Cognitive processing therapy for rape survivors in the Democratic Republic of Congo: Setting a new standard for post-conflict psychosocial care

Last week saw the publication of an important randomized control trial of cognitive processing therapy (CPT) for Congolese survivors of sexual assault in the New England Journal of Medicine (NEJM — and thanks, NEJM, for making the article available in full online). The fruit of intensive work by Judy Bass of Johns Hopkins, Jeannie Annan of the International Rescue Committee, Debra Kaysen of the University of Washington, and a host of others, this publication sets a new standard in the field of post-conflict mental health research and is welcome news for those affected by rape and other forms of sexual assault in low and middle-income (or, “LMIC”) war-affected settings.

The study involved almost 500 female survivors of rape in the eastern provinces of the Democratic Republic of Congo (DRC), an area of the world infamous for the absence of state control and an ongoing epidemic of sexual violence. Half were randomly assigned to a group-based version of CPT led by trained local counselors, half to generalized, patient-directed individual support and case management. Those attending CPT improved far more than those in the control group (although the latter also improved somewhat).

CPT has been shown to be effective for sexual assault survivors in several Northern, high-income countries, so that it was effective in the DRC may seem unsurprising. However, debates have raged in the past decade or so about the efficacy and effectiveness of doing psychotherapy in post-conflict settings that are not technically “post”-conflict and in populations with low-levels of education.

Prior research has suggested that short-term therapies may not be effective for populations exposed to ongoing trauma or multiple severe traumas. In our study, all villages reported at least one major security incident during the trial, including attacks, displacement due to fighting, and robbery by armed groups. In addition, there was concern that providing therapy to illiterate persons would be challenging. Our findings suggest that despite illiteracy and ongoing conflict, this evidence-based treatment can be appropriately implemented and effective.

This study shows that, with sufficient technical support, psychotherapy targeting trauma-related emotional problems can be delivered effectively in violence-affected LMICs as part of comprehensive psychosocial programs.

For a brief summary of the study and some commentary, see the related New York Times article from last Wednesday.

Recent focus on child soldiers and what the research says

The International Criminal Court (ICC) has made its first ruling, convicting Congolese rebel leader Thomas Lubanga of using children younger than 15 as soldiers. For basic media coverage, see here, here, and here. The conviction if Lubanga is the ICC’s first in its decade of existence, and for those of you interested, the BBC has a decent discussion of the costs, estimated at $900 million, here.

Lubanga could have been accused of any number of war crimes, but the ICC chose to focus on child soldiering (due to the quality of evidence, say prosecutors). The recent Invisible Children anti-Joseph Kony video recently trending on Twitter (no need for a link, I’m sure) chooses to also focus on child soldiering. Clearly this is compelling stuff for the media as well as legal teams, nightmare material for those who love kids and those who fear teenagers. From the sympathetic side we often hear simplistic pronouncements like this one from today’s New York Times:

Social workers say that even if children have enlisted willingly, looking for food, status or protection, they are often still permanently damaged by war-time violence and drugs.

There is, however, a research literature on child soldiers that presents a more nuanced picture. Although certainly former child soldiers suffer higher rates of physical and mental health problems than similar kids, the research suggests that there is more hope for them than is commonly portrayed. The work of Jeannie Annan and Chris Blattman show that there is wide variability in what child soldiering actually entails, and, that former child soldiers — far from being permanently damaged — are more active in peaceful post-conflict political processes than their peers. Theresa Betancourt‘s work shows that symptoms of emotional distress decrease over time among many, and I believe she has plans underway for treatment trials for those with continuing problems. Brandon Kohrt’s work presents (among other things) complex stories of reintegration through film, as well as research articles.

All this is not to say that child soldiering is in some way really not so bad. Making this a cause is indeed appropriate. But there is more to the issue than just crazed violent teenagers and their adult bad guy overlords. Child soldiers become former child soldiers, adults who live lives and can contribute to their societies.

Randomistas, development economics, and the poetry of evaluation

Last week’s New Yorker featured an engaging portrait by Ian Parker of MIT development economist Esther Duflo, perhaps the leading light among that field’s “randomistas.” These (mostly) young economists have made their mark on their profession by applying randomized control trials (borrowed from medicine) to development strategies. This really shouldn’t surprise anyone — randomized control trials have been used for other types social programs (e.g., delinquency prevention) for years now, and given that economics is about human behavior it’s surprising that economists haven’t embraced this earlier.

Also familiar to behavioral scientists are the objections to assigning participants at random to experimental and control groups.

“You shouldn’t be experimenting on people.” O.K., so you have no idea whether [your programs] work–that’s not experimental?

The former is met far to infrequently with the latter. Someone comes up with an idea for some intervention, they announce their intentions and put that idea into practice, and all of a sudden it is accepted as the right thing to do… and to test whether it works better than doing nothing (which really means “better than engaging the variety of things people do that you don’t know about”) thus becomes the wrong thing to do. That’s some sloppy ethics, at best.

The one objection to randomized control trials mentioned in the article that might hold water is that an intervention shown to be empirically supported in one context might not be empirically supported in another due to variation in ecological and temporal phenomena. Of course, the logical solution is more experimentation, not less. In their psychosocial programs in the Democratic Republic of Congo, the Center for Victims of Torture has instituted what Research Director Jon Hubbard calls “rolling control groups” to address the problem of changing context. The situation in conflict zones is often very fluid, and so if a program is shown to be better than doing nothing during one intervention period (6 weeks for CVT’s program) that doesn’t mean that it will be better during the next. So Hubbard came up with the rolling control: at the beginning of each intervention period, the program accepts and screens 125% of their capacity, then randomly assigns 25% to a wait list control; after the intervention period they give post-tests for each group, viola! They have a small-scale randomized control trial that shows their funders that they are monitoring the effectiveness of their programs for each cohort.

The article on Duflo ends with a couple paragraphs on the art of the evaluator’s profession that I found particularly striking — but admittedly, maybe only a data nerd like myself would love:

“It can’t only be the data,” Duflo said, showing a rare willingness to generalize. “Even to understand what data means, and what data I need, I need to form an intuition about things. And that process is as ad hoc and impressionistic as anybody’s

It can’t only be the data, but there must be data. “There is a lot of noise in the world,” Duflo said. “And there is a lot of idiosyncrasy. But there are also regularities and phenomena. And what the data is going to be able to do–if there’s enough of it–is uncover, in the mess and noise of the world, some lines of music that may actually have harmony. It’s there, somewhere.”