New Research
A Randomized Controlled Trial of Trauma-Focused Cognitive Behavioral Therapy for Sexually Exploited, War-Affected Congolese Girls

https://doi.org/10.1016/j.jaac.2013.01.013Get rights and content

Objective

To assess the efficacy of trauma-focused cognitive behavioral therapy (TF-CBT) delivered by nonclinical facilitators in reducing posttraumatic stress, depression, and anxiety and conduct problems and increasing prosocial behavior in a group of war-affected, sexually exploited girls in a single-blind, parallel-design, randomized,+ controlled trial.

Method

Fifty-two 12- to 17-year-old, war-affected girls exposed to rape and inappropriate sexual touch in the Democratic Republic of Congo were screened for trauma, depression and anxiety, conduct problems, and prosocial behavior. They were then randomized to a 15 session, group-based, culturally modified TF-CBT (n = 24) group or a wait-list control group (n = 28). Primary analysis, by intention-to-treat, involving all randomly assigned participants occurred at pre- and postintervention and at 3-month follow-up (intervention group only).

Results

Compared to the wait list control, the TF-CBT group experienced significantly greater reductions in trauma symptoms (F1,49 = 52.708, p<0·001, χp2 = 0.518). In addition, the TF-CBT group showed a highly significant improvement in symptoms of depression and anxiety, conduct problems, and prosocial behavior. At 3-months follow-up the effect size (Cohen’s d) for the TF-CBT group was 2.04 (trauma symptoms), 2.45 (depression and anxiety), 0.95 (conduct problems), and−1.57 (prosocial behavior).

Conclusions

A group-based, culturally modified, TF-CBT intervention delivered by nonclinically trained Congolese facilitators resulted in a large, statistically significant reduction in posttraumatic stress symptoms and psychosocial difficulties among war-affected girls exposed to rape or sexual violence. Clinical trial registration information—An RCT of TF-CBT with sexually-exploited, war-affected girls in the DRC; http://clinicaltrials.gov/; NCT01483261.

Section snippets

Trial Design

A single-center, equal-randomization, single-blind (outcome assessors), parallel-group (active and wait-list control) study was chosen to address this question.

An additional resilience questionnaire was piloted, translated, and back-translated for the study, but was eventually discarded after feedback from the interviewers/outcome assessors suggested that the clinical interview was long enough and that asking more questions could lead to fatigue and inaccurate responses.

Participants

Fifty-two war-affected

Baseline Characteristics

Randomized allocation placed 24 participants in the trauma-focused cognitive behavioral therapy group and 28 participants in the wait-list control group (Figure 1). Table 1, Table 2 summarizes ages, traumatic events exposure, and psychological and psychosocial symptoms at baseline. The mean age of the 52 participants at baseline was 16.02 years.

Inappropriate sexual touch was the most common traumatic event experienced (48 of 52), and lack of food or water, severe punishments, seeing blood or

Discussion

To our knowledge, this is the first randomized controlled trial of a trauma intervention for war-affected girls in low- and middle-income countries (LAMIC) who have been exposed to rape and sexual abuse. Findings show that group-based, culturally modified, TF-CBT significantly reduced psychological distress and psychosocial difficulties among this population. These gains were either maintained or improved (in the case of depression and anxiety symptoms and prosocial behavior) 3 months

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    This project was funded by World Vision, and by family and friends who contributed toward the carpentry and mechanics tools and the hygiene kits given to every girl in the study. World Vision and Conférence Régionale de l'Afrique de l'Ouest Francophone (CERAO; a local, Congolese community-based organisation) provided material support including local staff time to conduct the intervention, assistance in the logistical aspects of both the study design and interventions and assistance in interviews during the project. Neither organisation was involved in the management or analysis of the data.

    This article is discussed in an editorial by Dr. Judith A. Cohen on page 344.

    Dr. O’Callaghan had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    The trial protocol is available on request from the lead author at: [email protected]

    The authors acknowledge the invaluable support and assistance provided by Dr. Judith A. Cohen and Dr. Ben Saunders in planning this trauma-focused cognitive behavioural therapy intervention in the Democratic Republic of Congo. The authors also thank the staff of World Vision and CERAO, in particular Anna Fenten, Fernand Azonnannan, Françoise Maroyi, and Jonas Makusudi, who worked with World Vision and CERAO at the time the study was conducted, for their support and help in delivering the intervention. Finally, a special mention and thanks must go to the girls who participated in the project, who are truly an inspiration to the authors in courage, resilience, and honesty, with smiles and humor that lifted everyone.

    Disclosure: Drs. O’Callaghan, McMullen, Shannon, Rafferty, and Black report no biomedical financial interests or potential conflicts of interest.

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