptation process was guided by the local context, which included: therapists with little to no training in cognitive behavioral treatments or group interventions; a client popula- tion with low levels of literacy; and specific beliefs and structures of cultural groups within the Democratic Republic of Congo. The adaptation process was iterative, allowing us to benefit from feedback from multiple constituencies including the project research team from Johns Hopkins (LM, JB, & PB), the hosting non- governmental organization (International Rescue Committee), NGO-based psychosocial staff, and the psy- chosocial assistants. The first phase of the adaption process consisted of the US trainers (DK and SG), along with assistance from Cognitive Processing Therapy group trainer Carie Rogers, editing existing Cognitive Processing Therapy training materials and the treatment manual to replace technical terms and American idioms with standard, simple English terms and phrases. In addition, more information regarding providing group psychotherapy and managing group process was added to the manual. Review of the simplified materials was done in the US by members of the research team experienced in training persons with limited previous training and experi- ence in mental health care (PB, JB, & LM). The resulting materials were translated into French by profes- sional translators based in Democratic Republic of Congo. Materials were reviewed by a bilingual US-trained clinical social worker dedicated to the project for clarity and cultural appropriateness. Adaptation continued in the Democratic Republic of Congo during the two-week training of the psychoso- cial assistants, NGO-based psychosocial staff, and the bilingual US-trained clinical social worker. Feedback from the trainees was solicited on a daily basis throughout the training and used to further adapt the manual and training materials for subsequent training days. The field-based adaptation process focused on continu- ing to (1) improve clarity of all written materials; (2) increase the cultural fit of materials; (3) adjust client materials to be accessible for those who are illiterate; and (4) reduce barriers to implementation inherent in a low resource environment. Prior to initiating the trial, the adapted Cognitive Processing Therapy treatment was piloted by the psychoso- cial assistants and the clinical supervisor, allowing for additional feedback as they implemented the therapy for the first time. Minor changes were made to materials during this period. At the end of the study, a debrief- ing meeting was held with the psychosocial assistants and clinical supervisors to solicit any additional feed- back regarding the training, materials, supervision and implementation of the therapy. Based on this feed- back, a final set of materials was prepared for the psychosocial assistants and supervisors to use as reference material as they continue to provide the therapy as part of an ongoing mental health service program. Therapy Adaptation The structure of Cognitive Processing Therapy and essential elements were retained in the modified treat- ment, however some aspects were simplified. The main changes to the manual involved reducing technical Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 89 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, and modifying homework assignments for non-literate clients. Structural considerations Literacy. Cognitive Processing Therapy relies on homework as a way to facilitate emotional processing and to teach how to recognize and change maladaptive beliefs that maintain symptoms of PTSD and depression. It was not possible in the Democratic Republic of Congo to use written homework, therefore materials were simplified to be easier to understand and to memorize. We monitored the success of these modifications throughout the implementation process and also debriefed the psychosocial assistants about the modifica- tions during the final project meeting. In order to make Cognitive Processing Therapy accessible for low literacy and illiterate clients, the US trainers reduced the complexity of written materials and incorporated changes to help with retention of information. Skills taught to clients were simplified, both in terms of the language used and in terms of the number of items used for the skill. For example, one of the homework sheets is called ‘Challenging Questions.’ The standard skill has 10 questions, but for simplicity, the number was reduced to four. We retained questions that were the least abstract and were easiest to memorize, while still retaining enough breadth across the questions. Clients Worksheets were also modified to use pictures as cues to help illiterate clients remember the work- sheet instructions and/or skill. Thus the psychosocial assistants 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. Through brainstorming discussions with the psychosocial assistants we also developed a plan to help clients use exercises to memorize skills. For example, one of the sheets is called the ‘ABC sheet,’ which used a picture of a person standing as a cue for the “Activating event”, a picture of a person thinking as a cue for the “Belief ”, and pictures of people with various facial expressions as a cue for the “Consequence” or emotion column. Clients were also encouraged to tap their heads as a reminder to notice the belief and touch their hearts as a reminder to notice the related emotion. Lastly, we removed one cognitive skill, to identify overarching patterns of cognitive distortions (called patterns of problematic thinking). Due to the need for skills to be memorized rather than written down this skill was deemed too abstract for clients to memorize and practice. Efforts were also made to increase the chances that patients would practice the skills daily, regardless of their literacy level. The psychosocial assistants suggested that clients practice the therapy skills as part of their daily routine. Group members would also meet with each other between group sessions to help each other with practicing their homework. An additional adaptation was the removal of two behavioral assignments in session 10 of the treatment. The first skill encourages patients to complete one nice thing for oneself daily, and the second is to practice giving and receiving compliments. The removal of these activities was simplified the protocol for both patients and therapists. The modified Cognitive Processing Therapy protocol thus focused on the clients mastering skills related to identifying thoughts and feelings, challenging their own thoughts, and generating alternative ways of viewing the situation, all core skills of Cognitive Processing Therapy. Each session therapists would teach the new skill and review several examples within the group to help with memorization and consolidation of skills. Novelty of talk therapy. In addition to considerations regarding literacy, there were also important consider- ations related to the fact that there was not strong tradition of talk therapy or mental health treatment in the Democratic Republic of Congo. Based on suggestions from the local supervisors we added an additional in- 90 Appendix C: Adaptation of CPT dividual therapy session to describe mental health symptoms, describe the rationale for talk therapy, discuss what group treatment will be like, and to answer client questions and concerns. Cultural considerations Consideration of cultural factors was vital to adapting Cognitive Processing Therapy for use in the Democrat- ic Republic of Congo. The identification of these factors was a collaborative process, involving the US-based trainers, the study investigators, local and international staff at International Rescue Committee, and the Con- golese supervisors, psychosocial assistants, and interpreter, all of whom were born, raised, and currently live in the region. Some factors were identified before the training began (by means of a preliminary qualitative study), whereas others emerged during the training and/or implementation of Cognitive Processing Therapy. Cultural factors that needed to be addressed included factors related to specific beliefs about social status, rape, and language differences. With respect to beliefs about social status, psychosocial assistants and supervisors noted that many patients beliefs that rape would mean that women’s social status was permanently changed. These beliefs can make cognitive restructuring challenging. Consistent with traditional Cognitive Processing Therapy treatment, the psychosocial assistants were trained to use Socratic dialogue to identify, within the client’s own cultural and religious beliefs, those places where there is room for cognitive flexibility. For example, several female clients reported concerns about reduced social status due to being raped – e.g., “I have no voice in my home because I was raped.” “My family is ashamed of me because I was raped.”). To work with those beliefs, a strategy of us- ing Socratic questions to identify possible exceptions was used. In the former example, therapist explored in what ways the client could have a say in her household and whether this was true of all people or all the time. In the latter case, exploration centered on whether all of the family felt ashamed and how the client came to that conclusion. Language differences also necessitated some adaptations to Cognitive Processing Therapy. Some key con- cepts 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. The concept of homework did not translate directly and was instead translated as “small works you do at home.” The concept of extreme words was translated as “heavy words.” Lastly, the name of the therapy “cogni- tive processing therapy” did not translate to Swahili and was instead named “mind and heart” therapy. The final session order is listed below: Session 1: Introduction to therapy (individual) Session 2:Introduction to Cognitive Processing Therapy Session 3: Meaning of the Event Session 4: Identification of Thoughts and Feelings Session 5: Identification of Stuck Points (maladaptive beliefs) Session 6: Challenging Questions Session 7: Challenging Beliefs Session 8-12: Cognitive Modules: Safety, Trust, Power/Control, Esteem, Intimacy Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 91 92 PSA Name: ________________________________ CPT SYMPTOM CHECKLIST Date ____________ Site ____________________ Group number: ____________ Session number: _____ Duration of Group: _______ Problem Review - How much was this a problem for each survivor over the last week? Please put client number in each box. Not a problem A little problem A medium problem A very big problem Appendix D: Intervention Monitoring Forms 0 1 2 3 Feeling sad In Swahili In Mashi In Kihavu Feeling lonely In Swahili In Mashi In Kihavu Thoughts of ending your life In Swahili In Mashi In Kihavu Worrying too much or feeling fearful In Swahili Appendix D In Mashi In Kihavu Spells of terror or panic In Swahili In Mashi In Kihavu Recurrent thoughts/memories of the worst trauma In Swahili In Mashi In Kihavu Feeling on guard Intervention Monitoring Forms In Swahili In Mashi In Kihavu PSA Name: ________________________________ CPT SYMPTOM CHECKLIST Date ____________ Site ____________________ Group number: ____________ Session number: _____ Duration of Group: _______ Problem Review - How much was this a problem for each survivor over the last week? Please put client number in each box. Not a problem A little problem A medium problem A very big problem 0 1 2 3 Feeling sad In Swahili In Mashi In Kihavu Feeling lonely In Swahili In Mashi In Kihavu Thoughts of ending your life In Swahili In Mashi In Kihavu Worrying too much or feeling fearful In Swahili In Mashi In Kihavu Spells of terror or panic In Swahili In Mashi In Kihavu Recurrent thoughts/memories of the worst trauma In Swahili In Mashi In Kihavu Feeling on guard In Swahili In Eastern DRC with Cognitive Processing Therapy Addressing Sexual Violence Related Trauma In Mashi In Kihavu 93 94 PSA Name: ________________________________ Appendix D: Intervention Monitoring Forms Avoiding activities that remind you of the traumatic or hurtful event In Swahili In Mashi In Kihavu Nightmares about the worst trauma In Swahili In Mashi In Kihavu Avoiding thoughts or memories about the traumatic or hurtful event In Swahili In Mashi In Kihavu Feeling guilty or ashamed In Swahili In Mashi In Kihavu PSA Name: ________________________________ Supervisor Name: _________________________________ APS Name: ____________________________________ Pilot Group (ID#______) Session #_____ How many clients attended the group? ________ Were any clients late? Y N Were any clients in crisis (suicidal/homicidal/other risks) Y N What was done to manage or address that problem? Did the APS complete all TPC session components? Y N If no, please discuss which were addressed, which were missed, and what the challenges were: Group #1 (ID#______) Session #_____ How many clients attended the group? ________ Were any clients late? Y N Were any clients in crisis (suicidal/homicidal/other risks) Y N What was done to manage or address that problem? Did the PSA complete all TPC session components? Y N If no, please discuss which were addressed, which were missed, and what the challenges were: Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 95 PSA Name: ________________________________ Name: _________________________________ APS Name: ____________________________________ Group #2 (ID#______) Session #_____ How many clients attended the group? ________ Were any clients late? Y N Were any clients in crisis (suicidal/homicidal/other risks) Y N What was done to manage or address that problem? Did the APS complete all TPC session components? Y N If no, please discuss which were addressed, which were missed, and what the challenges were: Group #3 (ID#______) Session #_____ How many clients attended the group? ________ Were any clients late? Y N Were any clients in crisis (suicidal/homicidal/other risks) Y N What was done to manage or address that problem? Did the APS complete all TPC session components? Y N If no, please discuss which were addressed, which were missed, and what the challenges were: 96 Appendix D: Intervention Monitoring Forms PSA Name: ________________________________ Group #4 (ID#______) Session #_____ How many clients attended the group? ________ Were any clients late? Y N Were any clients in crisis (suicidal/homicidal/other risks) Y N What was done to manage or address that problem? Did the APS complete all TPC session components? Y N If no, please discuss which were addressed, which were missed, and what the challenges were: Rate the APS’s knowledge of TPC and delivery of TPC content (being able to explain it, respecting the steps, assigning the right homework) this week from 1-6: ______________ 1 (unacceptable), 2 (barely acceptable, several problems), 3 (acceptable but some problems), 4 (very good, only minor problems), 5 (excellent, very few if any problems) Rate the APS’s skills in group leadership (managing group members, getting people to show up, encouraging participation, getting group members to help each other, not being timid, finding common topics to draw group members together) this week from 1-6: ______________ 1 (unacceptable), 2 (barely acceptable, several problems), 3 (acceptable but some problems), 4 (very good, only minor problems), 5 (excellent, very few if any problems) What strategies were used to evaluate PSA skills this week (circle all that apply)? Case report Live observation Quiz Role play Note general impression of APS: Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 97 PSA Name: ________________________________ What TPC skills are they using well this week (e.g. open questions, explaining homework, teaching new skills)? o Checking symptoms o Teaching about caring stuck thoughts o Reviewing correct homework o Teaching how to identify thoughts and feelings & using ABC skill o Identifying and addressing avoidance in group o Identifying stuck thoughts about the trauma members (no showing, not speaking, being late, (hindsight bias, self-blame, minimizing, outcome not doing homework, avoiding outside of group) based reasoning) o Teaching about trauma problems o Teaching the Thinking Questions skill o Teaching about TPC and how it will help o Teaching the Changing Thinking and Feeling skill o Teaching about avoidance o Using gentle, open ended questions to help the group challenge stuck thoughts o Teaching about safety stuck thoughts o Leading group discussion about the trauma impact statement (session 3 and session 12) o Teaching about trust stuck thoughts o Assigning correct homework o Teaching about power stuck thoughts o Leading group discussions (managing conflict, managing quiet and dominating members) o Teaching about esteem stuck thoughts o Looking for common themes or stuck thoughts in the group. What TPC skills are they struggling with this week? o Checking symptoms o Teaching about caring stuck thoughts o Reviewing correct homework o Teaching how to identify thoughts and feelings & using ABC skill o Identifying and addressing avoidance in group o Identifying stuck thoughts about the trauma members (no showing, not speaking, being late, (hindsight bias, self-blame, minimizing, outcome not doing homework, avoiding outside of group) based reasoning) o Teaching about trauma problems o Teaching the Thinking Questions skill o Teaching about TPC and how it will help o Teaching the Changing Thinking and Feeling skill o Teaching about avoidance o Using gentle, open ended questions to help the group challenge stuck thoughts o Teaching about safety stuck thoughts o Leading group discussion about the trauma impact statement (session 3 and session 12) o Teaching about trust stuck thoughts o Assigning correct homework o Teaching about power stuck thoughts o Leading group discussions (managing conflict, managing quiet and dominating members) o Teaching about esteem stuck thoughts o Looking for common themes or stuck thoughts in the group. 98 Appendix D: Intervention Monitoring Forms PSA Name: ________________________________ TPC SESSION NOTE Date ____________ APS Name: ________________________________ Group number: _______ Session number: _______ Survivor ID: ________________ 1. Client’s sum of symptoms (add up from symptom checklist but still attach symptom checklist): ___________ Which symptoms have changed (improved or worsened)? 2. One stuck point this client has is: 3. Any challenges or problems in therapy for this client (homework completion, attendance, participation in group, changes in symptoms, crises)? Survivor ID: ________________ 1. Client’s sum of symptoms (add up from symptom checklist but still attach symptom checklist): ___________ Which symptoms have changed (improved or worsened)? 2. One stuck point this client has is: 3.Any challenges or problems in therapy for this client (homework completion, attendance, participation in group, changes in symptoms, crises)? TPC SESSION NOTE Date ____________ Site ____________________ Group number: ____________ Session number: _____ Duration of Group: _______ 1. What  questions  do  you  have  for  CT,  Janny,  Debra,  and  Shelly  this  week?   2. What  did  you  do  in  session  with  your  group?  (Check  all  that  apply)   o Checked symptoms Taught a skill: Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 99 PSA Name: ________________________________ o  Reviewed homework o  identify thoughts and feelings & using ABC sheets What homework did you review? ____________________ o  identifying stuck thoughts _________________________________________________ Provided education about: o  using the Thinking Questions tool o  trauma problems o  using the Changing and Feelings tool o  TPC and how it thinks about trauma o Listened for and talked about stuck thoughts with the group o  TPC and how it will help o Used gentle, open ended questions to help the group challenge stuck thoughts o  avoidance o  Discussed the trauma impact statement o  safety issues o  Assigned homework: o  trust issues What did you assign? _______________ - _________________________________   o  power issues o  esteem issues o caring issues 3. Please refer to the TPC Checklist at the beginning of the session in the manual. Did you complete all items on the checklist for the session you did with your group? o Yes o No If you did something differently from the check list, why did you do so? (check all that apply) o A client was late to session o Clients didn’t complete homework o I was late to session o Talked with group about avoidance o I accidently forgot to do a section o Talked with group about coming to sessions regularly o Didn’t have enough time o Other: ____________________________________ o A client had a crisis o Other: ____________________________________ o Clients had trouble doing homework o Other: ____________________________________ 100 Appendix D: Intervention Monitoring Forms Appendix E High Risk Protocol Clinical Crisis Flow Developed for Use with International Rescue Committee’s High Risk Participants in Psychosocial Programming in South Kivu Province, DRC Developed by: Laura Murray: lamurray@jhsph.edu Stephanie Skavenski: sskavenski@yahoo.com Johns Hopkins Bloomberg School of Public Health Catherine Poulton: Catherine.Poulton@rescue.org International Rescue Committee Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 101 English Version: Clinical crisis flow for DRC Initial responses by the APS • The APS finishes the checklist of symptoms form, and the follow-up form. Asks questions directly to the client with suicidal or homicidal ideation, with psychosis, or who is abusing substances. • If the client indicates suicidal ideas…. Further evaluate: a. “Have you ever tried to end your life?” b. “Are you thinking about ending your life?” c. “Do you have a plan to end your life?” d. “Do you have access to that plan, in order words, do you have the means to execute your plan?” If the client answers YES to questions c or D, call your supervisor immediately (CT), please! If the client answers YES to questions A and/or B, please move on to the review of steps at the end of this document. Talk to your supervisor while the client is still working with you. Decide, or agree on a plan BEFORE the client leaves. • If the client indicates homicidal ideas… Further evaluate: a. “Have you ever tried to end someone’s life/ hurt someone before?” b. “Are you thinking about ending someone’s life/ hurting someone?” c. “Do you have a plan to end someone’s life/ hurt that person?” d. “ Do you have access to that person, in order words, do you have the means to execute your plan?” If the client answers YES to questions c or D, call your supervisor immediately (CT), please! If the client answers YES to questions A and/or B, please move on to the review of steps at the end of this document. Talk to your supervisor while the client is still working with you. Decide, or agree on a plan BEFORE the client leaves. • If the client indicates psychotic symptoms or an intensification of substance use, for example alcohol or marijuana… 102 Appendix E: High Risk Protocol Further evaluate: a. “How frequently do you use these substances?” b. “What substances are you using?” c. “What are the psychotic symptoms that you experience?” Here, the APS will evaluate if the client has hallucinations or delusions” (the hallucinations and delusions de Call your supervisor immediately! Talk to your supervisor while the client is still working with you. Decide, or agree on a plan BEFORE the client leaves. If the client answers “yes” to any of these questions, call your supervisor at the end of the session. Here are certain things to do during the session: A. Did the client give her “security word” (verbal agreement by the client to keep herself safe). • “We want to be assured that you are safe. I understand that this can be difficult. Can you promise me to keep yourself safe for a short