A randomized controlled trial of mental health interventions for survivors of systematic violence in Kurdistan, Northern Iraq

Qualitative study data were used to adapt the Hopkins Symptom Checklist for Depression and Anxiety (HSCL-25) [18],[19], the Harvard Trauma Questionnaire (HTQ) [20], and the Inventory of Traumatic Grief [21],[22] to measure symptoms of depression, anxiety, posttraumatic stress and traumatic grief. Adaptation included adding 13 locally relevant symptoms. Table 1 presents all the mental health symptoms included in the final instrument, identifying which are from the standard measures and which came from the qualitative study. Participants reported symptom frequency for the prior two-weeks using an ordinal scale of 0 (never) to 3 (always). Analyses of intervention impact on mental health outcomes used mean item scores for each scale, therefore also ranging from 0-3.

The study instrument also included locally developed function scales for men and women based on frequently mentioned activities in the qualitative study that men/women do to care for self, family, and community. Respondents rated difficulty on an ordinal scale of 0 (‘no more difficulty than most men/women of the same age’) to 4 (‘frequently unable to do the activity’). Analyses of intervention impact on dysfunction used mean item scores for this scale, therefore also ranging from 0-4. Table 2 presents the items included in the function scales for men and women.

Instrument reliability and validity were tested for all outcomes among local survivors of systematic violence (N = 128). Interviewees were taken from lists of torture survivors provided by a local former prisoners association. Persons on these lists had previously been contacted by the interviewers and asked whether they would agree to be interviewed. For the purpose of testing they were asked whether they felt they were depressed, anxious, or experienced excessive fear (the latter term describing symptom similar to posttraumatic stress). Another adult in the house was asked the same questions about the survivor. Those survivors for whom they and the other adult agreed as to the presence or absence of these problems were selected from the lists for interview. This study was done in the year prior to the trial commencement and since the study criteria were the same some of the participants were also subsequently trial participants. Cronbach’s alphas ranged from .725 to .928, indicating adequate internal reliability. Pearson correlation coefficients for test-retest reliability (repeat interviews were conducted 1-3 days later) ranged between .728 and .864. Criterion validity was assessed using methods described elsewhere [23]. Briefly, criterion validity was assessed by comparing the previous statements of the survivors and others as to whether the survivors had depression, anxiety or excessive fear with the results of the instrument measuring the similar concepts of depression, anxiety, posttraumatic stress, and traumatic grief. A high level of agreement would be expected if people can accurately recognize the presence of these problems and if the instrument has criterion validity. Criterion validity was supported for all scales among men but only for posttraumatic stress symptoms among women. However, based on the results on the other tests of validity and reliability measures by sex we decided to retain the measures. Another reason for retention was that we suspected problems with the criterion validity testing procedure. In previous studies we have found that instruments tend to perform either well or poorly across most tests, so poor criterion validity in the face of adequate performance on other measures was unusual. Our local partners speculated that criterion validity was poor among women because their husbands may not be good judges of their wife’s mental state. Detailed descriptions of instrument development are provided elsewhere [24].

The authors consulted torture, trauma, and cross-cultural mental health experts and local stakeholders and mental health providers. Experts disagreed on whether an intervention could address depression without addressing trauma. The PI (PB) decided to evaluate both types of interventions by selecting BATD (depression only treatment) and CPT (trauma and depression).

BATD is an empirically supported psychotherapy for depression. It is published in a 12 session format [25] which is briefer than other variants of behavioral activation which often exceed 20 sessions [26] and focuses on strategies to engender structured engagement in healthy and positive values-based behaviors [27]-[29]. BATD has demonstrated efficacy in eight RCTs in diverse populations [30]-[33]. Preliminary evidence suggests that the full version of BA may also reduce PTSD symptoms [34]-[37].