period – at least until tomorrow?” B. Establish a “security guard” • “We want to help you stay safe. At times, we use family members to help us keep you safe. Can you think of someone in your family who could stay by your side?” • “Can we work together to get that family member to agree to stay by your side in order to keep you safe?” • If the APS does not succeed in getting in contact with her supervisor (CT), in this specific case, she will contact immediately her supervisor within the ASBL, and it will be the responsibility of ASBL to get in contact with Claudine or Maria. Response of the CT and at the management level once the APS has identified a crisis • The APS contacts the CT immediately if a crisis situation is identified (see above for initial responses by the APS) • The CT checks that the APS developed a plan of action before the client leaves, and makes sure that Claudine has been notified. Maria should be contacted if it concerns a TPC village. • The CT contacts the technical supervisors within the partner ASBL for an update on the continuous delivery of services. • The CT collects all information concerning the client’s crisis situation ˏˏ Client code ˏˏ Crisis ˏˏ Suicidal • Homicidal • Psychosis • Substance use ˏˏ Report on the client’s responses to the evaluation (see the initial questions by the APS) Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 103 ˏˏ Plan of action (till then) by the APS • The CT contacts Claudine or Maria (depending on who is reachable at that moment) to communi- cate the collected information. Maria should be contacted if it concerns a TPC village. • Claudine informs IRC of the report and the following steps • The US-based trainers (for the TPC villages) and Judy should be informed via email as soon as all of the information has been collected. • Maria, Claudine, CT and Judy (if available) discuss the risks and the action plan ˏˏ The action plan could include, asking the APS to: • Ask the client to promise verbally to keep herself safe ■■ “We want to be assured that you are safe. I understand that this can be difficult. Can you promise me to keep yourself safe for a short period – at least until tomorrow?” • Establish a “security guard” ■■ “We want to help you stay safe. At times, we use family members to help us keep you safe. Can you think of someone in your family who could stay by your side?” ■■ “Can we work together to get that family member to agree to stay by your side in order to keep you safe?” • And/ or contact SOSAM or Maltezer for additional support or hospitalization • It is the responsibility of CT to communicate the action plan to the APS • It is Maria’s responsibility to share the report (evaluation and action plan) with Judy • Maria, Claudine and the CT develop an action plan to communicate to the APS • Claudine makes a report for the IRC of the results of the plan, and provides any other report or feed- back that the IRC may require. These reports are shared with the ASBL partners. 104 Appendix E: High Risk Protocol French Version: Flux de Crises Cliniques pour la RDC Réponses Initiales par les APS • L’APS termine les fiches sur le Check-list des Symptômes et celles de Suivi. Pose directement des questions au sujet du suicide, homicide, psychose et l’usage des substances. • SI la cliente indique des idées suicidaires… Evaluer davantage a. “Avez-vous déjà essayé de mettre fin à votre vie?” b. “Pensez-vous à mettre fin à votre vie ?” c. “Avez-vous un plan afin de mettre fin à votre vie ?” d. “Avez-vous accès à ce plan ; c.à.d. avez-vous des moyens pour exécuter ce plan ?” Si la cliente repond OUI aux questions c ou d, appelez immédiatement votre superviseur (CT) s’il vous plait ! Si la cliente repond OUI aux questions a et/ou b seulement, passez s’il vous plait à la revue des étapes à la fin de cette fiche/feuille. Parlez avec votre superviseur pendant que la cliente est encore avec vous .Décidez ou mettez-vous d’accord sur un plan AVANT que la Survivante ne parte. • SI la cliente indique des idées homicides … Evaluer davantage a. “Avez-vous déjà essayé de mettre fin à la vie de quelqu’un/ lui faire du mal avant ?” b. “Pensez-vous à mettre fin à la vie de cette personne/lui faire du mal ?” c. “Avez-vous un plan afin de mettre fin à la vie de quelqu’un /ou faire du mal à cette personne ?” d. “Avez-vous accès à cette personne ; c.à.d. avez-vous les moyens d’exécuter ce plan ?” Si la Cliente repond OUI aux questions c ou d, appelez immédiatement votre superviseur s’il vous plaît ! Si la Cliente repond OUI aux questions a ou b seulement, passez s’il vous plait à la revue des étapes à la fin de cette fiche/feuille. Parlez avec le Superviseur pendant que la cliente est encore avec vous. Décidez ou mettez-vous d’accord sur un plan AVANT que la cliente ne parte. Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 105 • SI la cliente indique des symptômes de psychose ou d’intensification de l’abus de substances, par exemple alcool, chanvre, … Evaluer davantage a. “A quelle frequence utilisez-vous ces substances ? b. “Quelles sont les substances que vous utilisez ?’’ c. “Quels sont les symptômes liés à la psychose qui se présentent ? Ici l’APS évaluera par exemple si la survivante présente des hallucinations, et des délusions’’ (les hallucinations et les délusions ne font pas partie des symptômes spécifiques du traumatisme tels que les flashbacks et les phobies. “ Appelez votre superviseur immédiatement ! Parlez avec votre superviseur pendant que la cliente est encore là avec vous. Mettez vous d’accord ou décidez sur un plan avant que la cliente ne parte. Si la cliente dit oui à n’IMPORTE quelles questions, appelez votre superviseur à la fin de la séance. Voici certaines choses à faire pendant la séance : A. Est-ce que la cliente a donné son mot de sécurité (accord verbal par la cliente de se garder en sécurité) • “Nous voulons nous rassurer que vous êtes en sécurité. Je sais bien que ceci puisse être difficile. Pouvez-vous me promettre que vous vous garderez en sécurité pour une courte période-juste au cou- rant du jour suivant ?” B. Mettre en place un garde de sécurité • “Nous voulons vous aider à vous maintenir en sécurité. Plusieurs fois, nous utilisons les membres de la famille pour le faire. Pouvez-vous m’aider à penser de quelqu’un de votre famille qui puisse être à vos cotés?” • “Pouvons-nous travailler ensemble pour amener ces membres de famille à pouvoir se mettre d’accord qu’ils seront avec vous pour que vous soyez en sécurité ?” • Si l’APS ne reussit pas a entrer en contact avec son superviseur (CT) , dans ce cas précis elle contacte immédiatement son superviseur au sein de l’ASBL et il appartiendra à ce dernier de contacter à son tour soit Claudine ou Maria Réponse du CT et du niveau de la Gestion une fois qu’une APS a identifié une Crise • L’APS contacte immédiatement la CT si une situation de crise est identifiée (voir ci-haut les répons- es initiales par l’APS) • La CT se rassure que l’APS n’a pas laissé la cliente partir avant qu’il n’y ait un plan d’action qui est mis en place et Claudine soit été notifiées. Maria doit être contactée si c’est un village TPC. • Les CT contactent les superviseurs techniques au niveau des ASBLs partenaires pour une mise à jour par rapport à la livraison continue des services • La CT collecte toutes les informations autour de la situation au sujet de la crise ˏˏ Code de la Cliente 106 Appendix E: High Risk Protocol ˏˏ Crise • Suicidaire • Homicidaire • Psychose • Usage intense des substances ˏˏ Rapport de la cliente sur les questions d’évaluation [voir les questions aux réponses initiales par l’APS] ˏˏ Actions prises jusque là par l’APS • La CT contacte Claudine ou Maria(selon la personne qui est joignable à ce moment-là) pour com- muniquer les informations collectées. Maria doit être contactée si c’est un village TPC. • Claudine informe IRC du rapport et des étapes suivantes. • Les formateurs du coté des USA (pour les villages TPC) e et Judy doivent être informé en leur envoy- ant des e-mails aussitôt que toutes les informations sont collectées. • Maria, Claudine, CT et Judy (si disponible) discutent les risques et le plan d’action. ˏˏ Le plan d’Action pourra inclure ; demandez aux APS de : • Demandez à la cliente de promettre verbalement qu’elle se gardera en sécurité. ■■ “Nous voulons nous rassurer que vous soyez en sécurité. Je sais que cela puisse paraître dif- ficile. Pouvez-vous me promettre verbalement que vous veillerez sur vous au moins jusque demain ?” • Mettre en place un garde de sécurité ■■ “Nous voulons vous aider à vous maintenir en sécurité. Plusieurs fois nous utilisons les mem- bres de famille pour faire cela. Pouvez-vous m’aider à penser de quelqu’un de votre famille qui puisse rester à vos cotés ?” ■■ “Pouvons-nous travailler ensemble pour amener ces membres de famille à pouvoir se mettre d’accord qu’ils seront avec vous pour vous aider à rester en sécurité?” • Et /ou contacter SOSAM ou Maltezer pour un appui supplémentaire ou hospitalisation • Il appartient au CT de communiquer à la suite le plan d’action à l’APS. • A Maria de faire suivre le rapport (y compris l’évaluation et le plan d’action) , a Judy • Maria Claudine et les CT développent un plan de suivi à communiquer aux APS • Claudine fait rapport à l’IRC des résultats du plan et produit n’importe quel rapport dont l’IRC pour- rait avoir besoin et partage le même rapport et autre feedback nécessaire avec les ASBLs partenaires. Addressing Sexual Violence Related Trauma In Eastern DRC with Cognitive Processing Therapy 107 THE WORLD BANK 1818 H, Street N.W. Washington, D.C. 20433 www.logica-wb.org