The core content of BATD is based on helping individuals plan for and engage in positive activities on a daily basis based on the values and goals of that individual in multiple life areas (e.g., relationships, career, and spirituality). Engagement in these activities is initially supported by the structure of the program and reinforced by the therapist, but the reinforcement becomes more intrinsic as the activities lead to more positive life experiences and the satisfaction that comes with living according to one’s own values and goals. The treatment was highly consistent with the original treatment manual but with two types of adaptations: First, changes based on cultural issues including a) consideration of societal expectations regarding acceptable and unacceptable activities and b) modification of the discussion of values to be less individual-focused and more collective, focused on the participant’s place in the larger society. Second, changes to address patient adversities including limited language/writing proficiency and extreme poverty. These included a set of stickers developed for patients to use in place of written monitoring of activities, and focus on identifying low cost easily accessible activities to reduce financial barriers.

CPT is a12-session psychotherapy that includes cognitive restructuring (i.e., identifying, challenging, and modifying maladaptive beliefs) and emotional processing of traumatic events (i.e., using a writing narrative to help clients identify and feel their emotions about their worst traumatic events). Cognitive restructuring initially focuses on rigid or inaccurate beliefs about the trauma itself (i.e., reasons why it happened or what could have prevented). It then shifts to overgeneralized beliefs about the self or other that have been affected by the trauma in the domains of safety, trust, power/control, esteem, and intimacy. The ultimate goals of treatment are for clients to be able to approach (vs. avoid) their feelings about the trauma and to modify rigid, inaccurate, or overgeneralized trauma-related beliefs to be more flexible, accurate, and adaptive. Clients are taught these skills throughout the course of treatment and practice outside of session (i.e, homework) is a therapy expectation. CPT was designed to reduce PTSD symptoms in sexual violence survivors [38]. Multiple studies have examined CPT’s effectiveness among female rape victims [39]-[43]; child sexual abuse survivors [44]; combat veterans [45],[46]; physical assault survivors [43]; and refugees [47]. CPT has proven effective in reducing PTSD and depression symptoms compared to controls [41],[42],[45],[46] and reducing PTSD compared to minimal attention [40],[44]. Improvements in PTSD and depression symptoms among rape survivors are comparable to Prolonged Exposure Therapy [40]. Unlike the current study previous studies used PTSD diagnosis as an inclusion criterion.

A full description of the adaption of CPT to the Kurdish population can be found elsewhere [48]. Briefly, while the essential elements of CPT were not changed, we adapted training materials to the local culture and situation. Throughout the training manual, reference to American culture-specific examples or explanations were changed to examples relevant to Kurdistan. The final sessions of CPT focus on themes considered related to the experienced trauma: safety, trust, power, esteem and intimacy. Through discussions with the local CMHWs and mental health professional staff it became clear that no direct translations for esteem or intimacy were available in the Kurdish language so the alternative themes of respect and caring were identified that were more culturally appropriate and relevant to the study population. We also adapted the homework assignments to account for the limited literacy levels of the study population. We reduced the complexity and length of all written material and included images as visual cues for the skills being to taught (e.g., reducing the number of questions to challenge maladaptive beliefs from 10 to 5, using images of emotions to cue clients to identify their feelings in relation to a thought). For clients who were illiterate, we also made use of skills some CMHWs had previously learned from our partner, Heartland Alliance. These included rote memorization drills on the skill/assignment for clients to practice over the next week, using mobile phones to record homework, and involving family members as scribes (if there was a family member that the client trusted. No other content specific changes were made to the standard CPT protocol.

Study participants randomized to the control condition were informed that they would be waitlisted for treatment and then offered the treatment after approximately 5 months regardless of their re-interview results. During the wait period, CMHWs contacted controls monthly to enquire generally about the severity of their symptoms, particularly that they were not a danger to self or others, as a safety check. Controls were instructed to contact the CMHWs if symptoms substantially worsened, for assessment for possible transfer and referral to a psychiatrist or a torture treatment center in Sulaimaniyah.